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Coding - Practice Guidelines and Tips - 2023

Documentation and Coding: Fractures, CMS-HCC_V28 Model Updates

This tip sheet is intended to assist providers and coding staff with the documentation and ICD-10-CM selection, along with the Centers for Medicare & Medicaid Services (CMS) Hierarchical Condition Category (HCC) Version 28 Model Updates, on services submitted to Healthfirst—specifically for fractures.

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Clinical Documentation Improvement

CMS-HCC_V28 Model Updates

Plans & Benefits - Practice Guidelines and Tips - 2023

2023 Healthfirst Plans at a Glance

Healthfirst has health plans for all New Yorkers.

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At a Glance

Provider Alerts - Coronavirus (COVID-19) - Practice Guidelines and Tips - 2023

Medicaid Members Under Age 19 are Eligible for the Vaccines for Children Program

Children under age 19 can receive the COVID‑19 vaccine at Vaccines for Children (VFC)‑enrolled providers, including their practitioner’s office, public health clinics, most county health departments, and any Medicaid‑ or VFC‑enrolled pharmacy.

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Medicaid

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2023

Reimbursement Policy: PO-RE-009 Diagnostic Testing of Influenza

Influenza is an acute respiratory illness caused by influenza A or B viruses resulting in upper and lower respiratory tract infection, fever, malaise, headache, and weakness.

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2023

Reimbursement Policy: PO-RE-014 Diagnostic Testing of Common Sexually Transmitted Infections

Sexually transmitted infections (STIs), often referred to as sexually transmitted diseases or STDs, include a variety of pathogenic bacteria, virus, and other microorganisms that are spread through sexual contact and can cause a multitude of complications if left untreated.

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2023

Reimbursement Policy: PO-RE-016 β-Hemolytic Streptococcus Testing

Streptococcus are Gram-positive, catalase-negative bacteria that are further divided into α-hemolytic, such as S. pneumoniae and S. mutans; β-hemolytic, such as S. pyogenes (Group A), S. agalactiae (Group B), and S. dysgalactiae subsp equisimilis (Groups C and G); and γ-hemolytic, such as Enterococcus faecalis and E. faecium (Wessels, 2022).

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2023

Reimbursement Policy: PO-RE-021 Testing for Diagnosis of Active or Latent Tuberculosis

Infection by Mycobacterium tuberculosis (Mtb) results in a wide range of clinical presentations dependent upon the site of infection from classic signs and symptoms of pulmonary disease (cough greater than two to three weeks' duration, lymphadenopathy, fevers, night sweats, weight loss) to silent infection with a complete absence of signs or symptoms (Lewinsohn et al., 2017).

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2023

Reimbursement Policy: PO-RE-022 Cervical Cancer Screening

Cervical cancer screening detects cervical precancerous lesions and cancer through cytology, human papillomavirus (HPV) testing, and if needed, colposcopy (Feldman et al., 2023).

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2023

Reimbursement Policy: PO-RE-028 Measurement of Thromboxane Metabolites for ASA Resistance

Thromboxane A2 (TXA2) is a metabolite that causes platelet activation in the cyclooxygenase metabolic pathway (Abrams, 2023).

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2023

Reimbursement Policy: PO-RE-031 Bone Turnover Markers Testing

Bone metabolism involves a continual, dynamic equilibrium between bone growth and resorption. Bone turnover markers (BTMs) are biochemical markers for assessment of bone formation or bone resorption.

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2023

Reimbursement Policy: PO-RE-032 Epithelial Cell Cytology in Breast Cancer Risk Assessment

Nipple aspiration and/or ductal lavage are non-invasive techniques to obtain epithelial cells for cytological examination to aid in the evaluation of nipple discharge for breast cancer risk (Golshan, 2022).

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Reimbursement Policy

Compliance, Regulatory & Policies - Policy, Billing, or Coverage Update - 2023

Reimbursement Policy: PO-RE-035 Prostate Biopsy Specimen Analysis

Prostate cancer is characterized by a malignancy of the small walnut-shaped gland that produces seminal fluid. This malignancy can present with a wide clinical range, from only being a microscopic, well-differentiated tumor that may never be clinically significant all the way to being an aggressive, high-grade cancer (Taplin & Smith, 2023).

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Reimbursement Policy