On April 1, 2014, President Barack Obama passed the legislation, Protecting Access to Medicare Act of 2014 that enacts a 13-month temporary patch for the sustainable growth rate (SGR) formula and delays the transition from ICD-9 to ICD-10 until October 1, 2015.

The U.S. Senate had approved the bill in March with a voice vote of 64-35, where 60 votes are enough for passage. This new administrative development is a temporary fix for the intimidating 24% cut to physicians’ Medicare reimbursement and their medical billing woes. It also provides more time for ICD-10 compliance preparation, which is a great relief for healthcare organizations that has not yet finished their ICD-10 implementation tasks. However, the American Medical Association (AMA) is not happy with this as they are looking for a permanent fix and wants to stop ICD-10 implementation altogether.

It may be very difficult for physicians to deal with the 24% cut in their reimbursements as they will have to cut corners (for example, cutting down staffs) and refuse taking Medicare patients. As more than 100 million Americans hold Medicare and Medicaid coverage, physicians will lose a significant number of patients through this. Also, the physicians will get very less time to spend with their patients after performing the paperwork related to billing tasks for Medicare and other insurers in order to receive maximum reimbursement. Overall, it will drastically affect physicians’ productivity and revenue. The Protecting Access to Medicare Act of 2014 avoids the payment reduction scheduled for April 1 and replaces it with a 0.5% increase in payments through December and freeze payment rates from January to March of 2015.

Now, let us take a look at ICD-10 compliance. The ICD-10 Readiness Survey conducted by the Workgroup for Electronic Data Interchange (WEDI) in 2013 revealed that the U.S. healthcare industry is much behind the key ICD-10 compliance milestones specified in the WEDI/NCHICA timeline for providers, payers and vendors, considering the survey earlier conducted in February. As per the survey, one-half of the healthcare providers are expected to start the external testing for ICD-10 implementation in the first half of 2014. Delay in ICD-10 compliance can provide the following opportunities for the medical practitioners who are not yet prepared to adopt the new medical coding system.

  • They will get more time to fully test systems and processes
  • Focus on their work again during the transition
  • Expand their relationships with other organizations, vendors and payers to improve their productivity
  • Extend their training process

However, this does not solve the complexity of the ICD-10 coding system, which will increase the diagnosis codes from around 14,500 to around 69,700. There should be experienced and ICD-10 ready coders for the smooth transition. A good revenue cycle management is unavoidable for medical practitioners to improve their productivity and revenue even with the temporary fix. A professional medical billing and coding company is the right choice in this regard as it provides the service of trained, AAPC-certified coders and great support for billing tasks.



Doctors Accepting MedicareMedicare doctors have been threatened with pay cuts each year over the past decade. The condition remains the same this year. The American Medical Association (AMA) president recently drew attention to the fact that physician payments under Medicare will drop by roughly 24% at the end of this month when scheduled cuts under the sustainable growth rate (SGR) payment formula kick in.

This scheduled cut is determined by targets set under the Sustainable Growth Rate (SGR) formula that was created as part of a 1997 deficit reduction law designed to rein in federal health spending by linking physician payment to an economic growth target.

Congress passes the legislation known as ‘Doc Fix’ regularly to avoid doctors taking the financial burden and keep the reimbursement levels around the same.

The Senate Finance Committee has passed a bill that would repeal the SGR and replace it with a system of rewarding physicians based on the quality of care they provide to Medicare patients rather than the number of services performed.

In addition to repealing and replacing the SGR formula, the senate bill would:

  • Freeze the base rate pay of any doctor who participates in Medicare through 2019
  • Shift the healthcare system from a fee-for-service model to one that reimburses providers based on the quality of care
  • Provide a 0.5% annual raise through 2018 to any doctor who participates in Medicare
  • Provide funding — known as Medicare extenders — for expiring programs that are considered highly essential to rural hospitals, such as ambulance add-on payments, outpatient therapy caps and low-volume provider adjustments.

This week Republican leaders in the House finally brought to a vote the legislation known as “Doc Fix” they’d unveiled in February. However, the vote was found meaningless and the bill is doomed to die because it’s tied to a delay of Obamacare’s individual mandate for five years through 2019.

The Congressional Budget Office (CBO) estimates that the senate bill to repeal SGR would cost $180B over 10 years. Though Congress efforts to repeal the Medicare sustainable growth rate (SGR) exist, there are chances that the SGR cuts may hit physicians as scheduled on April 1. This 24% pay cut will be too hard for physicians as they will have to cut corners due to this and may refuse to accept Medicare patients. They are likely to lose a considerable number of their patients as both Medicare and Medicaid cover more than 100 million Americans.

As medical outsourcing is proving economical, more physicians might gravitate towards outside companies to save money. Outsourcing to medical billing firms abroad is likely to increase. Without doing this, the doctors may be forced to cut corners and spend less time with each patient to accommodate more patients, which will in turn drastically affect the quality of care.



Calcium is better known as an element that builds and maintains strong bones and consuming milk and milk products is regarded as a good way of getting dietary intake of this nutrient as per the 2010 Dietary Guidelines for Americans from the US Department of Agriculture and the Department of Health and Human Services. It is often recommended to drink milk in the adolescence period to achieve optimum bone mass which will help to reduce the risk of hip fractures later in life. However, researchers at the Brigham and Women’s Hospital found this widespread notion to be wrong in the case of men. The researchers point out that the proof for these associations has been vague. Higher consumption of milk can contribute to height growth, which is a risk factor for hip fractures.

The study was conducted on more than 96,000 men and women to examine the effect of teenage milk consumption on hip fractures. The participants reported their milk consumption as teenagers and the study involved over 22 years of follow-up. The follow-up study found men who consumed four or more glasses of milk a day as teenagers were 1.9 cm (on an average) taller as adults compared to those men who consumed two or fewer glasses a week. As per the study, the women were 1.7 cm taller. Overall, men reported greater consumption of milk in their adolescence period (2.1 glasses per day) than women (1.6 glasses per day).

The study concluded that milk consumption between the ages of 13 and 18 is associated with higher risk of hip fractures in men and each additional glass of milk in a day can increase the risk by 9% while there is no association between teenage milk consumption and increased risk of hip fractures in women. The researchers found the positive association between milk consumption and hip fractures in men is partially due to the mediating effect of height. However, they emphasized the need for further research to clearly define the role of early milk consumption and height in order to prevent hip fractures later in life.

Accurate Medical Coding – A Major Factor in Research and Patient Follow-up

Medical research such as the above is very important with regard to identifying the causes of particular conditions and planning the right treatment. Physicians must document each and every symptom, history and other relevant details of their patients. Accurate medical coding is a major factor in research and patient follow-up as well as with regard to providers receiving the correct reimbursement for their services.

If we take the case of medical coding for falls and hip fractures, the important considerations would be:

  • Accurate diagnostic coding of falls
  • Proper diagnostic coding of hip fractures in the presence of osteoporosis
  • Appropriate diagnostic codes to fully identify and elaborate conditions such as pre-existing morbid conditions like osteoporosis, pre-existing conditions that made the patient vulnerable to a pathologic fracture, which may include osteoporosis or tumor
  • Informing the payer on the insurance form that a patient sustained the pathological fracture on account of a pre-existing condition. This will help identify risk factors and suggest that the patient may require extended or comprehensive care. This will also help establish medical necessity if longer hospital stays, frequent home care, or extended care is needed. When secondary conditions are reported, the insurer will understand how the fracture was sustained. Moreover, it will also prove helpful in research coding.

Medical Coding – Diagnosis Codes for Hip Fractures

Let us look at some of the codes that can be reported for hip fractures.

Stress Fractures

ICD-9

  • 733.96: Stress fracture of femoral neck

ICD-10

  • M84.359: Stress fracture, hip, unspecified
  • M84.359A: Stress fracture, hip, unspecified, initial encounter for fracture
  • M84.359D: Stress fracture, hip, unspecified, subsequent encounter for fracture with routine healing
  • M84.359G: Stress fracture, hip, unspecified, subsequent encounter for fracture with delayed healing
  • M84.359K: Stress fracture, hip, unspecified, subsequent encounter for fracture with nonunion
  • M84.359P: Stress fracture, hip, unspecified, subsequent encounter for fracture with malunion
  • M84.359S: Stress fracture, hip, unspecified, sequela

Pathological Fractures

ICD-9

  • 733.14: Pathologic fracture of neck of femur

ICD-10

  • M84.459: Pathological fracture, hip, unspecified
  • M84.459A: Pathological fracture, hip, unspecified, initial encounter for fracture
  • M84.459D: Pathological fracture, hip, unspecified, subsequent encounter for fracture with routine healing
  • M84.459G: Pathological fracture, hip, unspecified, subsequent encounter for fracture with delayed healing
  • M84.459K: Pathological fracture, hip, unspecified, subsequent encounter for fracture with nonunion
  • M84.459P: Pathological fracture, hip, unspecified, subsequent encounter for fracture with malunion
  • M84.459S: Pathological fracture, hip, unspecified, sequela
  • M84.559: Pathological fracture in neoplastic disease, hip, unspecified
  • M84.559A: Pathological fracture in neoplastic disease, hip, unspecified initial encounter for fracture
  • M84.559D: Pathological fracture in neoplastic disease, hip, unspecified subsequent encounter for fracture with routine healing
  • M84.559G: Pathological fracture in neoplastic disease, hip, unspecified subsequent encounter for fracture with delayed healing
  • M84.559K: Pathological fracture in neoplastic disease, hip, unspecified subsequent encounter for fracture with nonunion
  • M84.559P: Pathological fracture in neoplastic disease, hip, unspecified subsequent encounter for fracture with malunion
  • M84.559S: Pathological fracture in neoplastic disease, hip, unspecified sequela
  • M84.659: Pathological fracture in other disease, hip, unspecified
  • M84.659A: Pathological fracture in other disease, hip, unspecified initial encounter for fracture
  • M84.659D: Pathological fracture in other disease, hip, unspecified subsequent encounter for fracture with routine healing
  • M84.659G: Pathological fracture in other disease, hip, unspecified subsequent encounter for fracture with delayed healing
  • M84.659K: Pathological fracture in other disease, hip, unspecified subsequent encounter for fracture with nonunion
  • M84.659P: Pathological fracture in other disease, hip, unspecified subsequent encounter for fracture with malunion
  • M84.659S: Pathological fracture in other disease, hip, unspecified sequela

The increased number of codes and specificity with ICD-10 demand more accurate documentation from physicians. A professional medical billing and coding company can help physicians and researchers save their time spent on copious documentation. A reliable firm can also ensure excellent revenue management so that physicians remain stress-free, and can focus more on research and on providing healthcare service.



ICD 10 Implementation Delayed Until 2015

Posted by on April 14, 2014 8:13 am

ICD 10 ImplementationFor the last six months, there was a big push for ICD-10. However, the implementation of ICD-10 has now been delayed until October 1, 2015. The news is a big relief for many healthcare providers who were not ready to implement the new coding standards.

On March 31, the US Senate approved H.R. 4302, the legislation which delays the ICD-10 implementation deadline by one year to October 1, 2015. The Senate voted 64-35 to pass the bill. President Barack Obama has signed into law “doc fix” legislation (HR 4302) to delay scheduled cuts to Medicare physician reimbursement rates. Along with suspending the projected 24% cut to Medicare Part B payments, the bill also postpones the “two-midnight rule” and recovery audits of medically unnecessary claims until March 2015.

According to a blog post by AHIMA (American Health Information Management Association), “CMS estimates that a one year delay could cost between $1 billion to $6.6 billion”. However CMS has not yet said how it will translate the law into regulatory policy.

Reports suggest that there’s also an outside chance that the CMS might decide to skip ICD-10 entirely and shift focus to the ICD-11 standard currently under development. Amidst the controversies connected with the transition to ICD-10, The World Health Organization (WHO) has released a fact sheet noting that the final version of ICD-11 will be released in 2017, two years later than scheduled.

Is This Delay a Blessing or a Curse?

Though a few providers are happy with the delay of this new ICD code set, with less than six months until the earlier October 1, 2014 deadline, many clinics have already invested time and resources in upgrading their systems for ICD-10, contracting with vendors, and hiring consultants. Medical communities have already spent millions of dollars in educational grants from the HITECH Act to prepare workers for the ICD-10 transition. Staffs at reliable medical billing and coding companies were also ICD 10 ready. Now, with an extra 12 months before the deadline, their training process must continue for an additional year.

The hope with this new code set is that, with more detailed diagnosis codes available, the CMS and private payers will be able to process more insurance claims the first time they are submitted without requiring additional documentation.



The 2012-2013 flu season was quite harsh with 700 cases of flu reported at Boston and led to the declaration of public-health emergency there. The 2014 FluView report published by the Centers for Disease Control and Prevention (CDC) indicated that the influenza activity decreased during week 8 (February 16-22), but remained prominent in the United States. However, researchers from Columbia University and the University of Cologne figured out a formula to predict the evolution of influenza for the next year as per a study published in Nature, an international weekly journal of science. They studied how the common H3N2 flu virus mutated and changed over the years since 1968. Based on those studies, they created a mathematical model that can predict how it will change in future.

The researchers monitored the viruses circulating in a particular season and their genomes and looked at how many people get affected by those viruses. The adaptive mutations that occur in the haemagglutinin protein of certain viruses were shown to increase the growth and life-time of viruses. They formulated the equation after examining every strain of the influenza virus through decades. More weight was given to the mutations that were expected to boost the virus and the strength of each strain was found by factoring in its growth rate. When they compared the estimates to different years, their formula was found to be highly accurate.

Health experts do study the virus; and how it changes over time and the frequency of changes every year to determine what flu strains need to be included in the vaccine. But what makes the new predictive model significant is that it can make the flu shot that you receive every flu season more accurate and thereby help you remain flu-resistant. Even though the study results need to be simulated before applying to real-world seasonal vaccines, researchers hope that a more precise prediction method would lead to the development of a highly protective vaccine.

Seasonal Influenza Virus Vaccination for September 2013 – July 2014

The flu season extends from September to March. The seasonal flu vaccination starts by the time the vaccine is available (normally early September) and will continue till the season ends. Universal seasonal flu vaccination is recommended by the Advisory Committee on Immunization Practices (ACIP) for anyone aged 6 months and older. However, it is quite confusing for common people and healthcare providers how commercial companies and Medicare bill for seasonal vaccination for influenza, especially when Obamacare is already effective. Since this vaccination comes under preventive care service, this is covered by almost all state insurance exchange plans and no deductible, co-pay or co-insurance is there as per the Affordable Care Act.

Though both types of carriers bill this vaccination differently, there must be two medical billing codes for this service – a code for the flu vaccine itself and a code for its administration. Majority of carriers including Medicare provide reimbursement for both codes (though some do not pay an amount separately for administration). In addition to these codes, diagnosis code and modifier (in certain cases) are required for billing the vaccination correctly. Let’s take a look at these codes for the 2013-2014 season.

Vaccination Codes

There are two types of vaccination codes, HCPCS Q-codes and CPT codes (9xxxx). Normally, the former is for Medicare patients and the latter is for non-Medicare patients. However, CPT codes are used for Medicare patients in certain cases.

CPT codes

  • 90653: Influenza vaccine, inactivated, subunit, adjuvanted, for intramuscular use
  • 90654: Influenza virus vaccine, split virus, preservative-free, for intradermal use
  • 90655: Influenza virus vaccine, trivalent, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use
  • 90656: Influenza virus vaccine, trivalent, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use
  • 90657: Influenza virus vaccine, trivalent, split virus, when administered to children 6-35 months of age for intramuscular use
  • 90660: Influenza virus vaccine, trivalent, live, for intranasal use
  • 90661: Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use
  • 90662: Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use
  • 90672: Influenza virus vaccine, quadrivalent, live, for intranasal use
  • 90673: Influenza virus vaccine, trivalent, derived from recombinant DNA (RIV3), hemagglutnin (HA) protein only, preservative and antibiotic free, for intramuscular use
  • 90685: Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use
  • 90686: Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use
  • 90687: Influenza virus vaccine, quadrivalent, split virus, when administered to children 6-35 months of age, for intramuscular use
  • 90688: Influenza virus vaccine, quadrivalent, split virus, when administered to individuals 3 years of age and older, for intramuscular use

HCPCS codes

  • Q2034: Influenza virus vaccine, split virus, for intramuscular use (Agriflu)
  • Q2035: Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria)
  • Q2036: Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)
  • Q2037: Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin)
  • Q2038: Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)
  • Q2039: Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified)

CPT code 90673 replaced Q2033 (Influenza Vaccine, Recombinant Haemagglutinin Antigens, for Intramuscular Use (Flublok)) on January 1, 2014

Administration Codes

  • 90471: Immunization administration (includes percutaneous, intradermal, subcutaneous or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid.) If giving two or more vaccines at the same visit, use 90471 for the first and 90472 for each additional vaccine administration
  • 90473: Immunization administration by intranasal or oral route; 1 vaccine (single or combination toxoid.) If giving two nasal/oral vaccines, use 90473 for the first and 90474 for each additional vaccine administration
  • 90460: Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component
  • +90461: Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine/toxoid component
  • G0008: Administration code for Medicare

Diagnosis Code and Modifier

The ICD-9 diagnosis code V04.81 (Prophylactic vaccination and inoculation against influenza) should be used for influenza vaccination. If Pneumococcus and Influenza vaccinations are given on the same date, then V06.6 (ICD-9 code) should be used. While giving a vaccination at a time when seeing that same patient for a medically necessary office visit, use a modifier 25 on the E/M code and map to a diagnosis code that explains the reason for the medically necessary office visit.

Commercial Codes for Influenza Vaccine Products for the 2013–2014 Influenza Season

Trade Name How Supplied Age Group Product Code
Afluria (IIV3) 0.5 mL (single-dose syringe)

5.0 mL (multi-dose vial)

9 years & older 90656

90658
Q2035 (Medicare)

Fluarix (IIV3) 0.5 mL (single-dose syringe) 3 years & older 90656
Fluarix (IIV4) 0.5 mL (single-dose syringe) 3 years & older 90686
FluLaval (IIV3) 5.0 mL (multi-dose vial) 3 years & older Q2036(Medicare)
FluLaval (IIV4) 5.0 mL (multi-dose vial) 3 years & older 90688
FluMist (LAIV4) 0.2 mL (single-use nasal spray) 2 through 49 years 90672
Fluvirin (IIV3) 0.5 mL (single-dose syringe)
5.0 mL (multi-dose vial)
4 years & older 90656
Q2037(Medicare)
Flucelvax (ccIIV3) 0.5 mL (single-dose syringe) 18 years & older 90661
Flublok (RIV3) 5.0 mL (single-dose vial) 18 through 49 years 90673
Q2033(Medicare)
Fluzone (IIV3) 0.25 mL (single-dose syringe)
0.5 mL (single-dose syringe)
0.5 mL (single-dose vial)
5.0 mL (multi-dose vial), 6 through 35 months

5.0 mL (multi-dose vial), 3 years and older

6 through 35 months
3 years & older
3 years & older
6 through 35 months
3 years & older
90655
90656
90656
90657

90658
Q2038 (Medicare)

Fluzone (IIV4) 0.25 mL (single-dose syringe)
0.5 mL (single-dose syringe)
0.5 mL (single-dose vial)
6 through 35 months
3 years & older
3 years & older
90685
90686
90686
Fluzone High-Dose (IIV3) 0.5 mL (single-dose syringe) 65 years & older 90662
Fluzone Intradermal (IIV3) 0.1 mL (single-dose microinjection system) 18 through 64 years 90654

Note: On August 6, 2010, the ACIP (Advisory Committee on Immunization Practices) recommended that Afluria not be used in children younger than age 9 years. Afluria may be considered for a child age 5 through 8 years at high risk for influenza complications, after risks and benefits have been discussed with the parent or guardian, If no other age-appropriate IIV is available; Afluria should not be used in children younger than age 5 years. This recommendation is relevant for the 2013–2014 influenza season.

It is very important for healthcare providers to check with the patients’ insurance plans which vaccine and administration code they would reimburse for. Since Medicare reimbursement rates change periodically, it is quite imperative to stay updated too. Giving focus to both patient care and billing procedures is relatively challenging for physicians as it may affect their productivity and revenue. Seeking help from a professional medical billing and coding company that offers family practice billing service is a better option to streamline the billing process and receive the due reimbursement in time. Next year, family practice physicians may also provide highly protective vaccine owing to the new predictive model and improve the quality of their services too.



Obesity Rates of ChildrenAs per the press release published in February 2014 by CDC, obesity prevalence among U.S. children aged 2 to 5 years dropped from about 14 percent in 2003-2004 to over 8 percent in 2011-2012 which points to a decline of 43 percent. The rates were computed on the basis of CDC’s National Health and Nutrition Examination Survey (NHANES) data. The CDC director said that this report came upon the heels of previous CDC data that showed a significant decrease in obesity prevalence among low-income children in the age group 2 to 4 years, who had been participating in federal nutrition programs. He also said there have been signs of obesity prevention programs in various communities around the country such as Anchorage, Alaska, Philadelphia, New York City and King County, Washington. The restrictions imposed by the Obama administration on marketing junk food and sugary drinks in schools are a noticeable approach towards obesity prevention.

The exact reasons for the decline in obesity rates is yet unknown. However, CDC cites some factors that may have played a significant role in reducing the rates. Over the past few years, several child care centers had started to improve the nutrition and physical activity of children. Also, the CDC data shows a decrease in sugar-sweetened beverage consumption among youth in recent years. The other factor is the improvement in breastfeeding rates in the United States as the chance of obesity in breastfed children is much less.

Even though the national study shows a significant drop in obesity rate, certain pediatricians are still concerned about the fight against childhood obesity as per a report published in HeraldNet. They opined although the new study is encouraging, the actual cause of the decline is still unknown. The study itself shows that there is not much progress among older children and hints about the ongoing efforts to keep kids at healthy diets. A study by BMC Health Services Research also points to the importance of primary-care based interventions in preventing childhood obesity. Both of them point towards the role of primary care physicians and pediatricians in reducing obesity rates among children. They should counsel children, recommend effective methods to improve their health behaviors so as to keep them on healthy diets.

However, physicians should document their diagnosis and the preventive measures they perform correctly so that the coders can assign appropriate codes and ensure the due reimbursements.

Codes Used to Report Childhood Obesity

The codes discussed here are only for preventive cases. The severe cases of obesity and treatment procedures are not included.

Diagnosis Codes (ICD-9)

V codes are used when circumstances other than a disease or injury are regarded as “diagnoses” or “problems”

  • V18.0: Family history of diabetes mellitus
  • V18.1: Family history of endocrine and metabolic diseases
  • V49.89: Other specified conditions influencing health status
  • V85.51: Body Mass Index, pediatric, less than 5th percentile for age
  • V85.52: Body Mass Index, pediatric, 5th percentile to less than 85th percentile for age
  • V85.53: Body Mass Index, pediatric, 85th percentile to less than 95th percentile for age
  • V85.54: Body Mass Index, pediatric, greater than or equal to 95th percentile for age
  • V58.67: Long-term (current) use of insulin
  • V58.69: Long-term (current) use of other medications
  • V61.0: Family disruption
  • V61.20: Counseling for parent-child problem, unspecified
  • V61.29: Parent-child problems; other
  • V61.49: Health problems with family; other
  • V61.8: Health problems within family; other specified family circumstances
  • V61.9: Health problems within family; unspecified family circumstances
  • V62.81: Interpersonal problems, not elsewhere classified
  • V62.89: Other psychological or physical stress not elsewhere classified; other
  • V62.9: Unspecified psychosocial circumstance
  • V65.19: Other person consulting on behalf of another person
  • V65.3: Dietary surveillance and counseling
  • V65.41: Exercise counseling
  • V65.49: Other specified counseling
  • V69.0: Lack of physical exercise
  • V69.1: Inappropriate diet and eating habits
  • V69.8: Other problems relating to lifestyle; self-damaging behavior
  • V69.9: Problem related to lifestyle, unspecified

Procedure Codes

CPT Codes

Health and Behavior Assessment/Intervention Codes

  • 96150: Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment
  • 96151: Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; re-assessment
  • 96152: Health and behavior intervention, each 15 minutes, face-to-face; individual
  • 96153: Health and behavior intervention, each 15 minutes, face-to-face; group (2 or more patients)
  • 96154: Health and behavior intervention, each 15 minutes, face-to-face; family (with patient present)
  • 96155: Health and behavior intervention, each 15 minutes, face-to-face; family (without patient present)

Medical Nutrition Therapy Codes

  • 97802: Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with patient, each 15 minutes
  • 97803: Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes
  • 97804: Medical nutrition therapy; group (2 or more individuals), each 30 minutes

HCPCS Codes

Education and Counseling Codes

  • S9445: Patient education, not otherwise classified, non-physician provider, individual, per session
  • S9446: Patient education, not otherwise classified, non-physician provider, group, per session
  • S9449: Weight management classes, non-physician provider, per session
  • S9451: Exercise class, non-physician provider, per session
  • S9452: Nutrition class, non-physician provider, per session
  • S9454: Stress management class, non-physician provider, per session
  • S9455: Diabetic management program, group session
  • S9460: Diabetic management program, nurse visit
  • S9465: Diabetic management program, dietician visit
  • S9470: Nutritional counseling, dietician visit

It is very important for physicians to have knowledgeable and experienced coders for assigning the codes correctly according to the documentation so that their claims won’t be subject to unnecessary delays due to inappropriate coding. Since even minor coding mistakes can be really expensive, physicians can seek the help of a professional medical billing and coding company that offers the service of AAPC-certified medical coders.



Documentation Elements for Coding Traumatic Fractures ICD-10Orthopedic practices face the challenge of inappropriate use of codes labeled ‘unspecified’ while coding traumatic fractures for ICD-10, since this medical coding system differentiates traumatic fractures from pathological fractures. The American Health Information Management Association (AHIMA) has already insisted that the healthcare practitioners should focus on their documentation to identify the gaps that need to be filled before the ICD-10 implementation on October 1, 2014. In such a scenario, it is quite imperative for orthopedic practices to understand the ICD-10 documentation requirements for traumatic fractures to resolve the coding challenges. The ICD-10 codes S00-T88 are used to report traumatic fractures. The key ICD-10 documentation elements for traumatic fractures are:

  • Location and Laterality (L) – The documentation must have the name of the bone and the exact location of the fracture on the bone along with information about whether the fracture occur on the right or left side of the body when appropriate. For example, if contusion of left shoulder is diagnosed and you document it as ‘contusion of shoulder’, then the ICD-10 code assigned will be S40.01, which is not an appropriate code. There is an ICD-10 code for ‘contusion of left shoulder’ (S40.012). The coder can report this correct code only if your documentation shows ‘contusion of left shoulder’.
  • Encounter (E) – In ICD, the term ‘encounter’ indicates the treatment status. Initial and subsequent are the two types of encounters specified in ICD-10. If the patient is already receiving active treatment for traumatic fractures, initial encounter codes are used (for example, evaluation by a new physician). When the patient is receiving care for traumatic fractures in recovery phase once the active treatment ends, subsequent encounter codes are used (for example, cast change or removal). Unless you specify the encounter type along with ‘contusion of left shoulder’, the coders will not be able to assign the most appropriate code from S40.012A (contusion of left shoulder, initial encounter) and S40.012D (contusion of left shoulder, subsequent encounter). Even so, it has not been yet clarified whether you must use the word ‘initial encounter’ and ‘subsequent encounter’ as such in the documentation. A statement to ‘follow-up with routine healing’ indicates subsequent encounter.
  • Open or Closed (O) – A statement that describes whether the fracture is open or closed must be included in the documentation. Suppose a patient is diagnosed with displaced open fracture of neck of scapula at right shoulder and is receiving active treatment. If you are documenting ‘displaced fracture of neck of scapula at right shoulder’ only, then the code assigned will be S42.151, which is not an appropriate code. You should document it as open fracture and indicate the patient is receiving active treatment so that the most appropriate code, S42.151B (Displaced fracture of neck of scapula, right shoulder, initial encounter for open fracture) will be assigned.
  • Classification, Category, or Cause (C) – This element points towards different things according to the location and type of fracture. For example, documentation for a physical fracture must require the correct Salter-Harris classification while a modified Neer classification is used to describe certain fractures of the proximal humerus.
  • Fracture Pattern (F) – The documentation must include the fracture pattern and fracture locations. The terms used to specify fracture patterns at various locations are transverse, spiral, greenstick, comminuted, oblique, longitudinal and segmental. An example of an ICD-10 code that requires fracture pattern is S82.232 (Displaced oblique fracture of shaft of left tibia).
  • Alignment (A) – The documentation must note the alignment of the bones (whether it is a displaced or non-displaced fracture). For example, the coders can choose the appropriate code from S82.232 (Displaced oblique fracture of shaft of left tibia) and S82.235 (Non-displaced oblique fracture of shaft of left tibia) in case of a oblique fracture of shaft of left tibia only with this information.
  • Result (R) – The results including routine healing, delayed healing, malunion, or nonunion must be documented at each encounter following the active phase of treatment for traumatic fractures. This information will help the coders to choose the appropriate code among S82.232D (subsequent encounter for closed fracture with routine healing), S82.232G (subsequent encounter for closed fracture with delayed healing), S82.232K (subsequent encounter for closed fracture with nonunion) and S82.232P (subsequent encounter for closed fracture with malunion) in case of displaced closed oblique fracture of shaft of left tibia.

Even if you produce accurate documentation by following these rules, coding mistakes may occur if the documentation is not handled by trained coders owing to the complexity of ICD-10 codes, and ultimately result in revenue loss. By seeking the help of a professional medical billing and coding company that offers the service of trained AAPC certified coders, you can minimize such kind of mistakes and receive the due reimbursement.



ObamacareIndividuals who have started applying for health coverage in federal insurance exchange HealthCare.gov and cannot complete the enrollment process by March 31 can ask for extension until about mid-April. Federal officials confirmed this on March 26, 2014, reports the Washington Post. The new rules will be applied to the federal exchanges in three dozen states. Under these rules, people can qualify for an extension by checking a blue box on HealthCare.gov. This method is based on the honor system and will indicate a particular person has already tried to enroll into a health plan before deadline. Technically, the new change won’t alter the deadline, but it will help those who face technical difficulties in the enrollment process at the last minute.

The reason why the Obama administration changed its mind about the deadline could be the surge of people trying to apply for health coverage in the final days before the deadline. USA Today reported that the federal officials anticipate a larger volume of last-minute enrollees and they don’t want to penalize those people who stuck upon ‘complex or extenuating’ circumstances that prevent them from finishing the enrollment by March 31, even if the website can handle the numbers. Several factors have been identified as responsible for the delay – the website’s technical problems, inability of applicants to calculate subsidies they are entitled to, need more time to gather family information, understand basic insurance terms, and check if their doctor is within the plan’s network.

As per government figures, around 5.2 million people signed up for private plans through insurance marketplace as of March 1. Washington state announced that more than 12,000 residents were enrolled into health plans in one week which is four times more than their average enrollment, while New York state saw an increase in enrollment by a whopping margin of around 16,000 people in a single week. The measures to manage this surge and give people the opportunity to gain the benefits of insurance marketplace plans even after deadline have been implemented in states like Minnesota. MNsure, Minnesota’s new health care exchange announced new procedures for Minnesotans which will allow them to get coverage and avoid a federal tax penalty even if they don’t finish their enrollment when the deadline expires. In any case, Minnesota enrollment exceeded 136,000 on March 25, exceeding the state’s goal of 135,000 set last October.

The extension of the enrollment deadline will result in more enrollments and the physicians would surely see a surge of patients once the enrollment period ends and coverage starts. Opting for outsourced medical billing services would be a good idea in the circumstances as a professional medical billing company can handle the heavy claims volume and maximize reimbursements.

As per a Health and Human Services official, an actual time frame has not been set for extension period and it will depend on how many people ask for the extension. However, CMS set April 7, 2014 as the deadline for paper applications, which will give people a few days after the original deadline.



Sign Up for Health Insurance NOW

Posted by on March 28, 2014 5:16 am

Health InsuranceThe deadline is March 31, 2014! It’s coming soon, in a little more than a week, and you need to sign up for health insurance before it gets too late.

With insurance exchanges, the Obama administration has made it quite easy for individuals and small businesses to compare and select plans. The Healthcare.gov website is where you need to go to get the lowdown. You could just fill in your basic information and select the plan that’s right for you. Here are just some things you need to consider.

Information at the Healthcare.gov Website

To make use of the Health Insurance Marketplace you need to fill out a Marketplace application. This will give you access to a range of information including:

  • Plans covering essential health benefits
  • Preventive care and pre-existing conditions
  • Previews of plans that are available in your state or region
  • Lower costs that are based on the size and income of your household

You’ll have all that data here plus information on Medicaid’s eligibility expansion, whether it is applicable for your state, and CHIP (Children’s Health Insurance Program).

What if You Don’t Get Health Coverage

The penalty for not having health coverage in 2014 could be $95 per adult or 1% of the income you earn, whichever is higher, payable on your income tax from 2015. For kids the penalty in $47.50. So you better get yourself health coverage by enrolling at the Marketplace right now since enrollment period ends on March 31, 2014.

Are There Options beyond Open Enrollment?

After March 31 you cannot get yourself private health insurance within the Marketplace till the start of the next phase of open enrollment which is for 2015 coverage. If you wish to get health plan outside the Open Enrollment, you need to be qualified for the special enrollment period, details of which you can get on the Healthcare.gov site.

For 2015 coverage, the open enrollment period is between November 15, 2014 and February 15, 2015.

So get going and we wish you, as an individual or a small business, all the best to select the right health coverage.



Social Security BenefitsAccording to the Social Security Administration (SSA), social security benefits will be increased to a certain percentage depending upon your DOB (date of birth), if you hold off the benefits until after your normal retirement age. The benefit amount will be increased until you start receiving the benefits or reach 70 years of age. So what if you want to retire early? Does it entail losing thousands of dollars earned during the period between the stipulated retirement date and the full retirement age? If you have completed 35 years in your profession, it will not have a major impact on your social security benefits even if you are retiring before your normal retirement age.

To be more specific, the Social Security Administration calculates the amount of retirement benefits according to the workers’ wage history using their average indexed monthly earnings, or AIME. As per the current formula, the AIME is computed on the basis of workers’ earnings subjected to Social Security taxes during their highest 35 years of earnings. If a person has worked less than 35 years, the average will include years with zero earnings. Thus, if you retire before 35 years at an age less than full retirement age, it can seriously impact your social security benefits.

CNN money gives a good example to illustrate this. Consider a person retiring at 63 instead of at the full retirement age 66. If he makes $100,000 at 63 and received a 3% rise annually over 35 years of working, continuing for three more years would raise the monthly benefit to $41 or 1.6%. However, if that person makes the same amount of money and has worked only 32 years, leaving early would involve losing more because he will be losing $119 a month or 4.8%.

The Congressional Budget Office (CBO) plans to lengthen this AIME computation period to three years as an option to reduce the deficit: 2014 to 2023, which will take effect in January 2015. The averaging period will be extended to 36 years for people who will turn 62 in 2015, to 37 years for people who will turn 62 in 2016, and to 38 years for people who will turn 62 in 2017 and beyond. This extension of the computation period would reduce the benefits by requiring that additional years of lower earnings be counted in the benefit computation. This option would not change the number of years used to calculate AMIE amounts for disabled workers. However, retirement benefits would be affected. This option would impact people who worked for less than 38 years, since additional years with no earnings would be included in the benefit calculation. It would reduce the benefits for people who worked 38 years or more since they would have lower average earnings when it comes to the additional computation years than they would have in their highest 35 years of earnings.

An argument quoted by CBO for extending the computation period is the increased life expectancy of people. As the life expectancy increases, the number of aging people will also increase. As a result, there will be increased spending for Social Security as increase in Medicare at the same time (As per SSA, if you are receiving Social Security benefits when you turn 65, your Medicare Benefits will begin automatically). It is estimated that the combined spending on Social Security and Medicare will rise from 8% of the national income (gross domestic product) to 13% from 2004 to 2030. CBO estimates extending the computation period to three years would reduce federal outlays by $43 billion through 2023.

Since the Medicare premiums are deducted from social security gross amount, healthcare providers should have an understanding about the AIME computation period of their Medicare patients. As it is a tedious task, they can seek help from a professional medical billing company having expertise in medical billing and insurance verification to verify the patients’ documents.



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