Tip of the month

September ~ 2017

The easiest procedures to get quick payments on by medical benefit plans are exams/consults, radiographs (orthopantograms, occlusal films, Waters' views, and CT scans), biopsies/excisions, OSA and TMD appliances, and wisdom tooth extractions. That is how you start. DO NOT plunge into medical billing by starting with complex surgical procedures- you will make TONS of mistakes and eventually any payments issued to you will stop. Use The Z Method (c), step by step, and do not eliminate ANY steps. That is what our 22 years of success is based on. Just do it!

August ~ 2017

When a patient has a medical condition/current or past treatment/is taking medication that affects the oral cavity or dentition, be sure to request confirmation of same from the patient's primary care physician and then attach the documentation when requesting pre-certification, or with the claim, once treatment has been completed.

July ~ 2017

One of the ways to pretty much guarantee a “slam dunk” for payment of a surgical claim, is to include a pathology report as part of your documentation.

Any time that you remove contents of an abscess, inflamed tissue, a cyst, or any pathology during a surgical procedure, be it periodontal surgery, placement of implants, extractions, etc., send the specimen to your pathology lab. Ask them to include the ICD-10 code on the report, if they are not already doing so, then include that diagnosis code and bill the biopsy/excision code on your claim form as well. And don’t forget to mention the removal in your operative report!

June ~ 2017

It is critical that your operative report include a brief medical history, highlighting all points that are relevant to the presenting condition being treated during the current surgical session.

Example: Patient Surgery includes bilateral “sinus lifts” and multiple
implants in the Maxilla

Patient Clinical Presentation and Medical History:

Patient X presented with severe atrophy of the posterior maxilla, bilaterally, bilateral pneumatized maxillary sinuses, and diminished quality of life, due to an inability to properly masticate and digest food consumed. This had led to severe weight loss and general weakness, lethargy, and depression. Medical history includes hypotension and hypothyroidism. Patient X also has a current kidney infection. Rx and OTC meds include Etilefrine, Nexium, Synthroid, Cipro, a multivitamin, and a calcium supplement.

Medical History, as it appears in the Operative Report:

Patient X presents with severe atrophy of the posterior maxilla, bilaterally, bilateral pneumatized maxillary sinuses, and diminished quality of life due to an inability to properly masticate and digest food consumed. This had led to severe weight loss and general weakness, lethargy, and depression.

NOTE WHAT IS/IS NOT INCLUDED in the Op Rpt history.

May ~ 2017

Most dental patients count on their dental/medical benefits to help them pay for treatment that is needed. Those dentists that have tapped into medical benefits and use this very valuable tool to help their patients pay for their care, find that this has also lead to an increase in treatment acceptance, leaving the miniscule dental benefits for strictly “dental” procedures. Typically the insured (Subscriber/Patient) assigns medical/dental benefits to the Provider, so that the insurance company can then send payments directly to the Provider. Oftentimes, once the claim is processed, this payment is made in error, either deliberately or inadvertently, for many common reasons.

The contract for medical/dental benefits is one that exists between the insured member and the insurance company. The Provider, in this case the Dentist, is the third party creditor. When the Provider is mistakenly paid, followed by a request for a refund to the insurer at a later date, the question always arises: Is the Provider legally obligated to reimburse the monies back to the insurance company, when the Provider has rendered the services to the Subscriber/Member in good faith and expects to be paid for his/her services?

There are several angles that the courts have considered when determining liability for repaying an overpayment. One of them is called the “Restatement of Restitution” and it states, “Equitable concepts of unjust enrichment dictate that when a payment is made based upon a mistake of fact, the payor is entitled to restitution unless the payee has, in reliance on the payment, materially changed its position. (Rstmt., Restitution (1937) § 1.)”1 There can be exceptions to this rule. Section 14(1) of the Restatement of Restitution, which provides an exception to the general rule of restitution when a payment is mistakenly made, states the following:

“A creditor who has innocently received payment of a debt from a third party is under no duty to make restitution to the third party if it is later discovered that the third party had no responsibility to make the payment and payment was made solely because of the third party's mistake.” The court, in determining who should suffer the loss, placed the burden on the insurance company, because it was the only party in a position to know the policy provisions and its liability under the contract.”2

There are many other situations in which take-backs or refund requests have been denied by the Courts. DON’T PANIC! Before writing a check- STOP, take a deep breath, and contact us. We can help you fight take-back and refund demands by auditing your records and identifying the appropriate response, prior to any other actions that you may take. Let us know how we can help- the laws are on your side! Contact us for further details: thezgroupllc@gmail.com.


1City of Hope Nat. Medical Center v. Superior Court, 8 Cal. App. 4th 633, 637 (2d Dist. 1992)

2Rstmt. Torts, Restitution, § 14(1), p. 55 (1937)

April ~ 2017

OSA appliances that are billed to either commercial plans or to Medicare now require that you indicate TWO HCPCS modifiers. HCPCS is the Medicare code set that is applicable to both types of plans, when billing these appliances.


The two modifiers are KH and NU. Modifier 99 does not precede these codes.


Do NOT use modifier 26 if the lab is billing you. It is ONLY used when the lab will be submitting a separate bill/claim to the insurer.


Please refer to the 2017 “Z Book”, Procedures section/Modifiers, for additional information.

March ~ 2017

DOCTORS- Are you performing procedures using moderate conscious sedation and providing the sedation yourself? Then make sure you are aware of the CPT code changes that went into effect on January 1 2017. You can no longer use 99144-99145 when treating a patient over the age of 5. These codes, among many others in the anesthesia section, are now obsolete. The replacement codes are 99152 and 99153, but they do not have the same descriptions are the deleted codes. Here is the information that you need to know:


99152             Moderate conscious sedation, by surgeon, first 15 minutes

99153                         each additional 15 minutes


All offices that have purchased the 2017 recently received an e-blast informing them of the coding updates that went into effect after the 2017 “Z-Book” went into print.



February ~ 2017

We are seeing a decrease/lengthy delay in payments to offices that are not following the step-by-step Z process for medical billing. Skipping steps is detrimental to your success.

Many offices are also not properly credentialed with medical insurers.

Be sure you have done the following so that payments to you are accurate and prompt:

1. Credentialing with CAQH, NPPES, updated NPI data;
2. Benefits and eligibility verification done online prior to ANY procedure on Dr. Z's Top Ten List;
3. Documentation submitted with the claim, for all procedures (other than the claims for exams/consults/orthopantograms) must include documents mentioned on pages 7-33/7-34 in the Claim Completion section of the 2017 Z book;
3. Pre-certification/authorization on file prior to performing each procedure, as required by the Subscriber's plan:

i. phone pre-cert for CT scans with authorization number provided by RN;
ii. written authorization from Medical Review for elective surgical procedures;
iii. Botox authorization, in writing from Pharmacy review.

IN ADDITION, all BCBS plans now require a written authorization for TMD appliances. Many insurers now also require that you notify them within 48 hours of all EMERGENCY procedures.

NOTE THAT payments from Insurers should be received within a month, at most, from Commercial payers, for basic procedures (exams, X-rays, biopsies/excisions, appliances). For Medicare, it is slightly longer.

For higher dollar procedures, where all documentation and any additional requested information has been sent, payments should be received within 3 months.

If you need help with any of these issues, please complete the Contact Form here: http://www.thezgroupllc.com/form.html. Also, check out our support packages (under the "Support" tab on our web site, thezgroupllc.com). Support options do not require any long term commitment when signing up for one/more of the support options.

January ~ 2017

You may have recently received a request to provide information about your practice/doctors to HEDIS. This clarifies what that request is all about:

The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. Altogether, HEDIS consists of 81 measures across 5 domains of care. Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans on an "apples-to-apples" basis.

You do not need to complete the form- that is not a mandatory requirement and is strictly voluntary at this time.

December ~ 2016

If you have been frustrated by Medicare audits requesting refunds on Medicare overpayments that you billed/collected three years ago, that frustration is now extended an extra two years. Medicare now has a five year "lookback" period to come after overpayments that were made to you. This went into effect in 2012, although most offices are unaware of this extended time period for return of monies received from Medicare.

Because Medicare was unable to collect over $332 million in overpayments due to the three year restriction, constraints and limitations for auditing and requesting overpayment were increased to, and are currently, 5 years.

Our Advice: If you receive an overpayment (compared to Medicare fees that you normally receive for specific procedures), return the overpayment immediately so that you do not have to deal with recoupment requests and frustration down the road.

November ~ 2016



Often there is confusion as to whether to code for a NEW or ESTABLISHED patient, when there are multiple general and specialty practitioners in the same group. This is how you determine the appropriate coding for examinations and consultations:


Has the patient received any service/treatment

from the Doctor, or another Doctor in the group

 of the same specialty in the last THREE years?


If NO, then code for a NEW patient.


If YES- is it the EXACT SAME specialty?


If NO, the code for a NEW patient.


If YES, is it a provider in the exact same SUB-specialty?


If NO, then code for a NEW patient.


If YES, then code for an ESTABLISHED patient.


Simple as that!


ALSO, keep in mind that consistently coding at a level 4 or 5 pretty much guarantees that you will be audited, unless your documentation clearly indicates that you are, in a majority of cases, treating severely medically compromised patients, or those that have sustained serious traumatic injuries.

October ~ 2016

ALL BCBS plans now require pre-certification of TMD claims (not nightguards). Be sure to submit your detailed TMD report, together with your LMN, when doing so.
This applies to ALL branches of BCBS, including Anthem, Highmark, Premera, Blue Shield, and metallic (Obamacare- Platinum, Gold, Silver, Bronze) plans.

September ~ 2016


Most dental offices are not familiar with medical insurance acronyms, nor the cost savings by filing electronically to medical plans, including Government plans (Medicare and TriCare). In order to help you understand what they're talking about, here are some common acronyms with which you should be familiar:

Electronic remittance advice (ERA)

ERA is a HIPAA-compliant electronic communication that contains claims payment information. It replaces the paper Explanation of Benefits (EOB) statement. Depending on your accounts receivable software, you may be able to post payments electronically without any manual intervention.

ERA is available for all benefit plans. You can receive separate ERA files for the same tax identification number (TIN) grouped by billing address. Once enrolled in ERA, you can access a printable version of the ERA to make it easier to submit coordination of benefits (COB) claims and view ERA files. To accept ERA files, you must use software and a vendor capable of accepting ERA files from Insurers.


Electronic funds transfer (EFT)

EFT lets Insurers send claims payments directly to your bank account.

EFT offers you a secure, efficient process for electronically depositing claim payments into your bank account(s). It’s most insurers preferred provider payment method. With EFT, you can:

• Get paid faster than by paper check

• Get confidential and secure deposits of claims payments transmitted directly to your designated bank account(s)

• Reduce mail coming to your office and handling time by your staff and eliminate the need for trips to the bank — it also saves paper and creates an audit trail

• Easily verify payments by matching them to submitted claims on an ERA or electronic Explanation of Benefits (eEOB) from the Insurer's secure provider website

• Enroll in EFT e-mail notification and receive e-mails when payments are transmitted to your bank account(s)


IMPORTANT: Getting EFT doesn’t change your payment frequency. To accept payments by EFT, your financial institution must be part of the ACH Network. Ask your financial institution if they’re part of the ACH Network. Insurers don’t charge you to accept EFT payments, but your financial institution may charge you a small fee. Check with them for more information.

NOTE: ERA/EFT options are available to both participating and nonparticipating providers, and you don’t need to have a vendor/clearinghouse to participate. Once enrolled in ERA, Insurers will shut off your paper EOBs within 30 days. You have the option to enroll for EFT only and stop receiving paper checks.

You can enroll in EFT only: Electronically using EnrollHub™, a CAQH Solution™, athttps://solutions.caqh.org (Registration is required even if you’re an existing CAQH user.)

Most payments are grouped by payee and are sent on a weekly basis. Payments from Medicare Advantage plans are sent daily, separated by pay-to provider or facility. Adjustments you’ll see on an ERA Reprocessed claims report. When a claim is reprocessed, you will see a reversal of the initial claim and then a correction.

Here is how you can benefit, based on the average dental office seeing 100 patients a month for exams and consults alone:

Provider Electronic Savings Calculator

Look how much you can save by doing business electronically instead of on paper or by telephone!
Manual Cost
Electronic Cost
Provider Savings
Per Transaction
$4.80$0.87$3.93Eligibility & Benefits Verification
$7.17$2.47$4.70Precertification Requests
$1.36$0.35$1.01Claim Submission
$2.85$0.99$1.86Claim Status Inquiry
$3.52$2.41$1.11Claim Remittance Advice
$1.52$0.96$0.56Claim Payment

If you have any questions, just contact us! Andrea.thezgroupllc@gmail.com.

August ~ 2016


When pre-certifying CT scans (referred to as Diagnostic radiographs), you will be talking directly with an RN, who can authorize the procedure (by phone- this is not done online) in under 2 minutes. Yes, you read that correctly- under two minutes. But you must be prepared! She/he will ask you questions, including some/all of the following:

1. What symptoms does the patient have?
2. What medications is the patient taking?
3. What did the screening radiograph show?
4. Why is the CT scan necessary?

Our experienced consultants, who all currently work as billers in their respective practices and have gone through extensive training with Dr. Z herself, have never had a CT scan denied. WHY? Because they know the Rules and Requirements pertaining to CT scans and all medically billable procedures! You must follow Z Group protocols and be prepared with a Comprehensive Head and Neck Evaluation (both extra- and intra-oral) performed by the Doctor, evaluating the patient from a medical standpoint. You can easily sign up for support with an available consultant familiar with the insurance companies in your area. (The Comprehensive Head & Neck Evaluation- 5 pages- is found on the Superbills CD, together with other very necessary information and forms).

July ~ 2016

Let your patients know. Soon to be a Federal Law. EDUCATE YOURSELVES ON THE MEDICAL BILLING OF OSA APPLIANCES to Commercial and Government Insurance Plans!!!

Feds inching toward implementing possible sleep apnea screening for truckers

By Melinda Carstensen

Published June 16, 2016



Soon, the federal government may require all commercial truckers, bus drivers and railroad workers to undergo screening for obstructive sleep apnea (OSA), a disease that can lead to drowsy driving and increase the risk of crashes. The Department of Transportation’s (DOT) Federal Railroad Administration (FRA) and Federal Motor Carrier Safety Administration (FMCSA) are taking the first step toward that potential rule, which could also mandate treatment for those diagnosed, by gathering public comments until July 8.

“It is imperative for everyone’s safety that commercial motor vehicle drivers and train operators be fully focused and immediately responsive at all times,” U.S. Transportation Secretary Anthony Foxx said in a statement in March, when the DOT announced the proposal. “DOT strongly encourages comment from the public on how to best respond to this national health and transportation safety issue.”

While sleep experts say the rules would promote public safety as well as commercial operators’ wellbeing, some associations have criticized the idea, questioning the validity of reported OSA and fatigue statistics, and arguing current medical examinations that rely on self-reporting are sufficient.

It’s unclear whether such a mandate would apply only to current drivers, and what the consequence of a diagnosis would mean for their jobs. It also is unknown whether the rule would be used as a screening tool to determine future drivers’ job acceptance. Duane DeBruyne, a spokesman for the FMCSA, said the agencies could not comment on the proposal during the public commenting period.

The FMCSA has already recommended that commercial drivers undergo screening for OSA. In 2013, the trucking lobby prompted Congress to require a formal process before such rules are implemented. However, data suggests sleep apnea may be a large contributing factor to fatigue-related crashes.

A November 2014 report by the AAA Foundation for Traffic Safety estimated drowsy driving causes 328,000 crashes, 109,000 injuries, and 6,400 deaths each year. Commercial drivers are more likely to drive drowsy, according to the Centers for Disease Control and Prevention (CDC).

Pilots are already screened regularly for OSA, but there’s no formal screening for the disease in place among truckers and railroad workers. The National Transportation Safety Board (NTSB) has found sleep apnea to repeatedly be a culprit in commercial driver crashes. Investigators found an undiagnosed case of sleep apnea led to the Dec. 1, 2013 Metro-North train derailment in the Bronx that killed four people and injured 60. The engineer had fallen asleep while operating the train.

A study conducted by the University of Pennsylvania and sponsored by the FMCSA and the American Transportation Research Institute (ATRI) of the American Trucking Associations found that about one-third of commercial truck drivers have mild to severe sleep apnea. The Cleveland Clinic estimates as many as 80 percent of OSA cases nationwide go undiagnosed.

“What we know is that for commercial drivers with obstructive sleep apnea who are treated …. we see a 73 percent reduction in preventable driving accidents,” Dr. Nathaniel Watson, immediate past president of the American Academy of Sleep Medicine, and a board certified neurologist and sleep specialist, told FoxNews.com.


 “One of the biggest problems of [OSA] is excessive fatigue,” Watson said, “and so clearly for anybody working in a safety-sensitive position where alertness is crucial to public safety, this is the type of illness that would be a major public health concern if it were not addressed.”

Watson referenced a recent report by the market research firm Frost & Sullivan that analyzed the cost of undiagnosed versus diagnosed OSA. Data suggested the economic cost of an individual having OSA would be $6,300 on average without a diagnosis, but $2,501 if he or she is diagnosed. The analysis accounted for health care utilization, increased insurance premiums, workplace absences and decreased productivity.

He pointed out that sleep-apnea not only is linked to daytime drowsiness, but also to an increased risk of cardiovascular disease, diabetes, mental illness, obesity and high blood pressure.

“The disease is costing people money whether they treat it or not,” Watson said. “They can pay more, and be dangerous and have a lower quality of life, or they can pay less, and be safer on the roadways and have a higher quality of life in the long run.”


June ~ 2016
When a pre-cert or claim for payment is denied, it is worth appealing only twice to the Provider of Benefits (Insurance Company), once to Director of Medical Review, and the second time to the Plan Administrator. These are the only people who have authority to override the previous medical denial. If your claim is still denied for no reason that makes sense to you, based on the patient's situation and documentation that was submitted by your office, then you should file a complaint to one of these parties, depending on the type of plan you are dealing with:

1. a standard policy- file complaint with the Director/Commissioner of Insurance for the state in which the employer is located (where the claim was filed); this can be done online or by mail (see Z book, Appeals section, for web and mailing addresses). Submit all documentation that your office provided and insurance company correspondence/responses;

2. an ERISA policy- engage the patient's HR department and get the patient involved. If there is little/no cooperation from HR, file your complaint with the US Department of Labor. We have found this to be enormously beneficial, with excellent results. Here is the web site link: http://www.erisaclaim.com/Appeal_Department.htm;

3. a TriCare policy- follow the appeals protocols, found on the TriCare web site:  http://www.tricare.mil/ContactUs/FileComplaint?sc_database=web

4. a Medicare policy- follow the appeals protocols, found on the Medicare.gov web site: https://www.medicare.gov/forms-help-and-resources/forms/medicare-forms.html

If the appeal is for an underpayment of all or part of a claim, then contact the Supervisor in Claims Adjudication (by phone) or file a written appeal for additional monies owed. Use the appropriate template letter in the Appeals section of the 2016 "Z book".

May ~ 2016


Most BCBS plans (Anthem, Premera, Highmark, Wellmark, etc) are no longer accepting Modifier 50 on one line. This is what is now recommended:

The first line should include the descriptive modifier i.e. LT (left side) or RT (right side). Modifier 50 should be the modifier used in the first modifier position on the second line, with the descriptive modifier in the second position.

If a provider bills a bilateral surgery to any BCBS plan on one line with modifier 50, the payment will reflect one half of one side. A corrected claim must then be submitted to obtain correct payment.

To indicate that an alveolectomy was performed bilaterally in the maxilla, it would be coded as follows:

41830 RT

41830 50 LT

April ~ 2016

Modifier 79 is defined by CPT as “unrelated procedure or service by the same physician during the post-operative period.” It is used in the strictest sense for care that is entirely unrelated to the prior surgery that created the current global period.

When performing the identical procedure(s) in a different part of the mouth, but within the "global surgical package" post-operative time frame, be sure to add modifier 79 to each procedure line to indicate that the procedures are unrelated to the first surgery. Also make sure this is pointed out, and made VERY clear, in your LMN.


Medicare now requires pre-certs for OSA appliances, part of the DME category of procedures.
They will no longer be paid without a pre-cert, starting March 1 2016.


Many insurers no longer recognize surgical modifier 59 (separate and distinct surgical procedure, in another location, separate body part or organ), or pay it incorrectly as a secondary/additional procedure, if they pay at all.

It is now strongly suggested that you use modifier XS instead.


CMS finalizes rule requiring prior authorization for DME, effective MARCH 1 2016

Centers for Medicare and Medicaid Services finalized a rule Tuesday December 29 2015  that requires prior authorization before Medicare will pay for certain wheelchairs, prosthetics, orthotics and other medical equipment – sources of Medicare fraud and improper payments for years.

The rule mandates prior authorization for some durable medical equipment, prosthetics, orthotics and supplies, known as DMEPOS. The rule “states that the documentation to meet authorization for DMEPOS is needed earlier in the process in order to furnish the items....”

The final rule was published in the Federal Register Dec. 30 2015 and will be implemented within 60 days. FYI that means March 1 2016.


Tip #1-Physician Quality Reporting System/WHAT ALL MEDICARE PROVIDERS MUST KNOW

The Centers for Medicare and Medicaid Services (CMS) have  several quality initiatives that provide information on the quality of care across different settings, including hospitals, skilled nursing facilities, home health agencies, and dialysis facilities for end-stage renal disease. The CMS believes these quality initiatives aim to empower providers and consumers with information that would support the overall delivery and coordination of care, and ultimately would support new payment systems that rewards physicians for providing improved quality care, rather than simply paying based on the volume of services.

Under the Tax Relief and Health Care Act of 2006 (TRHCA), CMS implemented the Physician Quality Reporting Initiative (now called Physician Quality Reporting System (PQRS)) with a bonus payment of 1.5 percent for successful participation based on the estimated total allowed charges for all cover services during the reporting period. Physicians and nonphysician providers who participate in the program transmit data to CMS regarding the quality measures reported on in caring for their Medicare patients. Under the Medicare Improvement for Patients and Providers Act of 2008 (MIPPA), the PQRS program was made permanent. MIPPA also required CMS to post on a website the names of eligible professionals and group practices who have satisfactorily reported under the PQRS. This information, along with additional measure performance information, is now posted on the Medicare Physician Compare website.

Several PQRS program changes were included in health care reform legislation enacted in 2010. The Affordable Care Act (ACA) requires the implementation of timely feedback and the establishment of an informal appeals process by 2011. The ACA also calls for PQRS payment penalties starting in 2015. CMS finalized in its 2012 Medicare Physician Fee Schedule rule that 2015 program penalties are based on 2013 performance. Therefore, those physicians who elect not to participate or are found unsuccessful during the 2013 program year, will receive a 1.5 percent payment penalty, and 2 percent thereafter. In the 2014 Medicare Physician Fee Schedule Rule, CMS finalized its proposal to base 2016 PQRS penalties off of 2014 reporting. Therefore, physicians who did not participate in PQRS in 2014 will receive a 2 percent penalty in 2016. 2014 was the last year a physician could receive an additional incentive for participating in the PQRS Maintenance of Certification (MOC) program or receive an incentive for participating in PQRS. In the 2015 Medicare Physician Fee Schedule Rule, CMS finalized its proposal to base 2017 PQRS penalties off of 2015 reporting.

The American Taxpayer Relief Act (ATRA) required the development of an additional PQRS reporting option in 2014. This option allows physicians to submit data to CMS through a qualified clinical data registry (QCDR) and physicians will once again have the QCDR option in 2015. View the National Quality Registry Network (NQRN®)’s Information Guide to the QCDRPDF FIle.

The chart below provides more information on the timing of PQRS penalties. Details regarding improved PQRS feedback, an informal appeals process, and PQRS penalties can be found on the CMS website.

Medicare Physician Quality Reporting System Incentives and Penalties

20130.5% (performance year for 2015 penalty)
20140.5% (performance year for 2016 penalty)

Tip#2-Master ICD-10 & Get Your Claims Paid! A month after implementation of ICD-10, it’s time to take a deep breath and look back and look forward. Between Oct. 1 and Oct. 27, Medicare processed 4.6 million ICD-10 claims per day, and most of them were denied due to an invalid ICD-10 code. Make sure that you are following the advice and examples in the Z book!

November 2015~
Medical insurers are no longer accepting code S8262 Mandibular Orthotic Repositioning appliance, as of July 2015. In it's place, please note the changes in coding that are included in the 2016 "Z Book"> Alternative codes can be either 20999 or 21299, with ZZ and JO qualifiers. As well, HCPCS code E1399 can be used with modifier NU.

October 2015~

ICD-10 Coding to Be Implemented Oct. 1, 2015 – Facts for Employees

The U.S. Department of Health and Human Services (HHS) has ruled Oct. 1, 2015, as the compliance date to implement version 10 of the International Classification of Diseases (ICD-10). All HIPAA-covered entities, including health plans, providers and billing services, are required to use the new codes.

Every medical diagnosis and procedure has a unique ICD medical code describing a condition. ICD-10 has almost six times more codes than the current version – providing more detail, which can be useful for sharing a patient’s medical history and supporting effective treatment. ICD-10 also helps capture global health data and analytics for research, as well as tracking epidemics like Ebola and SARS.

Blue Cross and Blue Shield of Illinois (BCBSIL) has made significant investments toward ICD-10 implementation for several years. We have updated more than 20 software system versions, trained staff members and conducted end-to-end claims processing tests with hundreds of network providers. We expect to successfully transition to ICD-10 by Oct. 1, 2015.

Because of the complexity of the ICD-10 implementation, you might get some questions. Feel free to share the Quick Facts below with your employees.

Quick Facts

  • ICD-10 implementation is among the largest initiatives in health care in more than a generation.
  • Every medical diagnosis and procedure has a unique ICD medical code describing a condition.
  • Because ICD-10 has almost six times more codes than the current version and includes greater specificity, it may take time for consistency in coding claims to be achieved across the industry.
  • It is expected that some claims will have coding errors, and they will need remediation.
  • Most medical practices use a billing service or a clearinghouse to begin processing claims. Coding errors will often be detected at this point and sent back to the medical provider to be re-coded. BCBSIL will not be aware of the claim because it would not be submitted to us at this point.
  • You may want to provide basic information about ICD-10 and explain that its implementation may cause a delay.
  • Additional information about ICD-10 may be found at the Centers for Medicare & Medicaid Services website.


September 2015~

BCBS is discontinuing paying for consultation codes 99241-99245 and 99251-99255, as Medicare has done for a long time. Other medical insurance companies and plans will surely follow suit in the near future.
Use the examination codes 99201-99205 and 99211-99215 (In office), or 99224-99226 (in hospital) in their place.

August 2015~

ICD-10 is just around the corner!!!! Codes go into effect October 1 2015. There will be NO grace period.
Procedures done up to, and including, September 30 2015, can be reported using iCD-9 codes. Treatment on, or after, October 1 2015, can only be reported using ICD-10. Any claims with the wrong code set will be automatically denied.
Pre-publication orders for the 2016 "Z books", with ICD-10 codes and all claim examples converted to same, are now being taken. Books will ship out/can be accessed in the Cloud, after September 15.
August 2015~
When billing the codes 99241-99245 and 99251-99255, note that neither Medicare nor BCBS cover these exam/consultation codes.
All other insurers are sure to follow suit.
Codes 99201-99205 and 99211-99215 continue to be covered by all insurers.

July 2015~

Billing anesthesia codes 00170 and 00190

ALL Anesthesia codes in the range 00100-00199 REQUIRE a physical status modifier. Select the appropriate one from the following:


P1: a normal healthy patient

P2: a patient with mild systemic disease

P3: a patient with severe systemic disease


QS: provided by Surgeon

QX: provided by CRNA, monitored by Doctor


IMPORTANT: MAC BILLING REQUIRES THAT YOU STATE THE NUMBER OF MINUTES (not the number of 15 minute Units) OF ANESTHESIA IN THE "UNITS" COLUMN ON THE CLAIM FORM. Thus 60 minutes of MAC would be stated as "60" in the Units column.

June 2015~

Bill calls for 18-month ICD-10 grace period

A new bill introduced in the House would require end-to-end testing of the transition from ICD-9 to ICD-10 by the Health and Human Services Department, and would provide an 18-month transition period to the new code set.

The Increasing Clarity for Doctors by Transitioning Effectively Now Act (ICD-TEN Act), proposed by Rep. Diane Black (R-Tenn.), would not stop or delay implementation of the coding system, according to an article in the Journal of the American Health Information Management Association (AHIMA).

However, Black's bill would require HHS to offer the testing to all providers participating in the Medicare fee-for-service program. In addition, the agency would have to submit to Congress certification on whether the system is working, according to AHIMA. If HHS finds that the full transition is not occuring, it would need to take additional steps to ensure completion.

During the transition period, reimbursement claims submitted to Medicare could not be denied due to "use of an unspecified or inaccurate subcode."

The deadline for ICD-10 implementation has been delayed several times. Many providers, especially small practice physicians, still have concerns about the transition, with a recent survey finding only 11 percent of respondents "highly confident" their staff will be sufficiently trained by the Oct. 1 deadline to transition to the new code set; 35 percent said they were "not at all confident" their staff will be ready. "Neither Congress nor the provider community support kicking the can down the road and supporting another delay, but we must ensure the transition does not unfairly cause burdens and risks to our providers, especially those serving Medicare patients," Black wrote in a letter urging fellow legislators to co-sponsor the bill, according to the article.

AHIMA officials do not support the proposed legislation, noting in the article that the Centers for Medicare & Medicaid Services-supported contingency plans already are in place. Margarita Valdez, senior director of congressional relations at AHIMA, said according to the article that the transition period would "create an environment that's ripe for fraud and abuse." Meanwhile, AHIMA CEO Lynne Thomas Gordon said she fears that providers would use the extra 18 months to "delay properly learning how to use the new code set."

There are some who would still like to see ICD-10 delayed yet again, or even thrown out.

Rep. Ted Poe (R-Texas) recently introduced a bill to Congress that would ban ICD-10 outright.

The Cutting Costly Codes Act of 2015 would prohibit the federal government from requiring medical professionals to comply with ICD-10 in lieu of ICD-9.

May 2015~

Not opting in or out of Medicare hurts specialists, pathologists, pharmacists, and patients

Dentists who treat Medicare patients who do not opt in or out of the federal program are putting the specialists and pathologists they refer cases to at risk of not being reimbursed. Ask Dr. Douglas Arendt. The Vienna, Virginia, oral and maxillofacial pathologist is closing his practice Aug. 31 because he's taken a loss on so many cases he's processed for his referring dentists because they were not identified as Medicare providers. For specialists and pathologists to get paid for the covered services dentists provide to Medicare patients, the dentists must use the Provider Enrollment, Chain and Ownership System (PECOS) to enroll as Medicare Providers or as Medicare Ordering and Referring Providers or opt out of the program altogether.

Dr. Arendt said he's tried to educate the dentists he works with but many of them have not taken action on their Medicare status or are unaware they need to for him to be reimbursed for the pathology cases they send him. It leaves him in an ethical conundrum: either refuse to process the cases because he won't be reimbursed or process them for the good of the patient but be out the money.

For dentists who send him cases who are not enrolled through PECOS, Dr. Arendt said he will send them the paperwork to help them get enrolled but it doesn't always help.

"Even though the practitioners are now trying to get into the PECOS database, it can be very tedious and you need to make sure their staff follows through with the Medicare customer service reps," Dr. Arendt said. "Patience and persistence is a must. Feedback from some of the providers who did their due diligence stated it was very challenging, and at times confusing, as to what information was really needed."

It was those reasons why four years ago, the ADA vehemently opposed requiring dentists to enroll in PECOS if they were to be Medicare providers. In 2010, then-ADA President Ronald Tankersley and ADA Executive Director Kathleen O'Loughlin wrote separate letters to the Centers for Medicare & Medicaid Services and Kathleen Sebelius, former Secretary of the Department of Health and Human Services explaining why the ADA is opposed to the requirement.

The ADA believes the PECOS enrollment process is too complicated and time consuming for dentists and requires information that is irrelevant for dentists who just want to refer and order prescriptions, according to the letter.

Dr. Arendt wants all dentists to understand that the pathologists they work with will not be reimbursed if the dentist is not enrolled as a Medicare Provider or as a Medicare Ordering and Referring Provider.

"I'm not sure how much longer I could have sustained a negative balance in my practice," Dr. Arendt said. "You always have a war chest, but I was honestly very concerned."

For more information on how to enroll, visit the website.

April 2015~

The Association of Obstructive Sleep Apnea and Erectile Dysfunction

Erectile dysfunction (ED) is common in patients with OSA. Sleep apnea induces hormonal alterations, deviations in neural regulation, endothelial dysfunction, and changes in microvascular perfusion that can cause or contribute to the development of ED.

The association of ED and OSA, and the causative nature of OSA in the development of ED, continue to be better defined, and there have been numerous recent publications exploring these relationships. Men with OSA experience more sexual dysfunction and sexual dissatisfaction when compared with age-matched controls.[1,2] Not only is there a high incidence of ED among patients with OSA, but the 2 conditions together also tend to cause further detriments in both mood and quality of life than either condition alone.[3]

Several studies have found that the prevalence of ED is high among patients with OSA. A study by Seftel and colleagues[4] found that 40% of OSA patients had ED. Similarly, Santos and colleagues[5]determined a prevalence of ED among 62 men with newly diagnosed OSA. Using the 5-item version of the International Index Erectile Function (IIEF) questionnaire, the authors identified ED in 64.4% of the cohort. Dombrowsky and colleagues[6] conducted a prospective analysis of 92 men who were nondiabetic and under the age of 60 years with newly diagnosed OSA to determine the prevalence of ED and decreased libido. Among the cohort, the mean age was 45.8 ± 8.2 years, and the mean apnea-hypopnea index (AHI) was 38.2 ± 27.6 events/hour. At baseline, ED was present in 45.6%, and 27.2% had diminished libido.

It seems that the reciprocal of this association is also true. While ED is common among those with OSA, OSA is also common in men presenting with ED. Hirshkowitz and colleagues[7] assessed patients with ED for evidence of sleep disordered breathing. They found that 91.3% men with ED also had OSA.

Sleep apnea, a disorder that causes breathing to be bbriefly obstructed during the night, may impair how your body metabolizes glucose, leaving too much in your bloodstream and not enough in your cells. In one study, subjects with mild to moderate form of sleep apnea were 23% more likely to develop diabetes. But here.s the good news: treating the condition with a CPAP or oral appliance may improve how the body absorbs glucose.

March 2015~

Deadline to Opt in/out as a Medicare Provider

Medicare covers very few dental services, as you know. Current Medicare coverage for these services includes those procedures that are either an integral part of a covered procedure (ie. reconstruction of the jaw following a traumatic injury), or for extractions done in preparation for radiation treatment for cancer involving the head and/or neck area. Medicare will also pay for oral examinations, but not treatment, prior to organ transplantation or heart valve replacement, under certain circumstances.

Despite the tight restrictions and parameters as to when Medicare might conceivably pay for dental treatment, there are two important reasons why dentists need to pay attention to upcoming changes and understand the potential impact to dental patients and one's dental practice.

First, because of the large number of "baby boomers" and patients with mental or physical handicaps, that are covered by Medicare, there are a lot of potential patients who may be impacted with the upcoming Medicare changes.

Secondly, CMS issued a recent rule requiring all physicians and eligible professionals — including dentists — who prescribe Part D-covered drugs must be enrolled in Medicare or "opt out" in order that those prescriptions, written by them, be covered under Part D by June 1, 2015.


What does this mean for dentists?

This means that if you have Medicare-eligible patients for whom you prescribe medication, or perform procedures covered by Medicare, or need to refer the patient to a specialist, you'll need to do one of the following:

1. Enroll as a Medicare provider

Dentists wishing to enroll as Medicare providers must choose whether they wish to become "Par-" or 'Non-par" providers with Medicare. The difference in status is explained in the Medicare section of the Z Book. A dentist choosing to be a Medicare Provider of either category must enroll either through the completion and submission of the CMS-855S form or by submitting their enrollment electronically through the Provider Enrollment, Chain and Ownership System (also known as PECOS).

2. "Opt Out" of Medicare Dentists may choose to "opt out" of the Medicare Program by privately contracting with Medicare-eligible patients utilizing a Private Contract Form (refer to 2015 Z Book page 10-10). When a dentist opts out of Medicare, the dentist cannot receive Medicare payments for a two-year period. Dentists choosing to opt out of Medicare and bill patients privately must complete the Medicare Opt-Out Affidavit (refer to 2015 Z Book, page 10-10) and send it to Noridian (addresses for each state/part of state are on the www.medicare.gov web site).

NOTE: Until requests to withdraw (opt-out) from the Medicare Provider has been approved, dentists are required by law to abide with all Medicare rule and regulations.

3. Enroll as a Medicare "Ordering and Referring" Provider

Regardless of whether a dentist has opted in or out as a Medicare provider, the dentist may enroll as a Medicare "Ordering and Referring" Provider. As an ordering and referring provider, dentists cannot send claims for their services to Medicare for reimbursement. By registering as an "Ordering and Referring" Provider, dentists will be placed on the Medicare Ordering and Referring Registry and will be able to order and refer patients to Medicare-enrolled providers and suppliers.



Dentists must take action ASAP to declare their Medicare provider status. The deadline for filing is June 1, 2015, but it takes approximately three months for the application to be processed. In order to minimize negative impact to their patients, local pharmacies and other dental providers, you must act immediately. Pharmacies, specialists and pathologists will not be reimbursed for prescriptions, treatment and lab work when referred by a dentist who has failed to enroll as a Medicare provider, has not enrolled as a Medicare "ordering or referring" provider, or who has  chosen to "opt out" of the program altogether.

This ruling was issued by CMS in order to comply with the Affordable Care Act and extended the Medicare enrollment requirements to physicians and eligible professionals who order, or provide, other categories of Medicare services, including covered Part D drugs.

February 2015~


When preparing operative reports, it is now recommended that you also include a brief history of the presenting condition (HPC), as well as general medical history factors and medications currently being taken/or past meds (if any) that lead to, caused, have contributed to, or exacerbated the patient's current condition, necessitating surgical intervention. This should be stated under the heading MEDICAL HISTORY.

This information should be included below the Anesthesia heading and before describing the Operative Technique.

Please refer to the 2015 Z book Operative Report Templates (pages 5-3 through 5-19) for details as to how this should be reported.

January 2015~

You still have to worry about employees’ laptops and portable devices when it comes to HIPAA — even if they aren’t employees anymore.

Case in point: A home burglary sparked a breach incident for St. Elizabeth’s Medical Center in Brighton, Mass. Thieves stole a former employee’s laptop and thumb drive that contained 595 patients’ protected health information, according to attorney Kathryn Sylvia of Nixon Peabody. The laptop and thumb drive were not encrypted and contained patients’ dates of birth, medical history, diagnoses, test results and medications.

The former employee was a physician at St. Elizabeth’s. Although St. Elizabeth’s has reported the theft to affected patients and officials do not believe that the thieves have misused the PHI, local police are still investigating the incident, Sylvia noted in a blog post.

Takeaway: “This should be a lesson ... to ensure that, upon termination, all employees return electronic patient data and all hard drives or USB thumb drives are wiped clean to avoid situations like this,” Sylvia stressed.

And it reinforces that PHI should be encrypted in any case, experts note.

December 2014~

Question: Our Doctor wants to talk to a specialist about a patient’s condition. He is planning to discuss the patient’s history and current diagnosis over the phone. I told the Doctor he needs the patient’s permission before he can discuss the case but he says I’m wrong. Can you advise?

Answer: The Doctor is correct—you do not need the patient’s permission. “The Privacy Rule does not require you to obtain a signed consent form before sharing information for treatment purposes,” the Department of Health and Human Services (HHS) says in its Fast Facts for Covered Entities document. “Health care providers can freely share information for treatment purposes without a signed patient authorization.”

Of course, if you are talking on the phone, you must still meet the regulations set out in the privacy rule to ensure that only the two doctors can hear the information being discussed. Make sure no one can overhear the doctor’s conversation and that the call is taking place on a secure line.

November 2014~

Your chairside or surgical assistant/nurse might be quite adept at recording your documentation—but if she/he documents too much, your notes might not be applicable to your coding choices. That’s the word from a new E/M Tip issued in September, reminding doctors what ancillary staff members can document in your Medicare records.

“Ancillary staff may only document the Review of Systems (ROS), Past, Family, and Social History (PFSH) and Vital Signs,” the latest tip, published Sept. 23, indicates.

As for the history of present illness, leave that to the physician or Nurse Practitioner, Palmetto says. “Only the physician or NP that is conducting the E/M service can perform the history of present illness (HPI). This is considered physician work and not relegated to ancillary staff. The exam and medical decision making are also considered physician work and not relegated to ancillary staff.”

October 2014~

When dispensing or administering any drugs in the office (not simply giving a prescription to the patient to take to a pharmacy), and billing for it on the medical claim form, the specific drug given, whether orally, SC, IM, or added to the IV line (not a part of the MAC induction/maintenance), you must indicate this with the qualifier N4, together with the National Drug Code (NDC) for the specific drug given. The code may be found on the web site:  Click HERE  and searching using either a proprietary name ie. Valium, or by the main ingredient ie. Diazepam. You then scroll down through the different modes of administration (tablet, capsule, liquid, etc.), individual dosages (2 mg, 5 mg, 5 ml, 10 ml etc.), and manufacturer's name (Lilly, Squibb, etc.) to determine the correct NDC code to use on the claim form, in the shaded area above the respective CPT code that represents either oral, SC, IM or IV administration. For further details, please refer to the Z book, Section 6, pages 13-14.

September 2014~

When submitting claims electronically using Emdeon, the doctor's degrees are not accepted in Sections 14 and 31 on the CMS 1500 (02/12) claim form, as they are read as the Doctor's initials, which is not the name that the NPI number is linked to on the NPPES web site. Omit them from claims completed and submitted when using Emdeon. They can still be used when filing paper claims that are sent through USPS, faxed in, or sent by any other means other than using Emdeon.