By Betsy Priest, Coding Manager

Did you know?

You can bill for both an E/M with a vaccination code when the visit warrants it.  Guidelines are below:

  • the presenting problem or problems should be minimal
  • five minutes are spent performing or supervising services such as blood pressure checks
  • There needs to be a diagnosis other than the vaccine itself (Z code) – Rash, reason for vaccine, chronic conditions, etc.
  • These services do not need to be performed by an MD or midlevel, they can be performed by a nurse.

Modifier 25 must be appended to the service and submitted without the vaccine diagnosis code. If done by time it is a 5 minute visit.

If the patient is coming in strictly for an immunization, and there is no counseling or work up for any other issue or side effect, only the Immunization code should be submitted.

If you are counseling the patient on the immunization itself there are codes for the administration with counseling (they may reimburse at a higher level than the regular admin codes). The codes are: 90460 and 90461.

If you would like more information about how we can tailor our services to meet your needs, please contact Betsy Priest, Coding Manager at 716.348.3904 or


By Becky Priest, Coding Manager

Effective February 1, 2017 coders will begin using the following:

  • For new patients, 8 organ systems is STILL a comprehensive exam.
  • Established patients: This will be VERY important on your established level 4’s (Office/ED settings) and subsequent level 3’s (Inpatient/OBS setting).
    • Instead of needing 2-7 body areas/organ systems, you will now need to document 6-7 BODY AREAS/ORGAN SYSTEMS (Expanded documentation of the areas and/or systems examined; requires more than checklists; it needs to have normal/abnormal findings documented upon

  • For an expanded problem focused exam the requirement now is 2-5 BODY AREAS/ORGAN SYSTEMS (Minimal detail for areas and/or systems examined: check list type documentation without any expansion of findings)

To summarize: The new exam scoring change and the E&M codes it affects, please refer to the table below:

Type of Exam OLD SCORING NEW SCORING A MUST for the following E/M levels:


2-5 BODY AREAS/ORGAN SYSTEMS Office established Patient 99213

Office New Patient 99202 & 99203
ED Patient 99282 & 99283

Hospital subsequent patient 99232 (Inpatient), 99225 (Obs)


DETAILED 2-7 BODY AREAS/ORG SYSTEMS (minimal detail) 6-7 BODY AREAS/ORGAN SYSTEMS Office Established Patient 99214

Office New Patient 99203

ED Patient 99284

Hospital subsequent patient 99233 (Inpatient), 99226 (Obs)


Office New Patient 99204

ED Patient 99285

New Hospital patient 99222, 99223 (Inpatient), 99219 and 99220 (Obs)


If you would like more information please feel free to reach out to us.

If you would like more information about how we can tailor our services to meet your needs, please contact Betsy Priest, Coding Manager at 716.348.3904 or


By Betsy Priest, Coding Manager

As of Oct 1, 2016, updates to the ICD-10 codes were put in to effect.  Some areas that may be of interest to you are:

  • Code assignment/Clinical criteria – A diagnosis will be added when a provider states that a condition exists. It is no longer dependent on showing the clinical criteria that brings the Physician to that diagnosis.
  • Laterality – The laterality of any injury needs to be documented to assign a code. If one side is treated and no longer is an issue, then the documentation needs to change from bilateral to the side that is now affected (cataracts are a good example).
  • Pathologic Fractures – 7th character A is for when the patient is receiving active treatment – not whether the provider has seen the patient before. 7th character D is for after the patient has completed active treatment.
  • Long Term use of Insulin – This needs to be documented so that it can be coded.

In addition to the above bullets, some diagnoses have been added, now requiring a 4th, 5th and 6th digit. It is important to look at any and all code lists that you use to ensure that they include all of the most up to date codes.

If you would like more information about how we can tailor our services to meet your needs, please contact Betsy Priest, Coding Manager at 716.348.3904 or Betsyp@pracfir


By Betsy Priest, Coding Manager


Two new codes are available to help capture a patient’s advanced care planning.  These can be used in any setting, regardless of the specialty.

99497: Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.

99498: Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

These codes will be used to capture the time you spend in addition to what is already being done with the patient.  If you have a regular visit with the patient, code that visit with a modifier 25 and then the above codes. If you are only seeing the patient for Advanced Care Planning, you would only use these codes.

These are time based codes.  99497 is for the first 30 minutes of Face to Face time with the patient and the 99498 is for each additional 30 minutes. This is only face to face time with the patient.

The documentation needs to clearly state the total time, that it was face to face, and what was discussed.  (The providers do not need to re-write parts of their note if this information is elsewhere. We need to be able to clearly see what was discussed and that it was advanced care planning).

Reimbursement amounts have not been determined yet. CMS states that in 2016, they will reimburse these services, but no payment amount has been established. This was open for discussion through December 31, 2015 and no final decision regarding the reimbursement amount has been published as of yet.

These services can be performed by physicians as well as mid-levels

If you would like more information about how we can tailor our services to meet your needs, please contact Betsy Priest, Coding Manager at 716.348.3904 or


By Betsy Priest, Coding Manager


Revisions, addition and deletions to the CPT and HCPCS code set are effective January 1, 2016. Use of deleted codes will delay payment, as we will need to “Chart Return” the charge slips to your office for the correct code.

To determine which clients will be impacted by the 2016 changes, we have compared these changes to each client’s procedures performed in 2015.

We will be faxing, mailing or delivering customized reports to our Clients that are impacted by the 2016 CPT changes.

If you would like a complete listing of all the Deleted, New, and Revised Codes, we can provide that upon request.


During some visits you may spend a lot of time with a patient counseling them or coordinating their care.  If this happens, and you have the correct documentation in your note, leveling of your Evaluation and Management codes can be captured by time in lieu of the 3 main components.

It is a good tool for those patients that use a lot of your time, knowledge and resources and wind up with a very straight forward problem.

A good example of documentation needs for coding by time is: “This encounter was 30 minutes long and over half of that time was spent on counseling and coordination of care”.  You can also give a brief overview of what was discussed, if you would like.  But it will not be needed in this statement if the rest of your note supports that.

Your visit can be coded by time if the statement above is listed in the body of the note.  “This was a 45 minute visit” or “I spent 45 minutes with the patient” is not considered to be acceptable by the payers.

If you would like more information about how we can tailor our services to meet your needs, please contact Betsy Priest, Coding Manager at 716.348.3904 or Betsyp@pracfir


 By Becky Priest, Coding Manager
Medical Record Documentation and Coding Tips:

1. State the diagnosis to the highest level of specificity known

  • Document all conditions treated or related to treatment at the time of the visit
  • State the conditions as worsening, improving, stable, acute, etc.
  • Clearly state how the condition is being treated or monitored

2. Create a clear relationship between the diagnoses

  • Use linking verbiage such as “due to”, “because of”, “related to”
  • Coding guidelines prohibit coders from making assumptions

3. Include all conditions related to health status

  • Document chronic and permanent diagnoses as often as they are assessed or treated
  • Document chronic and permanent diagnoses when they are a consideration in the care of the patient
  • Frequently overlooked, but significant conditions include: transplant status, quadriplegia, dialysis status, current ostomies, amputations and asymptomatic HIV infection

4. Abbreviations

  • Only use standard abbreviations
    • This includes  HIV, CHF, AIDS, CABG, HTN, UTI, ENT, and many others
  • Making your own abbreviations can cause coding issues including the wrong procedure or diagnosis being coded
  • If you are using abbreviations only use those that are universally known between other clinical staff, coders as well as the payers
If you would like more information about how we can tailor our services to meet your needs, please contact Betsy Priest, Coding Manager at 716.348.3904


By Tom Maher, President and CEO


By now, ICD-10 is likely fully operational in your practices.  Practicefirst’s offers you the following tips while using the new code set:

  1. BE SPECIFIC-the layers in ICD-10 are deep. Accurate reporting is a CMS expectation.
    1. Tell us if a motor vehicle accident happened in a car, suv, pickup truck or van
    2. Cellulitis vs. Abscess
      1. ICD-10 gives different codes for each whereas they were combined in ICD-10.
      2. Do NOT use the term CELLULITIS & ABSCESS in your documentation interchangeably.
    3. Sprain vs. Strain:
      1. ICD-10 classifies these as different.
      2. Specify STRAIN vs. SPRAIN
      1. More specificity, please! See the fracture section of your ICD-10 manuals for elaboration.  This is a highly expanded section containing much detail.

Diagnosis Coding Tips:

  • Always code each health care encounter to the level of certainty known for that encounter. All providers are expected to code correctly and have sufficient documentation to support the codes selected.
  • Medicare did not require external cause reporting in ICD-9-CM and does not require external cause reporting in ICD-10-CM. Similar to ICD-9-CM, there is no national requirement for mandatory ICD-10-CM external cause code reporting. Unless you are subject to a state-based external cause code reporting mandate or these codes are required by a particular payer, you are not required to report ICD-10-CM codes found in Chapter 20 of the ICD-10-CM, External Causes of Morbidity.
  • In both ICD-9-CM and ICD-10-CM, sign/symptom and unspecified codes have acceptable, even necessary, uses. While you should report specific diagnosis codes when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, in some instances signs/symptoms or unspecified codes are the best choice to accurately reflect the health care encounter.
  • If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information is not known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code (for example, a diagnosis of pneumonia has been determined but the specific type has not been determined). In fact, you should report unspecified codes when such codes most accurately reflect what is known about the patient’s condition at the time of that particular encounter. It is inappropriate to select a specific code that is not supported by the medical record documentation or to conduct medically unnecessary diagnostic testing to determine a more specific code.

If you are not currently a coding client of Practicefirst, call us to find out how you can become one!

If you would like more information about how we can tailor our services to meet your needs, please contact Practicefirst at 716.834.1193 or


Billing Updates
By Tom Maher, President and CEO
On 10/19/15, NGS notified the provider community regarding claims denying in error for the following CPT codes: G0010, G0009, 90630, 90669, 90670, 90732, 90739, 90740, 90743, 90744, 90746, and 90747.
The error deals with claims submitted under ICD-10 Z23. NGS has indicated that a mass adjustment will soon be completed for those claims that denied in error.
BCR issued a STAT Bulletin on October 23, 2015 to PCP’s, OB-GYN’s, Endocrinologists, Orthopedists and Behavioral Health Practitioners regarding a change to the Performance and Quality Programs Measures. The National Committee for Quality Assurance (NCQA) recently announced the following HEDIS measure will no longer be used: Use of Appropriate Medication for people with Asthma. Effective November 1, 2015, this measure will be removed from the BCR 2015 Pay for Performance Incentive Program.
One cycle of BCR payments were paper checks vs. EFT. The check cycle was the week of 10/04/2015 and has since been corrected.
Effective immediately, referrals will no longer be required for IHA MediSource and Child Health Plus members.  Based on feedback from providers, IHA removed the referral requirement to ease the administrative burden in your offices.  IHA encourages providers to coordinate your patients care to ensure the best possible outcome. It is important to note that primary care physician referrals are still required for members in the Restricted Recipient Program.
IHA currently offers the Dual Difference Medicare Advantage HMO product in Erie and Niagara counties to Medicare beneficiaries who also qualify for Medicaid coverage. However, they will discontinue offering Dual Difference as of December 31, 2015. They will be working closely with their community partners and their members to help them find a plan that meets their needs.
For Billing questions, please contact Tom Maher at 716-834-1193 or


The wait is over! ICD-10 has arrived!

Practicefirst’s is pleased to announce that all coders coding beyond 10/1/2015 are ICD-10 proficient!


  1. EXERCISE CAUTION when choosing ICD-10 codes from your EMR. The lists are VERY detailed and it is very important the chosen code contains ALL characters and that it does not conflict with any other documentation in the patient’s record.
  2. UNDERSTAND CODING GUIDELINES AND SEQUENCING RULES!! Every practice should have a current ICD-10 book and/or subscribe to an online service such as
  3. Be sure your SUPERBILL’s dated 10/1/2015 (date of service) and forward indicate ICD-10 codes otherwise they will be returned to you.
  4. Ask these questions before assigning an ICD-10 code:
    • Presence or absence of complication = potential combination code?
    • Any Manifestations?
    • Is there a causal relationship?
    • Have I indicated the episode of care (initial, subsequent, late effect) where appropriate (e.g. injuries?)
    • Have I defined subsequent fracture care appropriately (healing status)?


Last minute TIP….ASTHMA:

Have you classified the patient’s asthma properly? Please see the guidelines below

Stages of asthma

National Asthma Education & Prevention Program Guidelines

Mild Intermittent Symptoms < 2X week asymptomatic Symptoms < or = 2X monthly >80%
Mild Persistent Symptoms > 2X daily to < 1X daily Symptoms > or + 2X monthly >80%

>Variability 20-30%

Moderate Persistent Daily symptoms

Daily use of beta 2 agonist

Symptoms > 1X week 60-80%
Severe Persistent Continual symptoms

Limited physical activity

Frequent <60%


  1. ICD-9CM is outdated and has obsolete terminology
  1. ICD-10 provides more specific data, better reflects current medical practices, contains updated medical terminology and has improved accuracy in the definition/classification of diseases.
  1. Expanded data capture for reimbursement and data reporting!! Do not miss this!
  1. Continued reporting of ICD-10 codes that lack specificity may contribute to a downward adjustment (Value Based Modifier) and may impact any PQRS reporting your practice is currently doing or would like to do in the future.
  1. Quality is being measured!

If you are not currently a coding client of Practicefirst, call us to find out how you can become one!

If you would like more information about how we can tailor our services to meet your needs, please contact Practicefirst at 716.834.1193 or




Cyberattack affecting Excellus BlueCross BlueShield, Univera, Lifetime HealthCare Companies and Affiliates

On August 5, 2015 it was determined that a sophisticated cyberattack gaining unauthorized access to the information technology systems at Excellus BlueCross Blue Shield, Univera Healthcare and Lifetime Healthcare companies and their affiliates  on December 23, 2013!  The cyber attackers may have gained unauthorized access to individuals’ information which could include name, date of birth, Social Security number, mailing address, telephone number, member identification number, financial account information and claims information.    The current investigation has not determined that any data was removed from the IT systems and there has been no evidence to date that data has been used inappropriately.

The above carriers are working with Mandiant, a cybersecurity firm to conduct an investigation and have notified the FBI.  Notices will be sent to individuals impacted by this security breach by November 9, 2015.  Free credit monitoring and identity theft protection services are available for anyone affected by the attack.

The incident affects members, patients or other who have done business with the plans listed below:

  • Excellus BlueCross BlueShield
  • BlueCross BlueShield of Central New York
  • BlueCard Members – if services where received in the local Excellus service area
  • BlueCross BlueShield of the Rochester Area (Finger Lakes BlueCross BlueShield and BlueCross BlueShield of the Rochester Area)
  • BlueCross BlueShield of Utica-Watertown (BlueCross BlueShield of Greater Utica and Watertown BlueCross)
  • Univera Healthcare (HealthCare Plan, Prepaid Healthcare Plan, Univera Healthcare-CNY, Univera Community Health and Buffalo Community Health)
  • The MedAmerica Companies (Finger Lakes Long Term Care Insurance Company)
  • Lifetime Benefit Solutions (EBS Benefit Solutions, EBS-RMSCO and RMSCO)
  • Lifetime Care (Genesee Region Home Care Association and Genesee Region Home Care of Ontario County)
  • Lifetime Health Medical Group (HealthCare Plan Medical Centers, Health Services Medical Group and Lifetime Health Centers)