Tag: CMS

UB-04 Claim Form

Understanding the UB-04 Claim Form (CMS-1450) in Medical Billing

In the complex world of medical billing, accurate documentation is essential for timely reimbursements and claim acceptance. One of the most critical tools in hospital and institutional billing is the UB-04 claim form, also known as the CMS-1450. Whether you’re a healthcare provider, billing professional, or medical coder, understanding this form is crucial for ensuring […]
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G codes for mammograms

G Codes for Mammograms with CPT Codes: A Complete Guide

Mammography, a vital screening tool in the early detection of breast cancer, is typically billed using CPT codes and HCPCS Level II (G codes). However, the correct use of G codes for mammograms—particularly for Medicare beneficiaries—is often a source of confusion for healthcare providers and billing teams. In this comprehensive guide, we’ll explore: The difference […]
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Prior Authorization Automation

Can Automation Solve the Prior Authorization Problem in Healthcare?

In today’s healthcare ecosystem, prior authorization (PA) remains one of the most burdensome administrative processes, creating delays, denials, and dissatisfaction among providers and patients alike. Originally designed to ensure appropriate care and control costs, the process has become a major pain point due to its manual, repetitive, and inconsistent nature. But with the rise of […]
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FY 2026 IPPS Proposed Rule

IPPS Proposed Rule: Key Updates to HRRP, HAC, and VBP Programs

The Centers for Medicare & Medicaid Services (CMS) has unveiled its Fiscal Year (FY) 2026 IPPS Proposed Rule, which outlines significant updates to three key Medicare hospital quality initiatives: the Hospital-Acquired Condition (HAC) Reduction Program, the Hospital Readmissions Reduction Program (HRRP), and the Hospital Value-Based Purchasing (VBP) Program. These proposed changes, outlined in the IPPS […]
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Prior Authorizations

Prior Authorization in Medicare: What You Need to Know

Prior authorization, the requirement for pre-approval from your insurer for certain services, is a common practice in both Original Medicare and Medicare Advantage (MA) plans. While it helps manage utilization and costs, it can also be frustrating, especially when a request is denied. A 2023 study by health policy research revealed the increasing prevalence of […]
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Emergency Department Coding: Best Practices and Challenges

Emergency Department Coding: Best Practices and Challenges

Table of Contents The Emergency Department Coding Process Unique Challenges of Emergency Department Coding CPT Documentation Updates and Emergency Department Coding ED Facility Coding and National Standards The Limitations of Final Diagnosis-Based Payment ED Utilization and Evolving Treatment Paradigms The Importance of Emergency Department (ED) Coding in Medical Coding Companies Conclusion Emergency Department coding is […]
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Medicare Physician Reimbursement Cuts

Medicare Physician Reimbursement Cuts Threaten Patient Access to Care

With over 67 million Americans—nearly 20% of the population—relying on Medicare, the program plays a crucial role in ensuring access to quality healthcare. Unfortunately, looming Medicare physician reimbursement cuts threaten to undermine this vital service, potentially leading to reduced access to care and compromised patient outcomes Medicare physician reimbursement cuts, such as the proposed 2.8% […]
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Medicare Advantage Reform: Rising Scrutiny and Political Shifts

Medicare Advantage Reform: Rising Scrutiny and Political Shifts

Medicare Advantage (MA) plans, a type of private health insurance that serves as an alternative to traditional Medicare, have long been a subject of debate within the healthcare industry and among policymakers. However, recent political developments suggest a growing appetite for MA reform, marking a significant departure from previous bipartisan consensus. A Rising Tide of […]
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Latest ICD-10-PCS Codes and Guidelines

Latest ICD-10-PCS Codes and Guidelines

The latest ICD-10-PCS codes and guidelines for the fiscal year 2024 have been unveiled by the Centers for Medicare & Medicaid Services (CMS). With a net growth of 73 codes, the total count of inpatient procedure codes has reached 78,603. Notably, the New Technology Section has experienced the largest surge, introducing 40 new codes. The […]
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CMS Unveils Proposed Rules Impacting Medicare Payments for 2025

CMS Unveils Proposed Rules Impacting Medicare Payments for 2025

The Centers for Medicare & Medicaid Services (CMS) has unveiled a series of Medicare payment rules that will dramatically impact Medicare payments for 2025. These changes encompass payment rates, coding guidelines, coverage criteria, and quality measures for various healthcare providers. Physicians, in particular, face a proposed average payment rate cut of 2.93% under the fee […]
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