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Master medically unlikely edits to keep denials down

06/30/2025

CMS developed medically unlikely edits (MUE) as a way to limit the number of times a particular service is allowed to be billed by a single provider to a single patient on a given date of service. Medicare began using these unit-of-service edits in 2007 in an effort to reduce payment errors for Medicare Part B claims.

Medical decision-making: Know how to keep it on the level

06/30/2025

by: Terry Tropin, MSHAI, RHIA, CCS-P

Selecting a level of medical decision-making (MDM) is confusing and complicated. This article defines key terms and describes a simplified system for selecting a level.

Aside from XS, denial rates on X modifiers diverge widely

06/30/2025

by: Richard Scott

Practices turned to two of the X-series modifiers in place of modifier 59 (Distinct procedural service) more than 7 million times in 2023 and saw mixed results with denial rates on the top-billed codes.

Follow HIPAA rules when you receive employment-related requests

06/23/2025

by: Julia Kyles, CPC

Keep HIPAA compliance front-of-mind when a patient asks you to send their records to an employer. In particular, your practice should understand when you do and do not need a patient’s authorization to disclose protected health information (PHI) in response to an employment-related request.

Budget bill follow-up: Medicaid cuts to hit hospitals; sequester stays 2%

06/23/2025

by: Roy Edroso

While all Medicare providers should be interested in the prospective change to physician payments in Congress’ pending budget bill, there are a few other pieces of the bill that would affect them indirectly. Medicaid and Affordable Care Act (ACA) cuts, for example, appear to increase the number of uninsured and threaten at-risk hospitals. Also, the sequestration cut isn’t going up — or going away.

Review the latest rules for HIV PrEP, hepatitis vaccine, CRC screens

06/23/2025

by: Julia Kyles, CPC

Make sure you incorporate current CMS coding guidance for three preventive services into your workflow and check for denials that might be candidates for an appeal.

Stick to your documentation standards for self-pay services

06/23/2025

by: Julia Kyles, CPC

Question: Our providers have started to perform some services that are 100% patient pay, such as platelet rich plasma injections to treat pain. Do we need a separate policy for documenting services when the record doesn’t need to support a code?

Study: Higher upcoding rates seen across outpatient settings

06/23/2025

by: HCPro staff

Upcoding is becoming a more common practice across all outpatient settings, according to a recent Trilliant Health report.

Primary care, oncology specialties dominate substitute physician services

06/23/2025

by: Julia Kyles, CPC

Analysis of Medicare Part B claims data indicates that when practices bring in a substitute physician, they favor the fee-for-time arrangements over reciprocal billing arrangements. A closer review of the claims data reveals the specialists who are most likely to bring in a substitute when they take time off.

Introduce staff to new ICD-10-CM codes, tabular update for FY2026

06/16/2025

by: Julia Kyles, CPC

Start training your staff on the diagnosis code changes that will go into effect Oct. 1. CMS will adopt the ICD-10-CM additions, revisions and deletions that it previewed in April.

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