New Codes, New Schemes,

It’s A New Year

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 Housekeeping

• 1 AAPC CEU – Certificate is downloadable from

WEBEX and will also be emailed to all attendees
• A PDF version of the presentation will be emailed to all
attendees
• If we don’t get to your questions, we will respond via
email after the webinar
• Post-webinar survey will appear in a pop-up window.

Thank you!

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 Disclaimer
Any:
• fraudulent activities,
• schemes,
• or suspicious claims
discussed do not in any way represent the opinions of Healthcare Fraud
Shield regarding:
• race,
• religion,
• ethnicity,
• or nationality.
The information in this presentation is based on the experience and
knowledge of the presenter(s). Opinions may vary regarding this process.
This presentation is for educational and informational purposes only. It should
never supersede the procedures established by your organization.

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 Speakers

Kate Johnson, C.P.C.

Healthcare Fraud Shield, SIU Investigator

Jennifer Hendrix, C.F.E., C.P.C., C.P.M.A.

Healthcare Fraud Shield, Fraud Scheme Analyst

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 HCPCS Changes

C Codes M Codes
1 new 30 newM Codes
1 chg. 4 deleted
30 new
A Codes GG Codes
Codes
11 new 4 payment 96 new
A Codes 5 deleted 3896 new
deleted
4 deleted
11 new 6338 deleted
chgs

63 chgs

E Codes Q Codes
1 new J Codes 2 new
E Codes 6 new
Q Codes
J Codes
5 payment
1 new 1 deleted 2 new
6 new
5 payment
1 deleted

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 Aduhelm J0172 Alerts

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 What’s New?

Checking it Twice

249 new CPT codes

63 CPT code deletions

93 CPT code revisions

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 What These Changes Bring

Remote Monitoring 98975 98976 98977 98980 98981

Principal Care Management 99424 99425 99426 99427

Chronic Care Management 99437

Trabecular Bone Score 77089 77090 77091 77092

Tissue Analysis Cat III 0689T 0690T 0648 0697T 0649T 0698T
Drug-eluting implant 68841

Pathology Clinical Consults 80503 80504 80505 80506

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 Pathology Clinical Consultation
80503 Pathology clinical consultation; for
Pathology clinical consultation services describe a clinical problem, with limited
physician pathology clinical consultations provided at the review of patient's history and
medical records and
request of another physician or qualified healthcare straightforward medical decision
professional. making When using time for code
selection, 5-20 minutes of total
time is spent on the date of the
4 new codes introduced for 2022 consultation.
80504 Pathology clinical consultation; for
a moderately complex clinical
problem, with review of patient's
history and medical records and
moderate level of medical decision
making When using time for code
selection, 21-40 minutes of total
time is spent on the date of the
consultation.
80505 Pathology clinical consultation; for
a highly complex clinical problem,
with comprehensive review of
patient's history and medical
records and high level of medical
decision making When using time
for code selection, 41-60 minutes of
total time is spent on the date of
the consultation.
80506 Pathology clinical consultation;
prolonged service, each additional
30 minutes (List separately in
addition to code for primary
procedure)
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 Pathology Clinical Consultation
What to look for in the data:
Possible Schemes:
– Excessive units of 80505 and 80506
– Upcoding – Billing fewer units of 80503 compared to peers
– Misrepresentation of consultation – No prior relationship with referring provider
– Kickbacks between pathologist and – Disproportionate number of consults from one
referring provider referring provider

Case tips:

– Request provider’s orders when requesting

records to review
– Referring provider interviews
– Validate documented time in record
– What other services did the pathologist perform
on that date of service? Did they work beyond a
probable work-day?
– If reviewing for an improbable workday or
impossible day scenario, it may be beneficial to
request records for all members treated on
specific dates of service
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Pathology Clinical Consultation Alert

[2519-20] - UPCODING, PATHOLOGY

CLINICAL CONSULTATION: This Alert
identifies providers excessively billing pathology
clinical consultations for highly complex clinical
conditions versus a lower or moderate clinical
conditions, potentially due to higher
reimbursements, when compared to their peers.
(PEER COMPARISON)
[2519-30] - UPCODING, PATHOLOGY
CLINICAL CONSULTATION: This Alert identifies
providers excessively billing pathology clinical
consultations for highly complex clinical
conditions versus a lower or moderate clinical
conditions codes, potentially due to higher
reimbursements, on 80% or more of their claims.
(INDIVIDUAL TIER)

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 Remote Therapeutic Monitoring
98975
Remote therapeutic monitoring (RTM) is a telemedicine
service used to collect non-physiologic data—respiratory
system status, musculoskeletal system status, therapy
98976
adherence, therapy response, etc.
5 new codes introduced for 2022
98977
98980
98981
Remote therapeutic monitoring (eg, respiratory
system status, musculoskeletal system status,
therapy adherence, therapy response); initial set-
up and patient education on use of equipment
Remote therapeutic monitoring (eg, respiratory
system status, musculoskeletal system status,
therapy adherence, therapy response); device(s)
supply with scheduled (eg, daily) recording(s)
and/or programmed alert(s) transmission to
monitor respiratory system, each 30 days
Remote therapeutic monitoring (eg, respiratory
system status, musculoskeletal system status,
therapy adherence, therapy response); device(s)
supply with scheduled (eg, daily) recording(s)
and/or programmed alert(s) transmission to
monitor musculoskeletal system, each 30 days
Remote therapeutic monitoring treatment
management services, physician or other qualified
health care professional time in a calendar month
requiring at least one interactive communication
with the patient or caregiver during the calendar
month; first 20 minutes
Remote therapeutic monitoring treatment
management services, physician or other qualified
health care professional time in a calendar month
requiring at least one interactive communication
with the patient or caregiver during the calendar
month; each additional 20 minutes (List separately
in addition to code for primary procedure)

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 Remote Therapeutic Monitoring
Possible Schemes: What to look for in the data:

– Services not rendered – Excessive units of 98980 and 98981

– Misrepresented services – Diagnoses not related to the respiratory or
– Incident-to billing musculoskeletal systems
– Billing of 98975 more than once per patient
– Billing performed by an anomalous specialty
– Use of a non-FDA approved device

Case tips:

– Member interviews are critical

– Verify that the device is FDA approved
– Verify that data is recorded and transmitted
regularly
– Interaction between the patient and provider
must be documented at least once per calendar
month

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Remote Therapeutic Monitoring Alert

[2517-01] INAPPROPRIATE
NUMBER OF UNITS, REMOTE
THERAPEUTIC MONITORING:
This Alert identifies providers
billing remote therapeutic
monitoring device supply
codes more than once in a
30-day time span.

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 Principal Care Management
Principal care management (PCM) allows physicians
and qualified health care professionals to report care 99424 PCM services by a physician or
management services for patients with one complex QHP; ≥30 minutes of physician
chronic condition. or QHP time per calendar
month
4 new codes introduced for 2022 99425 each additional 30 minutes of
physician or QHP time per
calendar month (List
separately in addition to 99424
for each full 30 minutes
beyond the first 30 minutes)
99426 PCM services by clinical
staff/physician/QHP; first 30
minutes of clinical staff time
directed by physician or other
QHP per calendar month
99427 each additional 30 minutes per
calendar month (List up to 2
units separately in addition to
99426)

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 Principal Care Management
Possible Schemes: What to look for in the data:

– Services not rendered – Excessive units of 99425

– Misrepresented services – More than two units of 99427
– Kickbacks – Diagnoses inconsistent with a chronic condition
• What’s past is prologue: – Overlapping care management services
Alabama State Representative Ed Henry

Case tips:

– Member interviews
– Review records to verify that time billed is for
only one clinical staff member
– Verify that the time billed is for patient care
– Is a third-party performing care management
on behalf of the provider? If so, request
contracts.
– Do the records support the billed diagnosis?

CONFIDENTIAL © 2021. All Rights Reserved Healthcare Fraud Shield 16

 Principal Care Management Alert

[2518-20] - BILLING FOR

SERVICES NOT RENDERED,
PRINCIPAL CARE MGMT (PCM)
SERVICES: This Alert identifies
providers excessively billing
principal care management
services (PCM) when compared
to their peers.
(PEER COMPARISON)

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 Happy Holidays

CONFIDENTIAL © 2021. All Rights Reserved Healthcare Fraud Shield

 About Healthcare Fraud Shield

An AI-driven anomaly detection

module that identifies risk vectors
from emerging schemes and
behaviors

Expert analysis of claims, development of cases, data mining, record reviews and detection of systemic
weaknesses

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 Contact Us
Jennifer Hendrix
jhendrix@hcfraudshield.com

Kate Johnson
kjohnson@hcfraudshield.com

Karen Weintraub
kweintraub@hcfraudshield.com

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