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Proposed Rules for Calendar Year 2017 Released by CMS

On July 7, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that updates payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2017. This year, CMS is proposing a number of new physician fee schedule policies that will improve Medicare payment for those services provided by primary care physicians for patients with multiple chronic conditions, mental and behavioral health issues, and cognitive impairment or mobility-related disabilities.

CMS is proposing to expand the Diabetes Prevention Program model starting January 1, 2018.  This is the second CMS Innovation Center – and first preventive services – model that has been certified for expansion.  Expansion of this model will enhance access to these important services for Medicare beneficiaries who are at risk for developing diabetes. 

In addition CMS is also:

• Proposing modifications to the Medicare Shared Savings Program to update the quality measures set and align with the proposals for the Quality Payment Program, changes to take beneficiary preferences for ACO assignment into consideration, and changes that would improve beneficiary protections when ACOs are approved to use the skilled nursing facility (SNF) 3-day waiver rule;
• Requiring health care providers and suppliers to be screened and enrolled in Medicare in order to contract with Medicare Advantage health plans to provide Medicare-covered items and services to beneficiaries enrolled in Medicare Advantage;
• Increasing transparency of Medicare Advantage pricing data and medical loss ratio (MLR) data from Medicare health and drug plans, and;
Continuing to implement Appropriate Use Criteria for advanced diagnostic imaging services, including proposals for priority clinical areas and clinical decision support mechanism (CDSM) requirements, among other proposals as detailed in this fact sheet.

    The CY 2017 PFS proposed rule is one of several proposed rules that reflect a broader Administration-wide strategy to create a health care system that results in better care, smarter spending, and healthier people.

    Background on the Physician Fee Schedule

    The PFS pays for services furnished by physicians and other practitioners in all sites of service. These services include but are not limited to visits, surgical procedures, diagnostic tests, therapy services, and specified preventive services. 

    In addition to physicians, the physician fee schedule pays a variety of practitioners and entities, including nurse practitioners, physician assistants, physical therapists, as well as radiation therapy centers and independent diagnostic testing facilities. 

    Payments are based on the relative resources typically used to furnish the service.  Relative value units (RVUs) are applied to each service for physician work, practice expense and malpractice. These RVUs become payment rates through the application of a conversion factor, updated each year as specified in the statute.


    Improving Payment Accuracy for Primary Care, Care Management, and Patient-Centered Services 

    CMS is continuing the Agency’s ongoing efforts to improve payment within traditional fee-for-service Medicare for primary care and patient-centered care management. CMS is proposing several revisions to the PFS billing code set to more accurately recognize the work of primary care and other cognitive specialties to accommodate the changing needs of the Medicare patient population. 

    Historically, care management and cognitive work has been “bundled” into the evaluation and management visit codes used by all specialties. This has meant that payment for these services has been distributed equally among all specialties that report the visit codes, instead of being targeted toward practitioners who manage care and/or primarily provide cognitive services. 

    To improve payment accuracy for such care, in recent years, CMS created new codes that separately pay for chronic care management and transitional care management services, and solicited public comment on additional policies the Agency should pursue. Consistent with the public comments received, for CY 2017, CMS is proposing a number of coding and payment changes to better identify and value primary care, care management, and cognitive services:

    • Make separate payments for certain existing Current Procedural Terminology (CPT) codes describing non-face-to-face prolonged evaluation and management services.
    • Revalue existing CPT codes describing face-to-face prolonged services.
    Make separate payments using new codes to describe the comprehensive assessment and care planning for patients with cognitive impairment (e.g., dementia).
    • Make separate payments using new codes to pay primary care practices that use interprofessional care management resources to treat patients with behavioral health conditions. Several of these codes describe services within behavioral health integration models of care, including the Collaborative Care model that involves care coordination between a psychiatrist or behavioral health specialist and the primary care clinician, which has been shown to improve quality.
    • Make separate payments using new codes to recognize the increased resource costs of furnishing visits to patients with mobility-related impairments.  Like several of these proposed codes, this is especially relevant for the Medicare-Medicaid dually-eligible population.
    • Make separate payments for codes describing chronic care management for patients with greater complexity.
    • Make several changes to reduce administrative burden associated with the chronic care management codes to remove potential barriers to furnishing and billing for these important services. 

      CMS believes that these coding and payment changes could improve health care delivery for the types of services holding the most promise for healthier people and smarter spending, and advance our health equity goals.

      CY 2017 Identification and Review of Potentially Misvalued Services

      Section 3134(a) of the Affordable Care Act requires the Secretary to periodically identify potentially misvalued services and to review and make appropriate adjustments to the relative values for those services.

      Through the Achieving a Better Life Experience (ABLE) Act of 2014, Congress set a target for adjustments to misvalued codes in the fee schedule for 2016, 2017, and 2018. The target was one percent for 2016, and will be 0.5 percent for 2017 and 2018.

      If the net reductions in misvalued codes in 2017 are less than 0.5 percent of the total revenue under the fee schedule, a reduction equal to the percentage difference between 0.5 percent and the percent of expenditures represented by misvalued codes reductions must be made to all PFS services. 

      In this proposed rule, CMS has proposed misvalued code changes that would achieve 0.51 percent in net expenditure reductions. If finalized, these changes would meet the misvalued code target of 0.5 percent, therefore avoiding a broad overall reduction to PFS services.

      Valuation of Moderate Sedation Services 

      In prior rulemaking, CMS noted that it appeared that practice patterns for certain endoscopic procedures were changing, with anesthesia increasingly being separately reported for these procedures even though payment for sedation services was automatically included in payment to the physician furnishing the primary procedure.

      In response to CMS’ requests in prior rulemaking, the American Medical Association CPT Editorial Panel created separate codes for reporting moderate sedation, and the Specialty Society Relative Value Update Committee provided CMS with recommended values for the moderate sedation codes and recommended adjustments to valuation of the procedure codes. 

      In the CY 2017 PFS proposed rule, CMS is proposing values for the new CPT moderate sedation codes and proposing a uniform methodology for valuation of the procedural codes that currently include moderate sedation as an inherent part of the procedure.  CMS is also proposing to augment the new moderate sedation CPT codes with an endoscopy-specific moderate sedation code, and proposing valuations reflecting the differences in physician survey data between gastroenterology and other specialties. 

      Medicare Telehealth Services: End-Stage Renal Disease (ESRD) and Advanced Care Planning

      CMS is proposing to add several codes to the list of services eligible to be furnished via telehealth.  These include:

      • End-stage renal disease (ESRD) related services for dialysis;
      • Advance care planning services;
      • Critical care consultations furnished via telehealth using new Medicare G-codes.

        CMS is also proposing payment policies related to the use of new place of service code specifically designed to report services furnished via telehealth.  

        Payment for Mammography Services

        CMS is proposing to implement new CPT coding for mammography services. The coding revision reflects use of current technology used in furnishing these services, including a transition from film to digital imaging equipment and elimination of separate coding for computer aided detection services. CMS is proposing to maintain current valuation for the technical component of mammography services in order to implement coding and payment changes over several years.

        Updated Geographic Practice Cost Indices (GPCI) for CY 2017

        General GPCI Update

        As required by the Medicare law, CMS adjusts payments under the PFS to reflect local differences in practice costs using GPCIs for each component of PFS payment—physician work, practice expense, and professional liability insurance. Consistent with the law, CMS is proposing new GPCIs using updated data to be phased in over CY 2017 and CY 2018.

        In conjunction with this proposed update, CMS is proposing to revise the methodology used to calculate GPCIs in the U.S. territories for consistency among the Pacific and Caribbean islands.  This proposed revision would increase overall PFS payments in Puerto Rico.

        California Localities

        The Protecting Access to Medicare Act of 2014 requires that, beginning in CY 2017, CMS use new locality definitions for California based on a combination of Metropolitan Statistical Areas as defined by the Office of Management and Budget and the current locality structure.  The California locality provision is not budget-neutral, meaning that payments to physicians in California will increase in the aggregate without across-the-board reductions in physician services elsewhere.

        The movement to the new locality structure in California may increase payment to many physicians in urban parts of California without any reductions in specified counties that the law “holds harmless” from payment reductions.  In a few areas of California, the new locality structure may decrease Medicare PFS payments.

        Collecting Data on Resources Used in Furnishing Global Services

        Under the misvalued code initiative in the CY 2015 final rule, CMS finalized a policy to transform all 10- and 90-day global codes to 0-day global codes, beginning in CY 2018. Under this policy, CMS would have valued the surgery or procedure to include all services furnished on the day of surgery and paid separately for visits and services furnished after the day of the procedure. Subsequently, Congress enacted Section 523 of the Medicare Access and CHIP Reauthorization Act of 2015 prohibiting CMS from implementing this policy and requiring the agency to gather data on visits in the post-surgical period that could be used to accurately value these services. In this year’s proposed rule, CMS proposes a data collection strategy, including claims-based data collection and a survey of 5,000 practitioners, to gather data on the activities and resources involved in furnishing these services.  To the extent that this data results in proposals to revalue any surgical services, that revaluation will be done through notice and comment rulemaking at a future time.

        0-day Global Services that are Typically Billed with an Evaluation and Management (E/M) Service with Modifier 25

        CMS has noted that several high volume procedure codes are typically reported with a modifier that unbundles payment for visits from the procedure, even though the modifier should only be used for reporting services beyond those usually provided. Therefore, CMS believes the services may be misvalued. As a result, CMS is proposing to prioritize 83 services for review as potentially misvalued.


        The Diabetes Prevention Program is a structured lifestyle intervention that includes dietary coaching, lifestyle intervention, and moderate physical activity, all with the goal of preventing the onset of diabetes in individuals who are pre-diabetic. The clinical intervention consists of 16 intensive “core” sessions of a curriculum in a group-based, classroom-style setting that provides practical training in long-term dietary change, increased physical activity, and behavior change strategies for weight control. After the 16 core sessions, less intensive monthly follow-up meetings help ensure that the participants maintain healthy behaviors. The primary goal of the intervention is at least 5 percent average weight loss among participants.

        In March 2016, the Department of Health and Human Services announced that the CMS Office of the Actuary certified that expansion of the Diabetes Prevention Program model would reduce net Medicare spending.  The expansion was also determined by the Secretary to improve the quality of patient care without limiting coverage or benefits. These are the requirements a CMS Innovation Center model test must meet in order to be eligible for expansion as outlined in Section 1115A of the Social Security Act. The Diabetes Prevention Program is the second CMS Innovation Center – and the first preventive – model to meet these requirements.

        Today, CMS is proposing to expand the Diabetes Prevention Program into Medicare beginning January 1, 2018. Through its expansion, more Medicare beneficiaries would be able to access the benefits of the Diabetes Prevention Program, which could lead to the prevention of diabetes, improved health, and reduced costs. The Medicare Diabetes Prevention Program section included in the PFS proposal specifically seeks comment on the following:

        Medicare Diabetes Prevention Program Supplier EnrollmentCMS seeks comment on a proposal to allow CDC-recognized Diabetes Prevention Program organizations to enroll in Medicare beginning on January 1, 2017. CMS is contemplating requiring each person who provides services as part of a CDC-recognized Diabetes Prevention Program organization delivering these services to obtain a National Provider Identification number in order to provide Medicare Diabetes Prevention Program services.                                                    

        Payment StructureCMS seeks comment on a Medicare Diabetes Prevention Program payment structure, which ties payment to the number of sessions attended and the achievement and maintenance of a minimum weight loss. Claims for payment under the Medicare Diabetes Prevention Program would be submitted following the achievement of core session attendance and minimum weight loss, and following maintenance session attendance and maintenance of minimum weight loss.

        IT Considerations and CapabilitiesCMS seeks comment on requiring CDC-recognized Diabetes Prevention Program entities to submit claims to Medicare using standard claims forms and procedures, submitted electronically in batches. Claims submitted would be required to be traceable to care documented by the entity’s beneficiary records, which should include the requisite amount of detail associated with participation. Entities would also be required to maintain and handle any beneficiary Protected Health Information or Personally Identifiable Information, in compliance with HIPAA and CMS standards.

        Eligible BeneficiariesCMS seeks comment on defining an eligible pre-diabetic patient as a beneficiary having a body mass index (BMI) of 25 or greater (a BMI of 23 or greater for Asian beneficiaries) in addition to a hemoglobin A1c test with a value of 5.7-6.4 percent, or a fasting plasma glucose of 110-125 mg/dL within the last 12 months, or 2-hour plasma glucose of 140-199 mg/dl after the 75 gram oral glucose tolerance test, and no previous diagnosis of diabetes or life-threatening conditions, mobility issues, etc. that would prohibit them from participating in the program.

        Program Integrity InitiativesCMS intends to develop policies to monitor and audit Medicare Diabetes Prevention Program entities and is seeking comment on approaches to mitigate program integrity risks.

        Site of Service RequirementsCMS seeks comment on allowing service delivery in-person or virtually, clarifying that virtual services would not be considered part of current telehealth benefits.

        Learning and Technical Assistance RequirementsCMS seeks comment on providing education, training, and technical assistance on Medicare enrollment, data security, claims submission, and medical record keeping for Medicare Diabetes Prevention Program entities.

        Quality Measurement and ReportingCMS seeks comment on the quality metrics that should be reported by Medicare Diabetes Prevention Program entities in addition to the reporting elements required on Medicare claims submissions outlined above (attendance and weight loss) or by the CDC recognition program. CMS specifically seeks comment on what quality metrics should be considered for public reporting (not for payment) to guide beneficiary choice of entities.

        TimeframeCMS seeks comment on whether the Medicare Diabetes Prevention Program should be expanded nationally in the first year of the program or whether it should be phased in. If it is phased in, then the rule proposes that the Medicare Diabetes Prevention Program would be offered initially for a period in certain geographic markets or regions or to a subpopulation of provider/suppliers. The goal of the phased-in approach will be to anticipate and refine technical issues prior to consideration of broader model scaling. CMS seeks comment on such an approach generally, and specifically on what factors the agency should consider in the selection of initial sites or Medicare Diabetes Prevention Program entities.


        The proposed regulations will require health care providers and suppliers to be screened and enrolled in Medicare in order to contract with a Medicare Advantage organization to provide Medicare-covered items and services to beneficiaries enrolled in Medicare Advantage health plans.

        Background on Medicare Advantage Provider and Supplier Enrollment in the PFS  

        This proposal creates consistency with CMS’s current health care provider and supplier enrollment requirements for all other Medicare (Part A, Part B, and Part D) programs. It is also consistent with a recently published Medicaid Managed Care Rule that requires health care providers in a Medicaid managed care plan’s network to be screened and enrolled with the state Medicaid program.

        CMS believes this proposed rule is necessary to help ensure that Medicare enrollees receive appropriate or medically-necessary items or services from health care providers and suppliers that fully comply with Medicare enrollment requirements. The Medicare enrollment process helps to protect Medicare beneficiaries and the Medicare Trust Funds by carefully screening health care providers and suppliers, especially those that could pose an elevated risk to Medicare, to ensure that they are qualified to furnish Medicare items and services.

        Medicare beneficiaries, the Medicare Trust Funds, and the program at large are at risk when providers and suppliers that have not been adequately screened and enrolled. We believe our program integrity efforts in the Medicare enrollment process should be extended to all health care providers that receive Medicare payments, even when payment is received through an intermediary source such as a Medicare Advantage plan. 

        For instance, Medicare Advantage network providers that perform medically unnecessary tests, treatments, or procedures could threaten enrollees’ welfare, as could a physician who routinely overprescribes prescription drugs. Requiring providers and suppliers that contract with a Medicare Advantage organization and furnish Medicare-covered items and services to enroll in Medicare allows CMS to provide more robust and consistent oversight of these health care providers and suppliers. Anytime a health care provider or supplier fails to meet CMS requirements or violates federal rules and regulations, CMS may revoke enrollment and prevent them from billing Medicare’s Part A or B programs and from prescribing prescription medications covered by Medicare and Medicare Advantage Prescription Drug (MA-PD) Part D programs. This proposed rule also prevents Medicare Advantage participation by health care providers or suppliers that have had their Medicare enrollment revoked or have been excluded by the Office of the Inspector General.   

        Health care providers or suppliers – either as individuals or entities – can enroll in Medicare programs in accordance with the Social Security Act. For Medicare Advantage, the proposed enrollment and approved status requirement applies to:

        • Network providers and suppliers;
        • First-tier, downstream, and related entities (FDR);
        • Health care providers and suppliers in Program of All-inclusive Care for the Elderly (PACE) plans;
        • Suppliers in Cost Health Maintenance Organizations (Cost HMOs) and or competitive medical plans (CMPs). Medicare Cost HMOs and CMPs are types of Medicare health plans available in certain areas of the country. Some Cost HMOs or CMPs only provide coverage for Part B services. These plans do not include Medicare Part D prescription drug benefits; they are sponsored by employer or union group health plans or offered by companies that do not provide Part A services; 
        • Health care providers and suppliers participating in demonstration and pilot programs; 
        • Locum tenens suppliers that provide physician staffing services for hospitals, outpatient medical centers, government and military facilities, group practices, community health centers, and correctional facilities; and, 
        • Incident-to-suppliers that furnish integral, but incidental, professional services in the course of diagnosis or treatment of an injury or illness.


          As part of the proposed changes, the enrollment provisions would be included in CMS contracts with MA and MA-PD plans. Plans that do not meet these requirements may be subject to contract actions ranging from intermediate sanctions to contract termination. When final, these provisions will begin two years after publication of the final rule and will be effective on the first day of the plan year. 


          Consistent with the Administration’s commitment to transparency and making data publicly available, CMS is proposing to release two new sets of data related to plan participation in Medicare Advantage and the Part D prescription drug program. CMS hopes that making this data publicly available will assist public research that will support future policymaking efforts in the Medicare program and provide valuable information to beneficiaries in making enrollment decisions.

          Medicare Advantage Bid Pricing Data

          Each year, Medicare Advantage organizations (MAOs) apply to participate in the Medicare Advantage program through a bidding process.  MAOs submit bids to CMS that reflect the MAO’s estimated costs associated with providing benefits to enrollees.  CMS approves bids that meet a variety of statutory and regulatory conditions. 

          CMS is proposing to release data associated with these bids on an annual basis.  The data released would be at least five years old and would exclude information treated as proprietary.  CMS is also soliciting comment on what factors CMS should consider when proposing to release data that is more recent than five years old.

          Medical Loss Ratio Data

          The Affordable Care Act created a Medical Loss Ratio (MLR) for Medicare Advantage organizations and Part D plan sponsors, comparable to the standard created for commercial plans.  Under the MLR standard, at least 85 percent of revenues must be attributed to claims and quality improvement activities. 

          The Affordable Care Act required CMS to make commercial MLR data public, but did not require publication of Medicare MLR data. CMS is proposing to release Medicare health and drug plan MLR data on an annual basis for use by beneficiaries making enrollment decisions. 


          Section 218(b) of the Protecting Access to Medicare Act (PAMA) of 2014 establishes a new program under the statute for fee for service Medicare to promote the use of appropriate use criteria (AUC) for advanced diagnostic imaging services. 

          CMS established the first of the four components of this program in the CY 2016 Physician Fee Schedule final rule focusing on requiring an evidence-based and transparent process for developing AUC. AUC under this program may only be developed by qualified provider-led entities (the initial list of qualified entities is posted on the CMS website at This year’s proposed rule focuses on the next component of the Medicare AUC program and includes proposals for priority clinical areas, clinical decision support mechanism (CDSM) requirements, the CDSM application process, and exceptions for ordering professionals for whom consultation with AUC would pose a significant hardship. CDSMs are the electronic tools through which a clinician consults AUC to determine the level of clinical appropriateness for an advanced diagnostic imaging service for that particular patient’s clinical scenario. CMS has indicated in this proposed rule that the third component of the program (when ordering professionals must begin consulting CDSMs and furnishing professionals must append AUC related information to the Medicare claim) will not begin earlier than January 1, 2018. 


          The Medicare Shared Savings Program was established to promote accountability for a patient population, coordinate items and services under parts A and B, and encourage investment in infrastructure and redesigned care processes for high quality and efficient service delivery through provider and supplier participation in an Accountable Care Organization (ACO).  The CY 2017 PFS proposed rule includes the following proposed policies specific to certain sections of the Shared Savings Program regulations:

          • Updates to ACO quality reporting, including changes to the quality measure set and the quality validation audit, revisions to terminology used in quality assessment, revisions that would permit eligible professionals in ACOs to report quality apart from the ACO, and updates to align with the Physician Quality Reporting System and the proposed Quality Payment Program;
          • Modifications to the assignment algorithm to align beneficiaries to an ACO when a beneficiary has designated an ACO professional as responsible for their overall care;
          • Establishing beneficiary protection policies related to use of the SNF 3-day waiver; and,
          • Technical changes to certain rules related to merged and acquired TINs and for reconciliation of ACOs that fall below 5,000 beneficiaries, and other program refinements.

            CMS will accept comments on the proposed rule until September 6, 2016, and will respond to comments in a final rule. The proposed rule will appear in the July 15, 2016, Federal Register and can be downloaded from the Federal Register at:

            The Medical Management Institute – MMI – Medical Coding News & MMI Updates

            How an RMC Credentialed Coder Can Enhance the Business Side of Any Physician Practice

            RMC Registered Medical Coder Certification

            Long gone are the days in which physician practices could rely on a single office manager to oversee operations and perform the coding and billing. Today’s practices are under an almost unfathomable amount of scrutiny by auditors and payers, requiring a highly specialized knowledge of the healthcare system. Couple that with electronic medical record (EMR) implementations, the Affordable Care Act, and the recent transition to ICD-10, and you’ll find that many practices are struggling simply to stay in business. In fact, many practices have joined larger groups, hospital networks, or Accountable Care Organizations because of the option to share compliance risk and resources among various participants.

            ICD-10 and other regulatory requirements have also inspired a trend toward hiring credentialed coders who can help physician practices navigate regulatory changes with ease. Physicians are beginning to realize that selecting a code in ICD-10 is not a straightforward task. Physicians must choose from among hundreds of codes in an EMR dropdown menu. Even the narrative descriptions for many of these codes differ from their ICD-9 counterparts. Physicians either take the time to choose a correct and specified code—and therefore lose precious productive time—or they simply choose the first code that pops up regardless of its accuracy or specificity. Neither of these scenarios is good for the business side of the practice.


            Gaining a financial peace of mind


            In a post-ICD-10 world, certified coders provide an added layer of financial security by:

            • Validating code accuracy and specificity, which can, in turn, ensure accurate reimbursement and outcomes reporting
            • Determining whether documentation supports code assignment (i.e., Do clinical indicators and other details documented in the record match the code assigned?)

              Once this information is verified, billers are able to submit a clean claim with a lower likelihood of denial. Without this added level of review, practices run the risk of sending bills that are subsequently denied and that must be appealed or written off.

              In addition to promoting accurate code assignment, certified coders also enhance these other business processes within the practice: 

              • Clinical documentation improvement (CDI). CDI serves as the backbone of a practice, ensuring that patient severity and complexity is captured within the documentation.
              • Compliance. Certified coders establish ongoing internal audits that target E/M code assignment, diagnosis code assignment, and other high-risk areas identified by the Office of Inspector General and Recovery Audit Contractors.
              • Training and education. Certified coders provide training for all physicians and other staff members about important regulatory and coding changes, keeping everyone one step ahead of auditors.
              • Process improvement. Using data analytics and other tools within the EMR, certified coders monitor denials and identify/address the root cause of any problems. This is critical in ICD-10.


              Looking for the right credential


              Various organizations offer coding credentials and certifications; however, MMI’s Registered Medical Coder (RMC) credential is the only one in the industry that requires an annual retest to ensure ongoing competence. The retest measures coders’ knowledge of important CPT, HCPCS, and ICD-10-CM code changes that affect all specialty areas the majority of practices. An RMC-credentialed coder must also meet these requirements: 

              • Passing score of 76% or higher on the initial certification exam. Note that this is more stringent than any other coding certification industry standard. 
              • 12 CEUs annually.
              • Ability to demonstrate proficiency working in an online environment. MMI’s courses and certification exams are entirely online.


              MMI’s stringent standards for coding certification directly benefits physician practices seeking to maintain the highest degree of compliance. RMC-certified coders are able to identify areas of coding and documentation improvement and articulate important industry changes and their potential effects on the practice. By enabling prospective—rather than retrospective—compliance, RMC-certified coders enhance operational and financial efficiencies. A practice that employs a certified coder is ultimately a more profitable and compliant practice.


              About the Author

              Dari Bonner, RMC, CCP, CHCA
              Dari Bonner serves as the Chief Training Officer at the Medical Management Institute (MMI) where she is able to bring her 22 years of healthcare experience to the table. Dari has extensive consulting & project management experience, with her areas of expertise in both the public & private sector, hospitals, outpatient service centers and large & small physician practices. 


              About the RMC

              The Registered Medical Coder (RMC) certification is ideal for medical coders & billers in the physician office and outpatient setting. The credential is licensed through the Nonpublic Postsecondary Education Commission (NPEC) and is administered online through the Medical Management Institute (MMI). MMI is A+ accredited through the Better Business Bureau (BBB) and has been in business for nearly 30 years. MMI offers online medical coding training to prepare for the RMC Certification Exam. 





              The Medical Management Institute – MMI – Medical Coding News & MMI Updates

              …FREE CEU course on the 10th day of savings

              Free CEU Course Today Only

              On the 10th day of savings, MMI gave to me…a free CEU course with any purchase!

              Today only (December 21st) you will gain access to an online course worth 4-6 CEUs with ANY purchase. These courses have been pre-approved through MMI & the AAPC to be used towards your RMC, RMM, RMA, RMB, CPC, COC (CPC-H), CPC-P, CPMA and/or CPCP certification renewals. 

              Purchase your books, training courses or renewal fees today and specify the course you would like at the checkout page in the notes. You can choose from the following courses, normally $ 129 each: 

              1. ICD-10 and Other Factors Affecting Your Cash Flow (6 CEUs)
              2. Win with Medical Coding, Billing & Documentation (6 CEUs)
              3. Compliance in Pre-Registration & Registration (4 CEUs)
              4. Compliance in Billing, Claims Follow-Up and Appeals (4 CEUs)
              5. External Audits – Another Component of Compliance (4 CEUs)
              6. ICD-10 and Other Factors Affecting Your Cash Flow (6 CEUs)
              7. Claims Follow-Up, Appeals & Self-Pay Collections (6 CEUs)

              This promotion is valid on any of MMI’s training courses, books and certification programs. Reach out if you have any questions. Call 866-892-2765 or email


              12 Days of Savings

              Click here to learn more about the “12 Days of Savings” 


              The Medical Management Institute – MMI – Medical Coding News & MMI Updates

              MMI is Celebrating 30 Years of Excellence

              MMI is celebrating 30 years of business!
              MMI is proud to be celebrating 30 years of excellence! 

              2016 brings with it new projects, instructors & courses that we are excited to roll out. But what brings us the greatest pleasure is knowing that this will be our 30th year in business! We would like to take a moment to thank you for your continued support & business. It is because of clients like you that our company continues to improve and grow, so thank you for making this amazing milestone possible.

              Please take a look at our ongoing achievements and 2016 projects below and reach out anytime with any questions or need for support. 

              We hope you have a productive & Happy New Year!
              -The MMI Team

              Accreditation Achievements
              MMI is A+ accredited through the Better Business Bureau and the certification training programs are licensed through the Nonpublic Postsecondary Education Commission (NPEC). Postsecondary institutions choose to begin the licensing and accreditation process on a voluntary basis. In order to become accredited, institutions and programs must demonstrate they meet certain standards established by the accrediting agency. Click here to learn more about MMI’s accreditations & licenses. 

              RMC Medical Coding Program Format
              If you haven’t enrolled in MMI’s training programs in the past year, you should! MMI is revamping each online program with pre-recorded videos, practice tools & interactive instructor engagement to completely simulate a live environment, beginning with the RMC medical coding program. 

              Relevant, Up-to-Date & User-Friendly CEU Courses
              MMI prides itself on an engaging and user-friendly online training experience. We roll out a new batch of CEU courses quarterly which are completely online, self-paced, quick, convenient & highly educational. The most recent courses for 2016 have been pre-approved through the AAPC & MMI and are focused on ICD-10 and how you can protect your practice’s revenue. Click here to learn more about the 2016 CEU courses. 

              Xact/MMI Partnership
              MMI and Xact Healthcare Solutions, Inc formed a partnership to completely reinvent the idea of training online. With pre-recorded videos, an engaging learning platform and live webinars, medical professionals are able to train and certify from the comfort of their own home. 

              “We are excited to partner with Xact Healthcare Solutions, Inc and help our members and other healthcare professionals learn and grow in a convenient, online environment,” said Phillip Miles, CEO of MMI. “Working together we’ll deliver new solutions that connect the online learning aspect of MMI to the interactive training experience of Xact Healthcare Solutions,Inc so our clients can become certified without leaving their house.” Click here to learn more about the strategic partnership


              The Medical Management Institute – MMI – Medical Coding News & MMI Updates

              [Announcement] Private Payor Prices Will Be Used By Medicare to Set Payment Rates for Clinical Diagnostic Laboratory Tests Beginning in 2018

              Clinical Lab Tests

              On June 17, CMS released a final rule implementing Section 216(a) of the Protecting Access to Medicare Act of 2014 (PAMA), requiring laboratories performing clinical diagnostic laboratory tests to report the amounts paid by private insurers for laboratory tests. Medicare will use these private insurer rates to calculate Medicare payment rates for laboratory tests paid under the Clinical Laboratory Fee Schedule (CLFS) beginning January 1, 2018.

              The final rule includes provisions to ease administrative burdens for physician office laboratories and smaller independent laboratories. The final rule will generally require reporting entities to report private payor rates and test volumes for laboratory tests if an applicable laboratory receives at least $ 12,500 in Medicare revenues from laboratory services paid under the CLFS and more than 50 percent of its Medicare revenues from laboratory and/or physician services.

              For the system’s first year, laboratories will collect private payor data from January 1, 2016, through June 30, 2016, and report it to CMS between January 1, 2017, and March 31, 2017. CMS will calculate and post the new Medicare rates by early November 2017. These rates will take effect on January 1, 2018.

              For More Information:


              See the full text of this excerpted CMS press release (issued June 17).

              The Medical Management Institute – MMI – Medical Coding News & MMI Updates

              [Announcement] Helping Small Practices Prepare for the Quality Payment Program

              The Quality Payment Program is proposed to implement the new, bipartisan law changing how Medicare pays clinicians, known as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). On June 20, HHS announced $ 20 million to fund on-the-ground training and education for Medicare clinicians in individual or small group practices of 15 clinicians or fewer. These funds will help provide hands-on training tailored to small practices, especially those that practice in historically under-resourced areas including rural areas, health professional shortage areas, and medically underserved areas.

              As required by MACRA, HHS will continue to award $ 20 million each year over the next five years, providing $ 100 million in total to help small practices successfully participate in the Quality Payment Program. In order to receive funding, organizations must demonstrate their ability to strategically provide customized training to clinicians. And, most importantly, these organizations will provide education and consultation about the Quality Payment Program at no cost to the clinician or their practice. Awardees will be announced by November 2016.

              For More Information:


              See the full text of this excerpted HHS press release (issued June 20).

              The Medical Management Institute – MMI – Medical Coding News & MMI Updates

              Free Target Gift Card…On the 9th Day of Savings

              Free Target Gift Card Today Only (December 18)


              On the 9th day of savings, MMI gave to me…a free Target Gift Card with any purchase of training! Today only (December 18th) for every $ 100 you spend you will receive a $ 5 Target giftcard. For example, if you purchase a training course for $ 420, you will receive a $ 20 Target giftcard! 

              This promotion is valid on any of MMI’s training courses, books and certification programs. Reach out if you have any questions. Call 866-892-2765 or email


              12 Days of Savings

              Click here to learn more about the “12 Days of Savings” 

              The Medical Management Institute – MMI – Medical Coding News & MMI Updates

              …Free Books with the Purchase of Certification Training

              Free 2016 Coding Books

              On the 11th day of savings, MMI gave to me…FREE 2016 Coding Books!

              Today only (December 22nd) you will receive the 2016 CPT, ICD-10-CM and HCPCS II books for free (normally $ 279) when purchasing any of MMI’s certification training programs! The available training programs are detailed below: 

              Medical Coding (RMC and/or CPC®)
              Medical Billing (RMB)
              Medical Auditing (RMA)
              ICD-10-CM (Coders, Billers, Managers, Auditors, Clinical Staff)  


              Details: Select the program you would like to enroll in and use the drop-down menu to add on the books. At the checkout page, use promo code “12DaysBooks” for the discount. This promotion is only valid on December 21, 2015. Reach out if you have any questions. Call 866-892-2765 or email


              12 Days of Savings

              Click here to learn more about the “12 Days of Savings” 

              The Medical Management Institute – MMI – Medical Coding News & MMI Updates

              Five Documentation Vulnerabilities to Address in 2016

              Physician Documentation

              Expanding CDI to Physician Practices: Five Documentation Vulnerabilities to Address in 2016

              By Dari Bonner, RMC, CCP, CHCA, and Dr. Karen M. Fancher, MD, RMC, CPC, CANPC, CFPC . Originally published in AHIMA.

              Inpatient clinical documentation improvement (CDI) has thrived since the implementation of MS-DRGs. More recently, it has grown in popularity commensurate with the implementation of ICD-10-CM/PCS. In some cases, organizations took a holistic approach to ICD-10, deliberately embedding CDI specialists within their owned or affiliated physician practices to ensure a smooth transition—thereby expanding CDI efforts into outpatient and ambulatory settings.

              With the proliferation of accountable care organizations (ACOs) and the rise in healthcare mergers and acquisitions, many hospitals and health systems are looking for ways to continue the ICD-10 educational momentum and expand CDI efforts into outpatient, ambulatory, and physician practice settings. Beyond these hospital-led initiatives, many independent practices and private physicians are also quickly recognizing the importance of documentation quality—and how coded data translates to reportable outcomes. This article takes a deeper dive into implementing effective CDI programs within physician practices. 

              Why the Timing is Right

              In today’s healthcare environment, documentation is paramount, being used for medical coding and reimbursement. It’s also increasingly used to gauge the quality of care provided. When physicians accurately and thoroughly capture the true clinical picture of a patient’s condition or problem, not only do they justify medical necessity, they may also avoid third-party audit scrutiny and denials. This has a direct positive effect on cash flow and the overall successful operation of the business—for both hospitals and physicians.

              Regulatory changes have also forced physicians to take a closer look at clinical documentation. ACOs and bundled payments, for example, incentivize efficient and effective care, requiring physicians to document as specifically and completely as possible. Public outcomes data has also forced physicians to question the efficacy of their coded data, which almost always leads back to a discussion about documentation. In addition, the Physician Quality Reporting System (PQRS) and “meaningful use” Electronic Health Record (EHR) Incentive Program are pushing the need for better physician documentation. 

              In the years ahead, the Centers for Medicare and Medicaid Services’ (CMS’) new Merit-Based Incentive Payment System (MIPS) will become a significant regulatory driver behind physician practice CDI. This program, which consolidates the PQRS, value-based payment modifier (VBPM), and meaningful use incentive program, uses data collected during 2017 to determine potential payment adjustments in 2019. Payment adjustments are determined based on a MIPS composite score that is partially driven by the coding of hierarchical condition categories (HCC), making HCC capture vital in the practice setting. 

              Negative payment adjustments will be distributed as follows, depending on whether a provider’s composite score falls below a particular performance threshold: four percent in 2018, five percent in 2019, seven percent in 2020, and nine percent in 2021 through 2023. Above-par performance could earn a physician a bonus as high as 12 percent in 2018 and 27 percent by 2021.

              Because of this potential negative impact on finances due to lax clinical documentation, CDI programs in physician practices will certainly become the norm. The question today is: How can HIM professionals help support them?

              Logistics of CDI in a Physician Practice

              Unlike hospitals that have more operational and personnel resources for CDI, physician practices must often rely on a certified coding professional or office manager to perform the task. In addition to overseeing CDI efforts, these individuals may also be responsible for checking patients in and out, obtaining insurance authorizations, responding to audits, coding, billing, performing accounts receivable follow-up, contracting, and much more. 

              Given the plethora of responsibilities, CDI must therefore be extremely targeted and thoughtful in the practice setting. Those charged with CDI must audit documentation frequently so they can pinpoint educational opportunities for each individual provider—physicians, nurses, medical assistants, and scribes.

              Another challenge is that CDI in a physician practice is often retrospective. Practices typically receive a denial and then perform physician or staff education based on the reason for the denial. Unfortunately, by the time the education occurs most physicians don’t remember making the documentation error or omission, and don’t recall the specifics of the case. Retrospective CDI also permits subsequent errors to snowball, causing a cascade of denials before a correction is provided. 

              To be truly effective, practices need a “front-to-back” approach—proactive education and concurrent CDI on the front end of the process. This may require a more dedicated CDI resource within the practice as well as close collaboration with the practice’s EHR vendor to remediate documentation vulnerabilities, tweak templates, and update documentation alerts and prompts. 

              Physician Documentation Vulnerabilities

              To identify documentation vulnerabilities, one needn’t look further than the “FY 2016 Office of Inspector General (OIG) Work Plan” in which the OIG identifies trends and patterns of compliance risk and fraud. Some of these include non-covered chiropractic and anesthesia services as well as unreasonable use of prolonged services, high use of outpatient physical therapy services, and non-compliant referrals/orders for certain Medicare services, supplies, and durable medical equipment. But there are many other areas ripe for CDI. Consider the following five areas.

              1. Cloned notes and assessments

              This occurs when nurses or other providers copy and paste information from a previous visit into the current visit without verifying the accuracy of that information. In many cases, details are completely inaccurate or omitted entirely. There’s also often a mismatch between the chief complaint/history of present illness and the assessment. For example, a patient complains of neck pain but the entire assessment addresses the patient’s lower back pain. This incongruence can certainly benefit from a CDI specialist’s analytical eye.

              2. Medical necessity

              Physicians sometimes don’t understand that medical necessity isn’t synonymous with medical decision making. The specific ICD-10 diagnosis codes that the physician chooses can either make or break a payer’s decision to deem services medically necessary for the patient. Many physicians don’t even realize that local coverage determinations (LCDs) exist, requiring certain diagnoses as a prerequisite for payment. As payers continue to update these LCDs in light of ICD-10, someone focused on CDI can monitor changes and ensure that documentation is updated accordingly. 

              3. ICD-10 diagnosis specificity

              Certain specialties, such as orthopedics, OB/GYN, internal medicine, and cardiology, saw many more code expansions in ICD-10-CM than others. These specialties could benefit from CDI that prompts greater specificity related to laterality, disease manifestation, anatomical location, and more. An individual trained in CDI can help explain ICD-10 terminology to physicians and create ICD-10 favorite lists and shortcuts to alleviate the burden of sifting through diagnosis codes listed in the EHR—ultimately increasing productivity.

              Unspecified codes may prove to be particularly problematic in practices. That’s because CPT codes—not diagnosis codes—drive reimbursement in the practice setting, leaving little incentive for physicians to pay attention to diagnoses. In addition, the American Medical Association/CMS joint announcement made last July indicates that contractors conducting medical reviews (i.e., Medicare administrative contractors, recovery auditors, zone program integrity contractors, and the supplemental medical review contractor) during the 12-month period following ICD-10’s implementation on October 1, 2015 could not deny claims solely for the specificity of the ICD-10 code. This is as long as the code is in the correct family of codes (i.e., the correct ICD-10 three-character category) and there is no evidence of potential fraud. This flexibility applies to both automated and complex medical reviews. 

              Many physicians don’t understand that this flexibility pertains only to Medicare and only to retrospective audits. Some have misinterpreted the announcement to mean that they have complete flexibility with all payers for ICD-10 reporting on the front end. Someone well-versed in CDI can ensure compliant coding that won’t subsequently jeopardize reimbursement once the Medicare flexibility has expired.

              4. E/M levels

              Due to fear of denials and audits, physicians frequently down-code their evaluation and management (E/M) levels (i.e., code a lower-level, lesser paying E/M code). In some cases, a higher level might be justified if the individual trained in CDI can identify opportunities where documentation is lacking—and then query for clarification. In other cases, a CDI specialist can identify patterns of over-coding that could trigger an audit or raise a payer’s red flag. An example is when a physician provides a follow-up office visit or subsequent hospital visit and then bills using a higher level E/M code as though a comprehensive new patient office visit or an initial hospital visit had been provided.

              5. Bundling and modifier usage

              CDI specialists can help physicians identify when it’s appropriate to use a modifier and when a particular procedure or service is inherent in a more extensive procedure or service performed at the same time. 

              How to Get Started with Physician CDI

              In this age of documentation scrutiny, physician practices can’t afford to wait for an OIG or CMS audit to reveal noncompliance. Doing so could put a practice out of business. It’s also in the practice’s best interest to improve documentation if it’s part of an ACO, shared-savings initiative, or larger health system. Consider these three strategies:

              • Hire a certified coding professional. Several associations, including AHIMA, can point a practice to certified coding professionals. By ensuring that documentation meets regulatory requirements, a certified coding professional is an invaluable asset for any physician practice. A certified coding professional can also use his or her auditing skills to provide CDI feedback. Allow coding professionals to spend time in the clinical areas of the practice so they become more familiar with clinical diagnoses and procedures and can assist with documentation improvement.
              • Focus on collaboration. Collaboration among key staff members in the provider practice will help providers document better and more efficiently. Also, quality CDI programs can help a practice streamline processes and procedures that currently create extra work for office staff and providers alike. 
              • Seek assistance from hospital-based CDI specialists and HIM directors. These individuals can share valuable resources (i.e., policies, documentation tools/tips) that can help practices launch their CDI efforts.

                Documentation quality begins in the outpatient setting. Physicians who document well in their practices help establish a baseline for patient severity and justify medical necessity for inpatient services. Quality documentation enhances outcomes and ensures accurate revenue. Now is the time to evaluate needs, build partnerships, and begin the important task of improving physician practice documentation. 

                CDI Training

                Healthcare is rapidly changing. Stay in the game by taking a proactive approach to clinical documentation.

                Online Clinical Documentation Improvement Course: Click Here



                The Medical Management Institute – MMI – Medical Coding News & MMI Updates

                Home Health Care: Proper Certification Required

                Originally Published on

                The Affordable Care Act requires a physician or a non-physician practitioner to have a face-to-face encounter with the beneficiary before a physician certifies the beneficiary’s eligibility for the home health benefit. One aspect of the certification is for the certifying physician to certify (attest) that the face-to-face encounter occurred and document the date of the encounter. For medical review purposes, Medicare requires documentation in the certifying physician’s medical records and/or the acute/post-acute care facility’s medical records to be used as the basis for certification of patient eligibility. This documentation must include the clinical note or discharge summary for the face-to-face encounter. Avoid home health claims payment denials or improper payment recoveries by understanding Medicare’s requirements.




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                The Medical Management Institute – MMI – Medical Coding News & MMI Updates