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Medical Billing Clearinghouse: Understanding Medicare’s Role – Five Questions Medical Billing Companies Need to Know.

Understanding Medicare’s Role in Advance Care Planning.

As a follow-up to our recent article on the 2016 Medicare regulation change that allows physicians to bill for advance care discussions, we thought we’d share a few pertinent details on what “advance care” really means. Though doctors have some leeway to cover what they think is best, the more medical billing companies know, the better they can protect their clients.

Everything from updating patient management software to health insurance claims processing can be affected by the change – here’s a primer on advanced care terms and technicalities.

As a Matter of Fact…

  • ¾ of the 2.5 million Americans who pass away each year are 65 and older.
  • Medicare is the largest health insurance provider for Americans in their last year of life.
  • ¼ of all Medicare health care coverage is spent on beneficiaries in their last 12 months of life.
  • 90 percent of aging adults report that they’d prefer to die at home, though historically only 1/3 actually do.

What is “end-of-life care” exactly?

In simple terms, end-of-life care includes all the services provided for patients in the days (or even years) prior to their death. Medicare covers a comprehensive list of end-of-life health care services, including hospital stays, diagnostic testing, physician visits, home health care, prescriptions, and so forth. Though a patient’s prognosis may be “terminal”, end-of-life services can be intended to either cure conditions or simply provide symptom relief.

What does “advance care planning” entail?

The goal of advance care planning is to help patients and their family members/caregivers better understand all the care options available for them at the end of their lives. Typically, physicians will discuss the various options available (curative treatments, pain management options, at-home care or in-hospital stays for example), make recommendations on a treatment plan, then help the patient to determine which options best align with their individual desires. (In terms of billing for claims processing software, there are two codes to cover these conversations. The first covers the first 30 minutes of discussion – which may be all a patient needs. There is an additional code that covers additional 30 minute conversations as necessary.)

Are physicians the only Medicare-approved resources for advance care discussions?

No. Under the new regulation, Medicare covers advance care planning discussions provided by physicians and other health professionals, such as nurse practitioners, who bill Medicare according to the official physician fee schedule. Discussions should take place in medical offices and approved facilities and hospitals, and can be part of an annual check-ups or wellness visit. (Note for health insurance claims processing: Medicare should be billed separately for advance care.)

What are “advance directives” and in terms of patient management software, are facilities required to keep records of them?

In essence, advance directives are written instructions that define a patient’s wishes for end-of-life care. They become invaluable in instances where a patient is incapacitated or is no longer able to speak for themselves. They are often referred to as a “living will” and typically result from advance care planning discussions. Advance directives define specifically the medical treatments and types of treatments each patient prefers as they are nearing dying.

Advance directives fall under state regulations. Official forms for directives vary from state to state as do the requirements for documentation. Though patients are not required to have one, the Patient Self-Determination Act of 1991 requires that hospitals, skilled nursing facilities, etc. ask each patient if they have an advance directive at the time of admission.

What is “palliative care” and is it covered by Medicare?

As opposed to services intended to cure or treat a specific illness, palliative care generally focuses on managing symptoms and providing comfort to patients nearing the end of life. (Although palliative care is most common for patients receiving end-of-life care, it is not restricted to those with terminal illnesses. It’s also very common for people living with serious chronic illnesses including cancer, heart disease and depression.) In terms of health insurance claims processing, Medicare beneficiaries can claim coverage for palliative care services whether they are offered in combination with curative treatments or not.

Posted in: Medical Billing Clearinghouse

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Medical Billing Software: Turns Out Advance Care Planning Is Worthy – Medicare Now Covers End-of-Life Conversations.

 Is Your Medical Claims Billing Software Ready?

The discussion around paying doctors for helping patients with advance care, or end-of-life planning, isn’t a new one, but it finally got traction in 2015. After years of debate around the issue and countless conversations about whether reimbursing physicians for their time consulting the terminally ill is worthy, at the stroke of midnight on January 31, the country decided it finally is.

It’s difficult to talk about death. And difficult for doctors to tell their patients (and their patients’ loving families) that there’s really is no way to avoid it. In America we pull out all the stops to prolong life and pride ourselves on doing “everything we can” to keep folks alive. The reality, however, is that people die every day and the majority of people facing terminal illness don’t necessarily want to exhaust every medical option available. Most want to live out their final days free of pain, in relative peace and with the people they love.

Hence the advance care payment debate. Do we force the difficult conversations?

The government’s first attempt to reimburse for end-of-life planning occurred in the summer of 2009. The proposal was met with swift and furious opposition and so it was tabled until the winter of 2010. That year the administration quietly included the new benefit in a list of regulations that determined the value of various procedures for Medicare. It was a softer approach, but when the inclusion finally made the news, skepticism set in and the attempt was again abandoned. Why? It wasn’t that anyone felt doctors shouldn’t be paid for providing sound medical advice; it was that some considered it an example of the government’s intrusion into health care.

What was the catalyst for change?

In 2012 the medical community joined the conversation. At the meeting of the Illinois State Medical Society that year, several doctors proposed a resolution to ask the American Medical Society to create a billing code for advance care planning discussions. (The AMA creates all the medical billing codes for Medicare. The government regulates how much to reimburse for them.) The doctors based their request on their personal, clinical experience and with that, the AMA agreed. They created 2 new codes and finally, in early July 2015, Medicare published plans to pay for them.

Why should medical billing companies care that such a change has taken place?

Dying is expensive. According to research, the 6% of Medicare patients who die each year account for up to 30% of the program’s annual spend on health care. That means nearly a third of the Medicare’s resources are invested on the dying – and for many of them, the care doesn’t change the outcome. Medicare spent an average of $33,500 on recipients who passed away in 2011 — four times the amount it spent on the recipients who lived.

And in more practical ways, we need to ensure our medical claims billing software can manage the changes. Here’s what you need to know.

In the final ruling on the issue, published late in 2014, the Centers for Medicare and Medicaid Services established the two CPT codes for physicians to document advance care planning conversations. The first covers the initial 30 minutes of discussion. The second is an add-on code for additional 30 minute conversations.

The new codes went into effect for services provided on or after January 1, 2016 and are billable under Medicare Part B. Medical billing companies should be aware (as should administrative and billing staff) that these codes can be used by any physician or non-physician practitioner who bills Part B for their services. Palliative service providers can also bill for advance care planning while most hospice physicians will not.

The conversations included in paid discussions should cover patient goals for care and outcome, specific wishes in terms of advance care, and instruction on advance directives which are necessary for patients, family caregivers and professionals providing terminal care to understand and agree to.

Does your medical claims billing software help keep you compliant in terms of policy changes like this one? Apex EDI’s OneTouch® electronic healthcare claims processing certainly does. Ask us why we’re one of the top-rated medical billing companies in the industry.

Posted in: Medical Billing Software

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2016 Healthcare Claims Processing

Medicare Regulations Are Changing Come 2016. Apex EDI’s OneTouch® Healthcare Claims Processing Service Makes Change Easy

With the advent of 2016 just around the corner, we’re sure many of you are already aware of the coming Medicare Physician Fee Schedule (MPFS) regulation update this January. If not, here’s a quick look at just a few of the policies that will be affected by the new 2016 payment rules:

    Home Health Value-Based Purchasing

    Driven by mandates in the Affordable Care Act, Value-Based Purchasing incentivizes providers to increase the quality of their care. In fact, the amount of incentives participating agencies receive is directly proportional to the quality scores they earn. The program has been piloted through various disciplines within the medical industry, and beginning January 1, all Medicare-certified home health agencies operating in Massachusetts, Maryland, North Carolina, Florida, Washington, Arizona, Iowa, Nebraska, and Tennessee will move to a Value- Based model.

    The “Two-Midnight” Rule

    After considerable debate, the controversial “Two-Midnight” Rule CMS first introduced in 2013 will officially go into effect. In essence the rule clarifies that in terms of Medicare payments auditors must assume a hospital stay was legitimate and necessary as long as the stay spanned two midnights. (Stays under the two-midnight mandate will now be billed as outpatient observation care; a key difference in terms of healthcare claims processing.) According to CMS, this illustrates the “long-standing emphasis on the importance of a physician’s medical judgment in meeting the needs of Medicare beneficiaries.”

    End-Stage Renal Disease Quality Incentive Program

    Like the Value-Based Purchasing initiative discussed above, the new End-Stage Renal Disease rule will tie the incentives dialysis facilities receive to the quality of the dialysis care their patients actually receive. Quality of care will be determined with respect to measures such as infection rates, safety violations and overall patient experience. In fact, facilities that fail to meet a “total minimum performance” requirement will be penalized with a reduction in their rates.

    New Physician Payment System

    This change is garnering attention because it’s the first final rule issued since the sustainable growth rate formula was repealed by the by the Medicare Access and CHIP Reauthorization Act of 2015. The new rule covers quite a bit of ground, but most notably, also begins a new period of physicians and practitioners being paid according to merit. Like many other agencies, physicians will receive payment incentives for providing high-quality, while those who fail to meet standards may be subject to payment reductions. Also included is the institution of two new, separate billing codes for advance care planning services provided to Medicare beneficiaries. Formerly all advanced care planning has been coded under a single “Welcome to Medicare” visit. This change allows for Medicare coverage of more in-depth discussions.

While regulation change can seem confusing, rest assured that with Apex EDI’s OneTouch® electronic healthcare claims processing, we’ve done the heavy lifting. In all the ways possible, our real-time eligibility verification, patient statements delivery, and electronic remittance advice (ERA) will take regulation changes into account— ensuring that the process for collecting payments come January 1 is as simple and secure as always.

For more information on the 2016 regulation changes visit

Posted in: Healthcare Claims

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2016 Medical Claims Processing: Who Determines the “Value” of Value-Based Payments?

With all the discussion around value-based payments and quality-incentive programs newly instituted by Medicare, one begs to question…who decides what’s quality? How do we know that what’s considered value to one is legitimately valuable to everyone?

Of course the answer to both questions is relative. In terms of medical care (and most everything else for that matter) it’s hard to define what “quality” really means. Our hats are off to CMS for at least attempting to define it and for trying to incentivize physicians, practitioners and facilities for value over volume. Though it seems like a nightmare in terms of submitting medical claims, the end goal is to increase the quality and efficiency of medical care, and that’s a win for everyone.

Here’s how they’re doing it…

The value-based payment program is comprised of two basic components. The first is the Quality and Resource Use Report (QRUR), which is basically a confidential report about both the cost and quality of care provided to Medicare patients. Secondly, there’s a Value-Based Payment Modifer (VBPM) or “score sheet” that adjusts payments up or down according to the results of the QRUR.

Thankfully, for those of us in medical claims, payment adjustments don’t happen in real time. It would be incredible if rates were charged according to the actual care given at any particular office visit or during a particular procedure, but we aren’t there quite yet. In 2015 CMS started applying the new score sheet to a select group of physicians, all based on performance data collected from their patients back in 2013. And that’s how things will continue. In 2016, the Value Modifier will be applied a specific group of physicians, based on performance in 2014.

For more information on value-based payments visit the CMS website at

Posted in: Medical Claims Processing

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ICD-10 Codes: Free Fact Sheets – Common ICD-9-CM Codes and Possible ICD-10-CM Equivalents

ICD-10 Codes: Free Fact Sheets – Common ICD-9-CM Codes and Possible ICD-10-CM Equivalents

The ICD-10 deadline is here and Apex EDI realizes that you may need additional resources to help make the transition smooth. We have compiled three fact sheets identifying commonly used ICD-9-CM codes and matching them with their possible ICD-10-CM equivalents, one sheet for General Medicine codes, one for Ophthalmology codes, and one for Chiropractic codes.


Please note this tool is not designed to provide perfect matches between the two coding systems. In fact, except for a minority of cases, perfect matches between the ICD-9-CM and ICD-10-CM coding systems do not exist. Given the significant increase in detail and specificity in the ICD-10-CM coding system, in most cases there is no direct match between ICD-9 and ICD-10 codes. A clinical analysis is required to determine which code or codes should be used. It is important to remember that even when there is only one ICD-10 code, it is not necessarily completely equivalent to the source ICD-9 code. This tool is not designed to replace proper training and documentation.

Proper coding begins with the doctor and documentation. While Medicare Part B is not going to deny claims based solely on the specificity of the ICD-10 diagnosis code as long as the codes are from the right family, they may pay less than what they have paid in the past based on the specificity of the diagnosis code. These tools are meant to shorten the amount of time spent looking up codes for best specificity. Most of the conversions identify the family where the appropriate crosswalk can be found. In the rare occasions where there is a direct crosswalk a clinical analysis is still required to determine if the crosswalk is appropriate for the billing situation.

Posted in: ICD-10 Codes

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