Since the implementation of the No Surprises Act (NSA) in January 2022, out-of-network (OON) reimbursement has become a complex and resource-heavy challenge for hospital and health system revenue cycle leaders.

Although designed to shield patients from unexpected medical bills, the legislation has placed continuous financial pressure on physician practices and hospital systems. It has led to delayed payments, operational burdens, and strained resources.

In this episode of the CodeCast Podcast, Terry runs through how the NSA works not only for your RCM staff but also how she dealt with a personal “balance bill” for the win!

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Medical necessity is defined as services that are reasonable and necessary for diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body member and are not excluded under another provision of the Medicare Program.

Unfortunately, we have many practices trying to slide under the radar the experimental and/or investigational services that are considered not medically necessary or a covered benefit under most payers. Terry discusses the ins and outs of this practices and how to make sure you are not falling into a false claim trap.

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The post Medicare Rules For Experimental or Investigational Services appeared first on Terry Fletcher Consulting, Inc..

Terry discusses Behavioral Health services, best practices documentation and coding specifics. Also, Terry offers some bonus discussion on RAC auditors trying to bait providers into not responding to ADR requests.

Check out this episode for intel on these important topics and more.

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The post Behavioral Health Coding and Documentation appeared first on Terry Fletcher Consulting, Inc..

With all of the AI implementation into EHR and EMR systems, there is concern about how providers rely on these AI shortcuts more than ever. Without proper safeguards, accountability, and compliance perimeters, relying on AI could be problematic.

Terry discusses the red flags to look for and how to proceed with caution in this new world of technology.

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The post Did you know AI is integrated into EMRs? appeared first on Terry Fletcher Consulting, Inc..

The 2023 CPT® Errata and Technical Corrections added a one-liner on Independent Interpretations that responds to the question, “Can a practitioner get credit for both ordering and interpretation of a test, if documented?”

In this episode of the CodeCast podcast, Terry answers this question referencing the March 2023 CPT® Errata and Technical Corrections. She also covers the reality of this change and what an independent interpretation means, so that you are not upcoding based on assumptions.

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The post Can you get credit for ordering and interpretation of a test? appeared first on Terry Fletcher Consulting, Inc..

The 2021/2023 E/M guideline revisions read: “The evaluation and/or treatment should be consistent with the likely nature of the condition.” Before this, the CPT® guidelines did not discuss medical necessity. Guidance was left to the payers, particularly Medicare, via the Social Security Act.

CMS’s guidance doesn’t necessarily hold regulatory authority. However, it often reflects a new, shared understanding that medical services reported should meet documentation standards for level selection. Those standards should also appropriately indicate why the patient is visiting the provider, based on the presenting problems.

This episode of the CodeCast echoes Terry’s insights that auditors, coders, and medical professionals focus on medical necessity first, then look to coding.

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The post Medical Necessity Comes Before Coding appeared first on Terry Fletcher Consulting, Inc..

It’s time for another round of frequently asked questions as Terry’s expertise covers orthopedic surgery, imaging, data points for E/M, and administrative charges for practices.

She also answers questions relating to multiple E/Ms on the same date by the same and different physicians from the same group practice.

Tune in for a lot of good information covered on this week’s show.

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The post Top 10 Tuesday Q&A – Coding, Billing, and Compliance Questions appeared first on Terry Fletcher Consulting, Inc..

We all know the age-old question, “Where does it say that?” In this episode, Terry brings receipts, explaining it’s been this way since 2003:

“Reviewing results of laboratory tests, phoning results to patients, filing such results, etc., are Medicare-covered services. Payment is included in the physician fee schedule payment for the evaluation and management (E/M) services to the patient. The CPT lists different levels of E and M services for both new and established patients and describes services that are included as E/M services. Such activities include obtaining, reviewing, and analyzing appropriate diagnostic tests.”

Tune in to this episode for an in-depth discussion as Terry details trying to report a telehealth visit for giving test results may be considered double-dipping: and can get you into hot water!

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The post Giving Tests Results to Patients… Where’s the Payment? appeared first on Terry Fletcher Consulting, Inc..

An ADR (Additional Documentation Request) is a request from CMS or another insurance payer for additional documentation to review a claim. Most of these requests come from payer investigative units looking for medical necessity support.

Terry discusses how to handle these requests, as well as how to ensure they are addressed promptly to meet the deadlines typically associated with them.

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The post ADR Workflow Tips appeared first on Terry Fletcher Consulting, Inc..

If the provider discusses their preferred management options with the patient, do they receive the “risk” credit even if the patient declines it? If yes, how long do they get to capture it?

Terry breaks down, citing references, how to handle this MR element and ensure the providers are receiving the correct “risk” value for their encounter. Listen to this episode for all of the details.

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The post Who Gets the Credit for MDM Risk Element? appeared first on Terry Fletcher Consulting, Inc..