Billing & Coding

Center for Medicare and Medicaid Innovation (CMMI) models are created by CMS to test innovative payment techniques and service delivery models. As of November 2018, here are some CMMI models:

  • Medicare Diabetes Prevention Program
  • ACO Models (e.g., Pioneer ACO, Next Generation ACOs)
  • Independence at Home Model
  • Comprehensive Primary Care Plus
  • Oncology Care Model
  • Joint Replacement Model

See the References to be linked to Medicare's page listing all Innovation Models.


Are you Ready for CMS' 2019 Medicare Physician Fee Schedule Final Rule?

The waiting is over, the Final Rule for CMS' 2019 Medicare Physician Fee Schedule (MPFS) is available - all 2,379 pages for those looking for a little light reading. As anticipated, there are some pretty significant changes. Most of us were carefully watching the proposed changes to the Evaluation and ...

Q/A: What Codes do I use for CLIA-Waived Tests?


I am a certified DOT medical examiner and have applied to get my CLIA lab (waiver) for urinalysis, finger prick blood tests for A1c, cholesterol and glucose. I realize I cannot diagnose patients with these tests, but I am using them to make decisions in the DOT process and with nutritional counseling. What codes do I use for these tests?



We have been receiving several DDS referrals to our massage therapists who do intra-oral work. The only problem is that the referral from the DDS lists code R51 for headaches as the only DX code. Since most plans don't cover massage therapy for headaches alone, are there any codes that can distinguish the headaches as TMJ related so they can be more widely covered?


The list of settings where a physician’s services are paid at the facility rate include:
  • Telehealth (POS 02);
  • Outpatient Hospital-Off campus (POS code 19);
  • Inpatient Hospital (POS code 21);
  • Outpatient Hospital-On campus (POS code 22);
  • Emergency Room-Hospital (POS code 23);
Physicians’ services are paid at nonfacility rates for procedures furnished in the following
  • Pharmacy (POS code 01);
  • School (POS code 03);
  • Homeless Shelter (POS code 04);

Medicare Timed Codes Guidelines

Medicare's guidelines for reporting of timed codes is found in Medicare Claims Processing Manual Chapter 5, Section 20.2. Also known as the '8 minute' rule, it describes how to calculate time for appropriate reporting when more than one timed code is performed at the same time.
It should be noted that while ...

On May 11, 2018, the Department of Veterans Affairs (VA) released its final rule on the "Authority of VA Health Care Providers to Practice Telehealth." Effective June 11, 2018, VA providers will be able to provide telehealth services across state lines. This move will make it easier for veterans to obtain ...

CMS Proposes Changes to Evaluation & Management Requirements

It is no secret that providers have long argued that E/M coding is burdensome and does not truly reflect the services provided. This fact is acknowledged by CMS with the following statement "Prior attempts to revise the E/M guidelines were unsuccessful or resulted in additional complexity due to lack of ...

Dual Medicare-Medicaid Billing Problems

It is important to keep in mind that Medicaid is run at a state level so there can be some differences when it comes to coverage. However, the rules regarding balance billing of covered services is set at the federal level. The law states (emphasis added):


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