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CMS says it will axe primary care, other CMMI innovation models

03/24/2025

Medical groups will see the early termination of several payment models from the Center for Medicare and Medicaid Innovation (CMMI), including two primary care-focused models, an end-stage renal disease (ESRD) model and a Maryland-specific program.

Avoid absolutes when selecting the level of risk for MDM

03/24/2025

by: Julia Kyles, CPC

Question: When calculating risk for an E/M visit, is total parenteral nutrition (TPN) moderate risk or high risk? We found some sources that state it should be compared to prescription drug management, which would be moderate risk. Other sources say it should be compared to drug therapy requiring intensive monitoring for toxicity, which is high risk.

Review the full descriptors for patient relationship modifiers X1-X5

03/24/2025

by: Julia Kyles, CPC

CMS introduced patient relationship modifiers in 2018. Even though they are not mandatory, reporting of the modifiers continues to increase, particularly with modifier X5 (Diagnostic services requested by another clinician). Here are the full descriptors for each code.

Position may influence denials on patient relationship modifiers

03/24/2025

by: Julia Kyles, CPC

Look at your claims with patient relationship modifiers X1-X5 and move the modifier to the second position if you’re seeing high denials.

What’s behind Medicare Advantage growth drop? Benefit cuts, prior auth cited.

03/17/2025

by: Roy Edroso

New numbers suggest that the growth of Medicare Advantage enrollment, which has been faster than traditional Medicare’s for years, has begun to slow. The program faces headwinds, some self-generated, as beneficiaries see potential reductions to their benefits and their providers decoupling from plans.

OCR alert addresses human vulnerabilities in social engineering attacks

03/17/2025

by: Dom Nicastro

The October 2024 Cybersecurity Newsletter from the Office for Civil Rights (OCR) focuses on social engineering — a significant and growing cyberthreat aimed at exploiting individuals to gain unauthorized access to sensitive information.

You need a scorecard to track telehealth coverage in 2025

03/17/2025

by: Julia Kyles, CPC

You know that CMS will not reimburse the new CPT telehealth codes (PBN 1/23/24). However, some commercial plans are picking up the new codes (98000-98015).

Doing the splits: MDM offers more flexibility for split/shared visits

03/17/2025

by: Julia Kyles, CPC

The answers to a reader’s questions about split/shared visits demonstrate that medical decision-making (MDM) can boost your care team’s effectiveness.

Roster billing for hepatitis B — July 2025 release

03/17/2025

by: DecisionHealth staff

On Feb. 21, CMS published Medicare Claims Processing Transmittal 13091 to communicate the roster billing process for submitting Part B claims for hepatitis B vaccines and their administration. CMS recently expanded coverage of hepatitis B vaccinations to include individuals who have not previously received a completed vaccination series and individuals whose previous vaccination history is unknown.

Denial trends favorable on 59-appended procedural services

03/17/2025

by: Richard Scott

Practices upped their use of modifier 59 (Distinct procedural service) in recent years, adding nearly 1 million 59-appended claims to the most frequently reported same-day procedural codes.

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