medical coding

To maintain Medicare billing privileges, Skilled Nursing Facilities (SNFs) must now do an off-cycle revalidation of their enrollment record with Medicare. This is being done as CMS’s effort to collect updated data on ownership, managerial structures, and related parties. Previously, Skilled Nursing Facilities (SNFs) had 90 days for submission and were required to submit Revalidation for Medicare by May 1, 2025. As of Wednesday, April 16^th, this submission date has been pushed back to August 1, 2025.  

To complete revalidation, SNFs need to assess their ownership and structure to help identify every relevant party. The new guidelines require SNFs to report all members of their governing body, all people with general ownership or interest in the SNF, all individual and organizational owners, and more, no matter their business type.  

Facilities are encouraged to use this extra time wisely to avoid delays or issues with reimbursement. As always, it is important to double-check all application details and ensure timely submission to prevent lapses in billing privileges.  

Below is the CMS Guidance for SNF attachment on form CMS-855a. This guidance should be read and understood thoroughly to submit accurate revalidation.   

Disputing Medicare Advantage (MA) payment denials is a growing challenge for healthcare practices, especially as the number of denials continues to rise due to tighter payer guidelines and increased scrutiny. As denials increase, so do bad debts, while the bottom line decreases. If denials are not addressed promptly and correctly, they can result in significant revenue loss. If approached effectively, practices can create clear processes for revenue cycle teams to address denials and even recover lost income. 

Before disputing a denial, the Explanation of Benefits (EOB) or denial letter should be reviewed and cross-referenced to the claim. Practices can most easily resolve technical issues with a corrected claim that may include a new modifier or different code. Strong documentation is crucial if a claim is denied due to medical necessity. A clear narrative should connect the patient’s condition to the services rendered. One should be able to follow the narrative through test results and physician notes.   

Below are tips for more successful disputes. If denials or bad debts are getting out of hand, contact Dean Dorton’s Revenue Cycle experts for support.  

Tips for Successful Disputes

• Appeal timely: Don’t put off disputing denials—the appeal window is limited, typically 60 days for MA plans.  
• Know the payer’s process: Each MA plan has different appeal procedures; follow them exactly.  
• Use templates: Create appeal letter templates to standardize responses while customizing clinical details. This approach will save time for teams and allow for a quicker dispute of denied claims.  
• Track all correspondence: Keep detailed records of all correspondence. This information may often need to be referred to if the first appeal fails.   
• Leverage provider portals: Many payers have online tools to track appeals and upload documentation efficiently.  
• Educate your team: Continual training on payer updates, documentation best practices, and billing codes will help to prevent future denials and keep everyone on the same page. 

The start of the Trump Administration has ushered in a wave of new healthcare regulatory changes that will affect healthcare providers across the care spectrum. The most immediate changes impacting healthcare providers are the following: 

Affordable Care Act Enrollment

President Trump’s Executive Order 14148 rescinded a Biden Administration order that extended enrollment periods and provided funding for third parties—navigators—to assist Americans in enrolling in ACA marketplace plans. Providers should expect these actions to reduce the number of patients covered by marketplace plans. For CY 2025, more than 23.6 million Americans had obtained healthcare coverage through a Marketplace plan.  

Drug Spending

The Center for Medicare and Medicaid Innovation (CMMI) was developing three new models to lower drug costs. President Trump issued Executive Order 14148, which stopped these programs. Providers may find patients less compliant with medication regimens due to increased consumer prices and should plan accordingly. 

Medicaid

The fate of the Medicaid program is currently in peril as Congressional Republicans contemplate reported massive cuts and changes to the Medicaid program. House Republicans passed a budget resolution that directed the Energy and Commerce Committee to find $880 billion in program cuts through 2034. While the resolution does not specifically call out the Medicaid program or give specifics on how these cuts would be achieved, these levels of cuts cannot be attained without reductions to Medicaid. Providers need to stay informed about these new healthcare regulatory changes. 

AI in Healthcare

On January 23, 2025, President Trump rescinded Executive Order 14410, Safe, Secure and Trustworthy Development and Use of Artificial Intelligence. This Executive Order issued by the Biden Administration established government-wide efforts to guide responsible AI development. It established a framework that Federal agencies and others could use to evaluate various AI programs’ safety and security, potential bias, consumer protections that may be needed, and privacy considerations. Given how heavily regulated healthcare providers’ patient data remains, healthcare organizations should establish and maintain their own AI evaluation, adoption, and implementation policies that guard against these threats.

Medical Research

On February 7, 2025, the National Institutes of Health (NIH) issued Supplemental Guidance to the 2024 NIH Grants Policy Statement: Indirect Cost Rates, which caps the number of indirect costs a research institute can claim at 15% of total grant amounts from the National Institutes of Health (NIH). These costs cover items such as support staff, human subject research protections, hazardous waste disposal, facilities, and utility costs needed to conduct highly complex medical research. Some institutions’ indirect cost rate can be as follows: 50% of grant funding. The NIH is the single largest funder of biomedical research in the world. A Federal judge has issued a temporary stay, preventing the cuts from taking place for now. However, healthcare entities with significant biomedical research operations should begin planning for how such cuts could be absorbed and how to accomplish administrative and compliance activities with reduced funding and potential staffing cuts.

Robert F. Kennedy Jr. was sworn in as the Department of Health and Human Services (DHHS) Secretary on February 13, 2025. Mr. Kennedy has signaled that the following areas will be priorities within DHHS: 

• Focusing on the causes of chronic childhood diseases. 
• Reducing the Federal Health Agency workforce. 
• Reevaluating the childhood vaccine schedule. 
• Assessing the risks of anti-depressant and anti-psychotic medications. 
• Reviewing other public health measures, such as fluoridating public water supplies. 

Such actions could have wide-ranging and long-lasting impacts on the health of provider’s patient populations in varied ways. Providers in areas with lower vaccination rates should plan for potential increases in diseases previously eradicated, such as measles.

If you have questions about how these regulatory changes could affect your practice, please contact the Dean Dorton healthcare team today.

The American Medical Association (AMA) added a Telemedicine Services category to CPT’s Evaluation and Management (E/M) section. Below is a summary of these codes.

Telephone-only E/M codes 99441, 99442, and 99443 have been deleted. They have been replaced with codes 98008 to 98015 for synchronous audio-only E/M visits with more than 10 minutes of medical discussion. CPT codes 98008-98011 apply to new patients, and 98012-98015 apply to established patients. These new codes must have documented more than 10 minutes of medical discussion.

CPT	Technology	Patient Type	MDM	Time Minimum
98008	Audio-Only	New	Straightforward plus > 10 minutes medical discussion	15 minutes
98009	Audio-Only	New	Low plus > 10 minutes medical discussion	30 minutes
98010	Audio-Only	New	Moderate plus > 10 minutes medical discussion	45 minutes
98011	Audio-Only	New	High plus > 10 minutes medical discussion	60 minutes
98012	Audio-Only	Established	Straightforward plus > 10 minutes medical discussion	10 minutes
98013	Audio-Only	Established	Low plus > 10 minutes medical discussion	20 minutes
98014	Audio-Only	Established	Moderate plus > 10 minutes medical discussion	30 minutes
98015	Audio-Only	Established	High plus > 10 minutes medical discussion	40 minutes

New Audio-video E/M codes have been created in addition to the audio-only E/M codes.

CPT	Technology	Patient Type	MDM	Time Minimum
98000	Audio-video	New	Straightforward	15 minutes
98001	Audio-video	New	Low	30 minutes
98002	Audio-video	New	Moderate	45 minutes
98003	Audio-video	New	High	60 minutes
98004	Audio-video	Established	Straightforward	10 minutes
98005	Audio-video	Established	Low	20 minutes
98006	Audio-video	Established	Moderate	30 minutes
98007	Audio-video	Established	High	40 minutes

CMS determined that these codes would not be covered based on the current language in the Social Security Act.

Providers will need to verify with each payer to determine which payers require office visit codes (99202-99215) and which require the new telemedicine codes.

Our medical coding audits routinely reveal ways for practices to save more time, generate more revenue, and avoid more risk. In our previous blog, we explored an opportunity many practices overlook: using prolonged services codes. For this blog, we will look at a similar situation where small changes could potentially boost revenue in big ways.

A Quick Introduction to Total Time

As of January 2021, practices can determine the level of office visits based on medical decision-making or the total time spent on the day of service. Since most coders were already accustomed to following medical decision-making, and the possible upsides of total time were not obvious, many haven’t made the switch. They do things now the same as before—and that may be a lost opportunity.

Let’s first highlight what activities count towards total time:

• Preparing to see the patient: reviewing tests, old records, etc.
• Getting or reviewing separately obtained history
• Doing the exam
• Counseling or educating the patient or the caregivers
• Ordering meds, tests, procedures
• Referring and communicating with other healthcare professionals (only when it’s not reported separately)
• Documenting in the medical record
• Independently interpreting results & giving those results to the patient or caregivers
• Care coordination (when it’s not separately reported)

Now, let’s cover what cannot be included:

• Staff time – Only the provider’s time counts, not any support staff.
• Day after – Only the day of service counts, so complete all notes on the same day.
• Medically unnecessary – Only justifiable time counts—a simple bug bite shouldn’t take an hour to examine.

Why Use Total Time?

Provided you follow these guidelines and get a little practice, coding by total time becomes second nature. So why haven’t more practices switched to this method yet?

In our experience, they see too much risk and not enough reward. Coders assume they will record the time incorrectly and cause problems with payers. And even if they got it right, this line of thinking goes, the revenue gains are minimal.

We have actually seen the opposite at practices that use total time. Rarely does it cause problems for providers or payers—or coders for that matter—and the extra revenue can be significant. We have seen practices make, on average, $20 more on each patient visit. If they average 30 visits each day, that’s an extra $600 per day, $3,000 per week, or $156,000 per year.

Should You Adopt Total Time?

The numbers above are hypothetical, but practices can get real estimates of how much total time would generate, along with plans to put those practices in place, by working with the coding experts at Dean Dorton. Let our team turn a change in process into an increase in profits. Contact us to learn more.