By Lisa Kropp, Manager Coding and Credentialing


There are no new ICD-9-CM code updates effective October 1, 2014.  This is due to the code freeze as implementation of ICD-10-CM approaches.


  • Definition:  A causal relationship is a documented link between a disease (etiology) and a condition (manifestation) caused by that disease.
  • Evidence:  The provider MUST establish an unambiguous link in the documentation.  Coders can NOT assume!


  • When hypertension is the cause of heart disease, document “Hypertensive Heart Disease”
    • Avoid separate statements of: Hypertension and Heart Disease.  This statement doesn’t establish a causal relationship.
  • When diabetes is the cause of Chronic Kidney Disease, document “Diabetic CKD”.
    • Avoid separate statements of: Diabetes, CKD stage III
  • When diabetes is the cause of Osteomyelitis, document “Diabetic Osteomyelitis”.
    • Avoid separate statement of Diabetes, Osteomyelitis.
      • **Note that ICD-9-CM guidelines allow us to assume a causal relationship between diabetes and osteomyelitis.  However, ICD-10-CM does not!


The National Government Services Medical Review Department was conducting prepayment reviews on CPT codes 99214 and 99215 effective 5/21/14. This prepayment review will be modified to remove CPT code 99214; CPT code 99215 will continue to be reviewed.

A prepayment review consists of a medical review of claims prior to payment. Request for records are most frequently electronically generated and referred to as Additional Development Requests (ADR’s). Please note that when medical records are requested, it is only necessary to submit the documentation for the specific date of service notated in the ADR. The supporting documentation would include, but is not limited to physician/nonphysician practitioner’s progress notes, orders, medication records, procedure/operative reports, relevant diagnostic/operative reports, or documentation of time that would assist in supporting the service(s) submitted.

The primary focus of this review is to identify common billing errors, develop educational efforts and prevent improper payments. Providers will be receiving ADR’s asking for documentation to support the service billed. Medical Review encourages providers to respond with the requested documentation in a timely manner to expedite adjudication of these claims.

Providers should:

  • Review all contractor provider publication and LCD’s
  • Understand Medicare coverage requirements
  • Ensure office staff and billing vendors are familiar with claim filing requirements
  • Perform self-audits of medical records against billed claims using coverage criteria, LCD, and coding guidelines
  • Respond to request(s) for records in a timely manner (CMS requires that providers respond to an ADR within 30 days of the request)
  • Ensure documentation is legible and demonstrates that the patient’s condition warrants the services being reported and billed

It was found that for June 2014 there were 1,935 services submitted for procedure codes 99214 and 99215 of which 565 (28.9%) were denied or reduced to a lower level of care. For July 2014, there were 2,384 services submitted for these same CPT codes (99214 and 99215) of which 801 (34.3%) were denied or reduced to a lower level of care.
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By Sarah Howarth, Billing Manager


EBS-RMSCO, Inc. has changed their corporate name to Lifetime Benefit Solution, Inc.  Patient insurance ID cards will change as their group comes up for renewal.  Please make a copy of your patient’s insurance cards and ensure the correct ID information is entered/sent to Practicefirst.



Independent Health is changing their claims payment process for full dual eligible Dual Difference Medicare Advantage members.  This applies to patients who have Medicare and are eligible for all Medicaid benefits.  As of October 1st, the reimbursement process for Independent Health’s full dual eligible Dual Difference Medicare Advantage will change.

  • Independent Health will reimburse services according to Independent Health’s Medicare Advantage contracted allowed amount, less the State’s portion of the Medicare-covered cost share.
  • Explanation of Payments (EOP) will show a claim-level message to bill New York State Medicaid for the Medicare covered cost share.  The EOP will read “Patient is a Medicaid/Qualified Medicare Beneficiary”.
  • The balance of the claim must be billed to New York State Medicaid.  The patient cannot be billed for this balance.  Full reimbursement according to Independent Health’s Medicare Advantage fee schedule will be made by billing Medicaid for the fee-for-service member cost share.


Independent Health members may receive the zoster vaccine at either a participating provider’s office or at a network pharmacy.  Patients interested in receiving the zoster immunization at a pharmacy must obtain a prescription from their physician or authorized health care professional, prior to receiving the vaccine. 



As of September 1, 2014, reimbursement rates for vaccines administered to members in Medicare Advantage products were set at rates comparable to Medicare fee-for-service rates.  Vaccines will be paid using the Medicare methodology; the average wholesale price, minus 5 percent.  Vaccine rates may be viewed at

Vaccines for children covered by Child Health Plus, HMO Blue Option or Blue Choice Option should be obtained through the New York Vaccines for Children program.  Only the administration fee will be covered in these cases.           

Excellus requires all claims for vaccinations include both the administration and vaccine codes.  This applies to all vaccines including those with a zero charge. 

The multi-component vaccine administration code 90461 is not reimbursable for Medicaid Managed Care, Family Health Plus, Child Health Plus or Healthy NY policies.


Clear Coverage is available for use when requesting referrals and pre-authorizations for outpatient services.  Clear Coverage is accessible on the Excellus website at:


On Univera’s website at: under their Referrals & Auth’s section.


Effective October 31, 2014, Blue Cross will no long offer Medicaid programs in Erie, Cattaraugus, Chautauqua, Orleans, Wyoming and Allegany counties.  Please verify your patient’s insurance coverage and request updated copies of insurance cards.  Contact our office should you need assistance identifying your practice’s patients that have a Medicaid plan through Blue Cross.