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Recalculated CMS Medicare Physician Fee Schedule Rates for 2021

Recalculated CMS Medicare Physician Fee Schedule Rates for 2021

Recalculated CMS Medicare Physician

Fee Schedule Rates for 2021

COVID-19 pandemic hit the world in late 2019 and continued to trouble us all through 2020. Apart from the physical setback, it had a terrible impact on every individual’s social, professional, and psychological well-being. During these challenging times, everything got on hold. Even the biggest of businesses were shut with no positive visibility. This hit the healthcare system too. Even the best of primary healthcare facilities was unsure of keeping themselves open with negligible IPD & OPD. 

This concern was raised by nearly 400 medical organizations, including ACR, as they requested Congress to revisit the year-end legislative package and stop the rate cuts. Along with this, more than 300 congress members also wanted to waive off the budget neutrality adjustment in the 2021 Medicare Physician Fee Schedule so as to mitigate or prevent the cuts. 

In a December statement, the American College of Radiology (ACR) had said that “While the COVID-19 pandemic rages and wreaks havoc on the health care system, providers continue to contend with overflowing hospitals and the financial impact of the spring-summer government-recommended shutdown of most non-urgent medical care. Against this backdrop, double-digit Medicare cuts will be devastating for patients, communities, and providers.” 

Considering the present scenario and to support the healthcare professionals, Congress passed The Consolidated Appropriations Act, 2021 on December 21, 2020, after a COVID-19 stimulus package mitigated budget neutrality cuts finalized in a December rule. As a highlight, the Act ratified a 3.75 % increase in overall Medicare Physician Fee Schedule payments for all providers for 2021.  

To reflect the COVID-19 stimulus package changes, CMS updated the Physician Fee Schedule as of January 7. Here are important glimpses: 

  • 3.75% increase in overall Medicare Physician Fee Schedule payments for 2021 
  • Suspension of payments for Healthcare Common Procedure Coding System (HCPCS) code G2211 for three years
  • Up to 10.2 % cut for certain specialties and services because of a budget neutrality requirement
  • Boost rates for E/M (evaluation and management) services that support primary care and chronic disease management
  • Suspension of the 2 % payment adjustment for the statutory Medicare sequester through March 31, 2021
  • Reinstatement of the 1.0 floor on the work Geographic Practice Cost Index through 2021
  • Revision of the conversion factor for the Physician Fee Schedule in 2021 from $32.26 to $34.89 

As a surprise in 30 years, this finalized policy has the most significant updates for E/M codes. According to the American Medical Association (AMA), “G2211 (an add-on code for the complexity inherent to evaluation and management (E/M) visits) accounted for about $3 billion, or 3 %, of spending in the Medicare Physician Fee Schedule”. But the finalized policy has reduced the burden of the coding system from doctors and rewarded time to be spent on evaluation and management of patient care. With the delay in implementing the code, there will be a reduction in the budget neutrality adjustment. All this will prevent the significant rate cuts for some specialists and services during the COVID-19 pandemic, as laid out in the 2021 Medicare Physician Fee Schedule final rule. 

Also, there is a decrease in the Physician Fee Schedule conversion factor by $3.68 to $32.41. This has been done to reflect a statutory update of 0.00 percent and the adjustment to account for changes in relative value units and expenditures that would result from finalized policies.

To view the revised Consolidated Appropriations Act, 2021, providers can view payment rates in the Downloads section of the CY 2021 Physician Fee Schedule final rule (CMS-1734-F) webpage.

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Billing Codes for Monoclonal Antibody COVID-19 Infusion

Billing Codes for Monoclonal Antibody COVID-19 Infusion

The FDA issued an EUA on November 21, 2020, for the investigational monoclonal antibody therapy, casirivimab and imdevimab, administered together to treat the adult and pediatric patients with mild-to-moderate COVID-19 having positive COVID-19 test results high at risk for progressing to severe COVID-19 and/or hospitalization. The administration can only occur in settings where healthcare providers have immediate access to medications to treat a severe infusion reaction and the ability to activate the emergency medical system (EMS), as necessary.

During the COVID-19 public health emergency (PHE), Medicare ensures coverage and payment for these infusions the same way it does for COVID-19 vaccines, thus allowing coverage for a broad range of providers and suppliers, including home health agencies, nursing homes, and freestanding and hospital-based infusion centers, and entities with whom nursing homes contract for this, to administer these treatments. Medicare will refuse payment for the COVID-19 monoclonal antibody products that providers receive for free. If providers begin to purchase COVID-19 monoclonal antibody products, Medicare anticipates setting the payment rate for the products, which will be 95% of the average wholesale price (AWP) for many healthcare providers, consistent with the usual vaccine payment methodologies. Medicare soon anticipates establishing codes and rates for the administration of the products.

CMS recognized specific code(s) for each COVID-19 monoclonal antibody product and specific administration code(s) for Medicare payment:

EUA effective November 10, 2020, for Eli Lilly and Company’s Antibody Bamlanivimab (LY-CoV555)

Healthcare providers can now use the HCPCS code Q0239 for the injection of 700 mg of Eli Lilly and Company’s investigational monoclonal antibody therapy cocktail and code M0239 for intravenous infusion and post-administration monitoring, according to CMS source on Monoclonal Antibody COVID-19 Infusion

EUA effective November 21, 2020, for Regeneron’s Antibody casirivimab and imdevimab (REGN-COV2) (ZIP) 

Healthcare providers can now use the HCPCS code Q0243 to inject 2,400 mg of Regeneron’s investigational monoclonal antibody therapy cocktail and code M0243 for intravenous infusion post-administration monitoring, according to CMS source on Monoclonal Antibody COVID-19 Infusion

Get the latest and most up to date list of billing codes, payment allowances, and effective dates.

Payment for Product & Infusion

Medicare will not provide payment for the COVID-19 monoclonal antibody products that healthcare providers receive for free, as will be the case upon the product’s initial availability in response to the COVID-19 PHE. If healthcare providers begin to purchase these monoclonal antibody products, CMS foresees setting the payment rate in the same way it was addressed the rate for COVID-19 vaccines.

In order to ensure immediate access during the COVID-19 PHE, Medicare will cover and pay for these infusions per Section 3713 of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). CMS proposes to address potential refinements to payment for COVID-19 monoclonal antibody infusions and their administration through future notice and comment rulemaking.

Initially, the Medicare national average payment rate for the administration will be $309.60; this payment rate is strictly based on one hour of infusion and post-administration monitoring in the hospital outpatient setting. In the future, CMS may utilize a similar methodology to determine the payment rate for the infusion of additional monoclonal antibody products based on the expected infusion time in line with the FDA EUA or FDA approval of such products.

CMS is hopeful that this Medicare coverage for the two therapies will help providers overcome the hurdles of acquiring and employing new treatments. Yet, it is a known fact that healthcare facilities and providers are still expected to encounter challenges obtaining an adequate supply of such therapies for infected patients.

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Telehealth and Covid-19: 2020 Coding & Billing Tips

Telehealth and Covid-19: 2020 Coding & Billing Tips

Telehealth and COVID-19:

2020 Coding and Billing Tips

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2020 Annual Wellness Visit (AWV) Coding and Documentation Tips

2020 Annual Wellness Visit (AWV) Coding and Documentation Tips

2020 Annual Wellness Visit (AWV)

Coding and Documentation Tips

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The Ultimate Guide to Revised E&M Guidelines for Office and Other Outpatient Services in 2021

The Ultimate Guide to Revised E&M Guidelines for Office and Other Outpatient Services in 2021

The Ultimate Guide to Revised E&M Guidelines 

for Office and Other Outpatient Services in 2021

Centers for Medicare and Medicaid Services (CMS) has embraced the recommendations of the AMA in regards to Evaluation and Management (E&M). Starting January 1, 2021, these changes will be applicable for coding office and other outpatient services.


In 2017, CMS brought an initiative “Patients Over Paperwork” to streamline work, increase efficiency, improve patient experience, and reduce administrative burden.

The purpose of this initiative was to revise the existing and archaic E&M coding guidelines. According to CMS, increasing paperwork and reporting tools were the main bottlenecks that kept physicians and medical practices busy.

They were required to spend more time managing administrative tasks instead of caring for patients. It resulted in poor patient experience and monumental administrative tasks that added to the cost as physicians needed to hire additional staff and comply with the government rules and regulations.

What Changes Will Take Effect

History and Tests Removed as Mandatory Elements for Coding. These two components tend to delay clinical decision making and are time-consuming as the clinicians need to document this in the patients’ medical record.

Documents related to Medical Decision Making or Time

Physicians cannot use both these documentation methods for the same patient visit. They need to select either option for each patient visit.

Updated Time-Based Coding

Time is explained as “total time on the date of the encounter.” It includes time spent by authorized healthcare professionals and clinicians for in-person and other modes or non-face-to-face discussions with the patient.

Revised Coding for Prolonged Services

It should be used for time-based coding when the duration of the encounter exceeds the defined time for 99205 and 99215 in 15-minute increments.

Updated MDM Criteria

Using the present CMS Table of Risk as a standard guideline, the MDM elements for code selection were refined and clarified to avoid complexity and increase efficiency patient management.

Restructuring of RVUs and Charges

Considering the RVU guidelines from the AMA’s CPT/RUC Workgroup on E&M, CMS has stated that relative value for the codes is evaluated depending on the total duration spent by a physician from three days before patient’s visit through seven days following the visit as the standard work will be same irrespective of the time when it is completed.

Source: https://www.ama-assn.org/

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Does Your Practice Management Software Avoids These Common Medical Billing Errors?

Does Your Practice Management Software Avoids These Common Medical Billing Errors?

Does Your Practice Management Software Avoid These Common Medical Billing Errors?

Effective revenue cycle management is the foundation of every medical practice. But what is the impact of medical billing errors on a healthcare practice? As healthcare providers, you are aware of the high cost of care and the competitive market. High medical claim denial rates can affect the bottom-line and reduce your revenues significantly.

Whether your practice is big or small, you can’t be casual about medical billing errors that could easily be prevented. Yet, small and independent practices have more to lose when it comes to billing errors.

A 2014 Advisory Board study reveals that 90 percent of claim denials are preventable. Practices need to build a prevention-focused claims management approach, use automated processes, use data to analyze claim denial reasons, and improve their front-end revenue cycle management process.

Fortunately, if you are cautious, you can avoid these common medical billing errors easily. In this article, we run through the most common billing errors and how you can avoid them.

1. Patient’s Eligibility Verification and Benefit Verification (EV and BV)

The Error:

Coverage availability is one of the most common areas where practices tend to slip up. A recent Healthcare Information and Management Systems Society (HIMSS) survey shows that 76% of healthcare leaders find denials to be their biggest challenge.  Healthcare practices can be more effective in reducing denials by using analytics to determine the leading causes of denials.

The study found that a breakdown in the front-end processes causes some of the most common denials. For instance, patient registration and eligibility errors alone account for 23.9%.

One of the easiest ways to avoid denials is being accurate with crucial information when it comes to EV and BV.

Many practices that depend on in-house resources for Eligibility and Benefit Verifications miss out on key information because they focus on moving the transactions. They lack the software and the know-how to audit real-time eligibility information based on individual player rules and denial patterns. And by the time you realize this, and the claim is denied, it is too late.

The Solution: 

You need a system that provides automated eligibility verification and benefits mapping to take the guesswork out of the process. Technologies such as ours can reduce your eligibility denials by 50% by offering eligibility verification in real-time and alert you on coverage, coordination of benefits, policy termination, the correctness of demographics, co-pays, and deductible. A good technology platform will provide not only real-time checks but scheduled eligibility rechecks, batch eligibility checks and verify co-pay, co-insurance, and deductible information.

There are many benefits of a streamlined verification process. 

  • Fewer Denials & Rejected claims
  • Reduce the need for tedious in-house manual verification
  • Full Use of Your Relevant 271 Eligibility Data
  • Higher speed of Registration while you free-up resources for other tasks
  • Minimize your bad debt
  • Improve and speed up your recovery cycle

2. Avoid Duplicate Claims

The error and its impact:

Duplicate billing or double-billing is when claims are resubmitted for a single encounter for the same date by the same practice. These are among the top reasons for Medicare Part B claim denials (up to 32%).

The actual cost of duplicate billing goes beyond the revenue. There is a delay or loss in payment, reputation loss, and the possibility of fraud investigation.

Wonder why duplicate claims submission is so rampant across the industry? It is because most practitioners use a reactive medical billing process. According to Health Payer Intelligence, 46% of medical fraud cases in 2016 were due to either fraudulent provider billing or double-billing, costing a whopping $29 million in fines.

An intuitive technology revenue cycle software can alert you and help reduce manual errors and outdated information and keep your data clean, so there are no duplicate or double-billing chances.

3. Incorrect and/or Mismatched Codes (ICD-CPT Mismatch and Incorrect ICD Codes)

The Error:

Often an in-house staff will enter mismatched treatment and diagnosis codes. Usually, this happens when the biller upcodes the diagnosis without updating the treatment code. Insurance companies typically reject such claims, or sometimes the claim is inflated due to upcoding.

Another possibility is that the insurance company will reject the claim due to a lack of medical necessity. Problems occur because the biller and coder must have a thorough knowledge of ICD-10-CM codes and CPT codes for the procedure.

For example, using the code for a bunion procedure when the only diagnosis is asthma.

The Solution:

Physicians need to provide coders with the necessary information about the patient’s diagnosis. It requires comprehensive documentation and detailed patient records with all possible information, including accompanying conditions for better application of codes.

Invest in ongoing training and education programs and informal coaching to ensure that employees know the latest coding requirements.

Luckily, advanced billing software can help you avoid these errors by automatically suggesting the right ICD codes based on common diagnosis and keywords entered.

Choose technology wisely and invest in a system that codes to the highest specificity levels, ensuring that your claim is not denied. 

4. Data Entry Errors

The Error:

To err is human. Data entry errors are more common than one can imagine. Incorrect information in your claim will lead to claim denial. From the practice address, the phone number to the patient’s name, gender, birthday, and insurance details to the insurance company’s address and policy number, there are many places where billers goof up.

Manual data entry errors contribute the largest percentage from 23.9% claims denied due to eligibility errors and registration issues and other 12.4% owing to incomplete or missing authorizations. 

The Solution:

Software scrubbing can eliminate such manual and basic coding errors quite easily. For instance, if a wrong zip code is entered or an incorrect format for member ID is entered, the software will immediately prompt the relevant error messages.

5. Missing Pre-authorization and Referral

The Error:

While billers work hard to reduce claim denials, payers have, over the years, increased the number of visit types and procedures that need prior authorization or pre-authorization. It has led to a rising number of denials in most procedure-based practices.

The MGMA’s recent stat poll reveals prior authorization errors to be the leading cause for denials when respondents were asked, “What is the root cause of claims denials/pends?” About 31 percent answered “pre-authorization.”

A December 2017 study from the American Medical Association states that 86 percent of physicians have reported that prior authorizations have increased in the previous five years, whereas 51 percent report they have increased significantly.

The Solution

You need to be ahead of the game and use medical billing software that can help you set alerts on plans mandatorily requiring pre-authorization and referral numbers, missing, which leads to denial and loss of significant revenue for higher value procedures.

6. Handle Payer Mistakes

The Error:

If you are confident that your process was foolproof, but your claim has still been rejected.

Sometimes, it is the insurance company that makes a mistake. If you have reviewed your claim’s accuracy, then it is likely that the payer made a mistake.

And going by recent reports, the overall rates of inaccurate claims payments have been increasing. As per AMA, claims processing errors by insurance companies cost practitioners billions of dollars. Not to mention the frustration and avoidable delays. AMA’s latest findings show that commercial health insurers have an average claims processing error rate of 19.3 percent. This overall inaccuracy amounts to $1.5 billion in unnecessary administrative costs to the healthcare ecosystem. AMA estimates also show that eliminating payer mistakes could potentially save $17 billion.

The Solution:

An excellent way to find out if there has been a mistake on your claim from the payer’s side is to review the denial statistics. As a best practice, all physician’s offices must keep track of monthly denial reports to reveal patterns.

A medical billing reporting tool can help you speed up things by providing the requisite data and reports that make it easier to spot issues. You can easily confirm whether the claim was denied owing to a payer error using these reports.

7. Under-coding

The Error:

Under coding means billing for a less expensive service than the actual treatment performed or missing out on billing the codes all together. This error affects your practice’s bottom line but may also have legal repercussions from the audit perspective. In 2016 alone, the Medicare fee-for-service improper payment rate was an estimated 11 percent or nearly $40.4 billion.

The Solution:

Double-check patient information before filing the claim and ensure safety nets and peer reviews for maintaining accuracy. Always review the superbill and chart to make sure each procedure has been accounted.

Fortunately, with an audit form with medical billing software, you don’t have to worry about under coding or the potential risk of fraud implications.

8. Upcoding

The Error:

Upcoding or over-coding is when a practice bills the patients for services they haven’t received or services that were more expensive than what they were treated. It may happen for two reasons: accident or when the diagnosis and treatment codes are mismatched.

Unfortunately, some providers also do this to inflate the total amount a patient owes. It is considered fraudulent, and practitioners must be wary of upcoding, whether by accident or design.

A psychiatrist was fined $400,000 and permanently excluded from participating in Medicare and Medicaid in part due to upcoding.

The Solution:

Stay updated on billing and coding trends. Update your procedures and invest in your employees’ training and education. Be sure your billing team understands the latest updates in medical billing codes, modifications in healthcare regulations, new illnesses, or new treatments for diseases.

Medical billing software with inbuilt audit forms can also help you mitigate these errors as the software updates take care of the latest codes and regulations.

9. Unbundling and Bundling Errors

The Error:

Unbundling is the process of billing for individual services that are covered under a less expensive packaged treatment plan. It means that the charges that should be grouped under one code are listed separately, leading to an inflated package rate. Unbundling happens due to negligence or improper billing standards.

However, unbundling is more common than we can imagine. Unbundling was identified as one of the most common medical billing errors by the AMA in 2018.

The Solution:

Practitioners can avoid unbundling errors by making sure tricky scenarios where coders can easily slip up. Investing in the right technology solutions to create payer-wise charge templates can help you avoid this error.

Key Takeaways for Operational Efficiency and Revenue Discovery & Recovery

 Medical billing errors are shockingly common, and both practitioners and patients end up paying a heavy price for these mistakes. These errors are hurting healthcare as a whole, and the damage often goes beyond monetary loss by compromising the facility’s reputation or practice.

Here are some ways in which healthcare practitioners can be more cautious and proactive when it comes to claims denials:

  • Verify eligibility checks in advance to avoid costly denials
  • Collect prior authorization and referrals as necessary before the encounter
  • Recheck for manual errors and patient information details
  • Eliminate duplicate claims or double billing that can impact your revenue and reputation.
  • Code accurately, not under or up-code to avoid audits and optimize reimbursements
  • Train your team on common patterns of denial to improve collections

A state-of-art revenue cycle software and caring medical billing service can easily help you prevent these ‘avoidable errors.’ Invest in the modern-day right technology and the right resources to spot these mistakes and improve your operational efficiency and revenue.

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