In the fast-evolving world of healthcare, staying up to date with the latest regulations is not just a task—it's essential for smooth operations. This September, the Centers for Medicare & Medicaid Services (CMS) is introducing a series of software updates that will impact how encounter data is processed. These changes will affect Medicare Advantage, Cost, PACE, and Demonstration organizations starting September 13, 2024.

But don’t worry! We’ve broken down the updates for you, so you’ll be well-prepared to navigate them with ease.

1. New Checks for Mental Health Providers: Ensuring Compliance Made Simple

Let’s face it: healthcare is all about being in the right place at the right time—especially for providers. Edit 25080 is designed to ensure that Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) are practicing in the correct settings. This edit makes sure that claims from these specialists are only allowed in appropriate places like outpatient clinics.

So, if an MFT is mistakenly registered as working in an inpatient hospital, psychiatric facility, or rehabilitation center, the system will flag it. Why does this matter? Simple—incorrect submissions can delay claim processing. Avoid the hassle by ensuring your submissions reflect the right service location for MFTs and MHCs.

2. Social Determinants of Health: An Important Addition to Annual Wellness Visits

We all know how important it is to capture the full picture of a patient’s health. CMS is now emphasizing the Social Determinants of Health (SDOH)—those factors like living conditions, income, and social connections that impact well-being.

Edit 25095 ensures that when an SDOH risk assessment is done (with code G0136), it’s paired with an Annual Wellness Visit (AWV). This update means the assessment can’t be billed on its own—it needs to accompany an AWV. Why? Because integrating this with the AWV provides a more holistic view of patient care.

Make sure both are billed together to avoid errors and deliver more comprehensive patient evaluations.

3. Getting the Billing Right for Wellness Visits

CMS is tightening the rules for Annual Wellness Visits (AWVs), and Edit 20715 ensures that your billing matches the allowed types of bills (TOBs). It’s a bit like ensuring you’ve picked the right form for the right process.

AWVs should only be billed under certain categories like 12X, 13X, and 85X. If you submit the wrong one, expect delays. It’s another reason why precision in billing pays off!

4. Home Health Claims: Don’t Forget the Details!

For home health service providers, Edit 22510 adds an extra step to verify that claims include the correct state and county information. This helps ensure that home health encounters are accurately categorized by location.

Starting October 1, 2024, make sure you add Value Code 85 (which identifies the state and county where services were rendered) to avoid rejected claims. Even though it’s a small detail, missing this can create significant delays, so double-check before submitting!

5. Updated Rules for CPT Codes: Better Safe than Sorry

Lastly, Edit 25000 focuses on the Correct Coding Initiative (CCI), which has been updated to prevent claims with certain CPT codes from being processed incorrectly. Now, even if you’ve added a modifier like 59 or XE, the system will take a closer look to ensure everything is in line.

What’s the takeaway? Be sure your CPT codes—particularly 77427, 92012-92014, and 99201-99499—follow the latest guidelines. Submissions that don’t meet the mark will trigger an error and delay payment.

How to Stay Ahead of These Changes

While these updates may seem like small tweaks, they have big implications for data accuracy and payment efficiency. The good news? It’s easy to stay on top of these changes with a few proactive steps:

Update Your Systems: Ensure that your billing software is programmed to handle the new edits.

Train Your Team: Make sure your staff knows the new rules so that submissions are flawless.

Monitor Your Submissions: Check your claims closely, especially after September 13, to catch any errors early.

Conclusion: Adapting to a New Normal

As CMS continues to fine-tune its processes, healthcare organizations must stay agile and informed. These new edits are here to make encounter data more accurate and ensure the smooth flow of claims processing. By adjusting now, you can avoid headaches later and keep your data submissions running smoothly.

The September 2024 software release is just one of many steps CMS is taking to improve the Medicare program. And with a little preparation, your organization can continue delivering excellent care without missing a beat.

Stay compliant, stay informed, and you’ll be ready for whatever comes next!