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"Medicare" & "Auditing" Articles
Click on the title to see the article summary and a link to the full article.
March 17th, 2021
The OIG Turns their Gaze to Possible Inpatient Service Upcoding
By Jared Staheli | Published March 17th, 2021
The Office of Inspector General for the United States Department of Health and Human Services (HHS-OIG) is responsible for ensuring the integrity of programs operated by HHS, including the Medicare and Medicaid programs. One of the ways this is accomplished is through the identification of fraudulent activities, one of which ...
February 1st, 2021
New Procedure Codes for the Janssen COVID-19 Vaccine
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 1st, 2021
On January 19, 2021, the AMA announced two new CPT codes for reporting the Janssen Pharmaceutica (a division of Johnson & Johnson) COVID-19 vaccine. Of course, just as with the other COVID-19 vaccines, they must be given FDA approval for Emergency Use Authorization (EUA) to be administered before the codes can be reported.
As is ...
December 8th, 2020
IPPS and DRG's: What it Means
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 8th, 2020
Understanding hospital pricing can get complicated, so we have broken it down according to CMS and the acute Inpatient Prospective Payment System, also known as IPPS. Find-A-Code uses IPPS for inpatient pricing with our MS-DRG grouper. The following information comes from CMS.gov and answers the most common questions regarding DRGs ...
December 8th, 2020
Final Rule on Communications Technology and 2021 Physicians Fee Schedule
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 8th, 2020
To create a healthcare system that will benefit providers as well as Medicare beneficiaries there have been several new rules issued that begin on or after January 01, 2021. CMS released the final policy and payment provisions on December 01, 2020, which includes the physician fee schedule (PFS) for 2021. ...
November 18th, 2020
Cross-A-Code Instructions in Find-A-Code
By Raquel Shumway | Published November 18th, 2020
Cross-A-Code is a tool found in Find-A-Code which helps you to locate codes in other code sets that help you when submitting a claim.
October 12th, 2020
Medicare Improper Payment Report for Chiropractic (2019)
By Jared Staheli | Published October 12th, 2020
CMS audits claims on an annual basis to identify improper payments. These improper payments do not measure fraud. Rather, they estimate the share of payments that did not meet Medicare coverage, coding, and billing rules. In the most recent Improper Payment Report by specialty, chiropractic has the highest Part B improper payment ...
September 1st, 2020
Not Following the Rules Costs Chiropractor $5 Million
By Wyn Staheli, Director of Research | Published September 1st, 2020
Every healthcare office needs to know and understand the rules that apply to billing services and supplies. What lessons can we learn from the mistakes of others? What if we have made the same mistake?
July 21st, 2020
Office of Inspector General Says Medicare Advantage Organizations are Denying Services Inappropriately
By Aimee Wilcox | Published July 21st, 2020
We attended the recent virtual RISE National Conference and had the opportunity to listen to presenters share their knowledge about risk adjustment and HCC reporting and data validation. Among the presenters were representatives from the Office of Inspector General (OIG), who presented findings from encounter data from 2012-2016. They began ...
July 14th, 2020
Are NCCI Edits and Modifiers Just for Medicare?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 14th, 2020
The National Correct Coding Initiative (NCCI) edits were developed by CMS to help promote proper coding and control improper coding that leads to incorrect payments with part B claims. It is important to understand that NCCI edits do not include every possible code combination or every type of un-bundling combination. With that ...
July 7th, 2020
New ABN Form is Here
By Wyn Staheli, Director of Research | Published July 7th, 2020 - Last Review/Update July 8th, 2020
The anticipated changes to the Advanced Beneficiary Notice of Non-coverage (ABN) Form (CMS-R-131) have arrived. This important form is issued to the patient or client by providers, physicians, practitioners, and suppliers in situations where Medicare payment is expected to be denied.
You can begin using the new ABN immediately if you so wish. However, it becomes mandatory on August 31, 2020.
June 10th, 2020
MEGA - NCCI Edit Changes - WHO Knew?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 10th, 2020
There was no huge announcement when CMS released new files in April. The files that were released on April 7, 2020, actually replaced files to update the NCCI edits on Procedure to Procedure (PTP) edits and Medically Unlikely Edits (MUE). The updated files included;
291,902 Deleted Procedure to Procedure (PTP) edits
197 Deleted Medically Unlikely ...
June 2nd, 2020
Changes in Medicare Advantage and Part D
By Christine Taxin | Published June 2nd, 2020
The Centers for Medicare & Medicaid Services finalized several changes in Medicare Advantage and Part D on Friday.
The Trump administration has finalized several changes in Medicare Advantage (MA) and Part D in anticipation of bid submissions on June 1.
The Centers for Medicare & Medicaid Services (CMS) released Friday that includes ...
May 20th, 2020
Where is the CCI Edit with Modifier 25 on E/M?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 20th, 2020
If you are not seeing a CCI edit when reporting an E/M code with a certain procedure, it may be that there is no edit. CMS does not have a CCI edit for every CPT code, however, there are still general coding rules that must be followed.
The use of Modifier 25 is one example ...
May 18th, 2020
Packaging and Units for Billing Drugs
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 18th, 2020
To determine the dosage, size, doses per package and how many billing units are in each package, refer to the NDC number.
Take a look at the following
J1071 - Injection, testosterone cypionate, 1mg
For example; using NCD # 0009-0085-10 there are 10 doses of 100 mL
(100 mg/mL = 1 mL and there are ...
May 4th, 2020
Additional Telehealth Changes Announced by CMS
By Wyn Staheli, Director of Research | Published May 4th, 2020
On April 30, 2020, CMS announced additional sweeping changes to meet the challenges of providing adequate healthcare during this pandemic. These changes expand the March 31st changes. The article covers some of the key changes. See the official announcement in the references below.
April 15th, 2020
CMS Temporarily Suspends Contract-Level RADV Audits
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 15th, 2020
The Centers for Medicare and Medicaid Services (CMS) is suspending contract-level RADV audits, related to the payment year 2015 and will not initiate any new ones until after the public health emergency has ended. Any documentation already submitted will be reviewed as usual.
April 13th, 2020
COVID-19 Chiropractic Resources
By Wyn Staheli, Director of Research | Published April 13th, 2020
COVID-19 Chiropractic Resources contains current, updated information regarding COVID-19. Included are lists of webinars, articles, websites and links pertaining to the ongoing changes.
April 2nd, 2020
More Telehealth Changes Announced by CMS
By Wyn Staheli, Director of Research | Published April 2nd, 2020
On March 31, 2020, CMS announced further changes to their telehealth program in response to this unprecedented public health emergency (PHE). See this article for further information as well as references & links to CMS information
March 26th, 2020
Medicare Part D Coverage Gap (Donut Hole) Closes in 2020
By Jared Staheli | Published March 26th, 2020
Overview of the Part D coverage gap, how it got closed, what the picture looks like for 2020, and long-term outlook.
March 24th, 2020
"What is the ICD-10 code for...?" - Search Smarter With Find-A-Code Tools
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 24th, 2020
Do you still find yourself searching the internet for an ICD10 code? Medical coders often type into their search engine, what is the ICD10 code for ... and a specific diagnosis code, to avoid repeatedly dragging out the incredibly large ICD10 codebook. Ironically, some of the most commonly searched ICD10 diagnoses include: ...
February 19th, 2020
Medicare Begins Covering Acupuncture Services
By Wyn Staheli, Director of Research | Published February 19th, 2020
Medicare is changing their policy regarding coverage of acupuncture, but in order to provide these services, you must follow their rules.
February 10th, 2020
A 2020 Radiology Coding Change You Need To Know
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 10th, 2020
The radiology section of the 2020 CPT© has 1 new, 18 revised, and 14 deleted codes. Interestingly, six of the 14 deleted codes were specific to reporting single-photon computerized tomographic (SPECT) imaging services of the brain, heart, liver, bladder, and others. If your organization reports radiology services, it is...
January 30th, 2020
Medicare Announces Coverage of Acupuncture Services
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 30th, 2020
On January 21, 2020, a CMS Newsroom press-release read,
This new announcement is both exciting and refreshing. Acupuncture, a key component of traditional Chinese medicine and most commonly used to treat pain, is now being officially recognized by Medicare and several other large payers as a covered, alternative treatment option for ...
January 7th, 2020
Denials due to MUE Usage - This May be Why!
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 7th, 2020
CMS assigns Medically Unlikely Edits (MUE's) for HCPCS/CPT codes, although not every code has an MUE. MUE edits are used to limit tests and treatments provided to a Medicare patient for a single date of service or for a single line item on a claim form. It is important to understand MUE's are ...
December 13th, 2019
What did I do today?
By Namas | Published December 13th, 2019 - Last Review/Update January 7th, 2020
What did I do today?
Whether you are auditing inpatient or outpatient documentation, chances are you have come across a situation where the encounters repeat the same story, sometimes day to day, sometimes on every 3-month visit. When EHRs were implemented en masse, a key selling point of almost all of ...
November 19th, 2019
Changes to Portable X-Ray Requirements
By Wyn Staheli, Director of Research | Published November 19th, 2019
On September 30, 2019, CMS published a final rule which made changes to portable x-ray services requirements as found in the law.
October 18th, 2019
Medically Unlikely Edits (MUEs): Unlikely, But Not Always Impossible
By Namas | Published October 18th, 2019 - Last Review/Update October 23rd, 2019
Medically Unlikely Edits (MUEs) were created by the Centers for Medicare & Medicaid Services (CMS) to help lower the error rate for paid Part B claims. MUEs are the maximum units of a HCPCS or CPT code that a provider would bill under most circumstances for the same patient on ...
September 30th, 2019
CMS and HHS Tighten Enrollment Rules and Increase Penalties
By Wyn Staheli, Director of Research | Published September 30th, 2019
This ruling impacts what providers and suppliers are required to disclose to be considered eligible to participate in Medicare, Medicaid, and Children's Health Insurance Program (CHIP). The original proposed rule came out in 2016 and this final rule will go into effect on November 4, 2019.
There have been known problems ...
August 20th, 2019
Are You Aware of Medicare Advantage Plans Timely Filing Rules?
By Aimee Wilcox | Published August 20th, 2019
The Medicare Fee for Service (FFS) program (Traditional or Original Medicare) has a timely filing requirement; a clean claim for services rendered must be received within one year of the date of service or risk payment denial.
As any company who has billed Medicare services can attest, the one-year timely filing ...
August 9th, 2019
The OIG Work Plan: What Is It and Why Should I Care?
By Namas | Published August 9th, 2019 - Last Review/Update August 14th, 2019
The Department of Health and Human Services (HHS) founded its Office of Inspector General (OIG) in 1976 and tasked it with the responsibility to combat waste, fraud, and abuse within Medicare, Medicaid, and the other HHS programs. With approximately 1,600 employees, HHS OIG is the largest inspector general's office within ...
August 2nd, 2019
The Slippery Slope For CDI Specialists
By Namas | Published August 2nd, 2019 - Last Review/Update August 8th, 2019
Who knew that when Jack & Jill when up the hill to fetch a pail of water, they would have to ensure that in order to keep the level of water the same on the way back down, they would need to both support the pail.
Many of you in this industry are ...
July 23rd, 2019
Tips to Preventing Audits
By Christine Taxin | Published July 23rd, 2019 - Last Review/Update July 30th, 2019
There is an ever-increasing number of dental claims that have come under scrutiny for fraud. One such payer, Aetna, is actively pursuing dental fraud by employing their special investigative units (SIUs) to identify and investigate providers who demonstrate unusual coding and billing practices. When payers identify the activities they deem ...
July 22nd, 2019
Q/A: What do I Need to Document for Periodic Adjustments on a Medicare Patient?
By Evan Gwilliam DC MBA BS CPC NCICS CCPC CCCPC CPC-I MCS-P CPMA | Published July 22nd, 2019
Question:
What type of documentation is required for a Medicare patient with degenerative joint disease who get adjusted once or twice a month for occasional flare-ups of the D. J. D. region? The noted adjustments give good relief of the patient's symptoms.
Answer:
There is no question that these adjustments would be considered ...
July 17th, 2019
Act Now on CMS Proposal to Cover Acupuncture for Chronic Low Back Pain
By Wyn Staheli, Director of Research | Published July 17th, 2019
Now is the time to comment on a proposal to cover acupuncture for chronic low back pain. This comment period is the part of the HHS response to the opioid crisis. You only have until August 14th to officially comment.
July 5th, 2019
Helping Others Understand How to Apply Incident to Guidelines
By Namas | Published July 5th, 2019 - Last Review/Update July 16th, 2019
Over the past few months, I have worked with different organizations that have been misinterpreting the "incident to" guidelines and, in return, have been billing for services rendered by staff that are not qualified to perform the services per AMA and CPT. What I found within the variances is that ...
June 14th, 2019
A United Approach
By Namas | Published June 14th, 2019 - Last Review/Update June 18th, 2019
A United Approach
As auditors, we all have a different perspective when evaluating documentation. It would be unreasonable to think that we all view things the same way. In my opinion, differing perspectives are what makes a great team because you can coalesce on a particular chart, work it through and ...
June 13th, 2019
What Medical Necessity Tools Does Find-A-Code Offer?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published June 13th, 2019
Find-A-Code is a great resource for individuals working in all aspects of healthcare, from providers and ancillary staff to the attorneys and payers who assess and critique the documentation supporting the services performed. When recently asked what tools Find-A-Code has to help support medical necessity, our response was, "We provide many resources ...
May 24th, 2019
What to Look for When Auditing Smoking Cessation Services
By NAMAS | Published May 24th, 2019 - Last Review/Update June 19th, 2019
What to Look for When Auditing Smoking Cessation Services
April 29th, 2019
Medicare Revises Their Appeals Process
By Wyn Staheli, Director of Research | Published April 29th, 2019
On April 12, 2019, Medicare announced that there will be some changes to their appeals process effective June 13, 2019. According to the MLN Matters release (see References), the following policy revisions in the Medicare Claims Processing Manual (MCPM), Chapter 29 are taking place:
The policy on use of electronic signatures
Timing ...
April 29th, 2019
Q/A: I’m Being Audited? Is There a Documentation Template I can use?
By Wyn Staheli, Director of Research | Published April 29th, 2019
Question: Our Medicare contractor is auditing claims with 98942. Do you have any suggestions for a template for documentation to warrant the use of 98942?
Answer: When you submit a claim with code 98942 you are stating that you have determined that it was medically necessary to adjust all 5 of ...
April 23rd, 2019
Let's Talk High Risk E/M Services
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 23rd, 2019
Have you ever assigned a high-complexity E/M code (e.g., 99205, 99215, 99223, 99233, 99245, etc.) and wondered if it would stand up to further scrutiny? Well, let’s take a closer look at the requirements for reporting high-level E/M services.
Both the American Medical Association and Medicare-published E/M Guidelines agree that a ...
April 23rd, 2019
What is Medical Necessity and How Does Documentation Support It?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 23rd, 2019
We recently fielded the question, “What is medical necessity and how do I know if it's been met?"
The AMA defines medical necessity as:
It is important to understand that while the AMA provides general guidance on what they consider medically necessary services, these particular coding guidelines are generic and may be ...
April 8th, 2019
Q/A: What do I do When a Medicare Patient Refuses to Sign an ABN?
By Wyn Staheli, Director of Research | Published April 8th, 2019
Question: What do I do when a Medicare patient refuses to sign an ABN?
Answer: That depends on whether the patient is still demanding to have/receive the service/supply. If they aren’t demanding the service, then there is no need to force the issue. Just make sure that you still have an ...
April 8th, 2019
Prepayment Review Battle Plan
By Wyn Staheli, Director of Research | Published April 8th, 2019
Any type of payer review can create some headaches for providers and cause problems for a healthcare office. Even for a practice that has taken administrative steps to try and prevent a prepayment review, it can still happen. A prepayment review means that you must include documentation WITH your claim. ...
March 25th, 2019
Clearing Up Some Medicare Participation Misunderstandings
By Wyn Staheli, Director of Research | Published March 25th, 2019 - Last Review/Update April 2nd, 2019
Even though we may think we truly understand what it means to be a participating provider, Medicare doesn’t quite work the way that other insurance plans do. Far too many providers do not understand the difference and get into hot water. To further complicate matters, the rules are different for ...
March 21st, 2019
The Impact of Medical Necessity on High Level E/M Services
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 21st, 2019
I was recently asked the question, "Does 99233 require documentation of a past medical, family, and/or social history (PFSH)?"
The quick answer is, "it depends."
Code 99233 has the following minimal component requirement:
Subsequent inpatient E/M encounters can meet the code level requirement either by component scoring & medical necessity or time & medical necessity. ...
March 20th, 2019
Type of Bill Code Structure (2018-08-30)
By Find-A-Code | Published March 20th, 2019 - Last Review/Update March 25th, 2019
The UB-04 claim form (also known as CMS 1450) is the standard facility and residential claim form used to report health claims. The Type of Bill is reported in Block No. 4 of the UB04 claim form.
Type of bill codes are four-digit codes that describe the type of bill a ...
March 18th, 2019
Revised ABN Requirements Still Fuzzy
By Wyn Staheli, Director of Research | Published March 18th, 2019
Although it has been quite some time since ChiroCode published an article about the revised instructions for non-participating providers who use the ABN, there are still some outstanding questions about this change. So far, Medicare has not provided additional guidance about this question despite requests by us for clarification.
Medicare now requires non-participating providers to include the ...
March 7th, 2019
Q/A: Can you Help me Understand the New Medicare Insurance Cards?
By Wyn Staheli, Director of Research | Published March 7th, 2019
As many of you are aware, CMS began issuing new Medicare identification cards last year which required the replacement of social security numbers with a new Medicare Beneficiary Identifier (MBI). All cards have now been mailed out and patient's should have the new cards when they come in. Currently, we are in the transition period until January 2020.
March 1st, 2019
Understanding NCCI Edits
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 1st, 2019
Medicare creates and maintains the National Correct Coding Initiative (NCCI) edits and NCCI Policy Manual, which identify code pair edits. When performed on the same patient, on the same day, and by the same provider, the secondary code is considered an integral part of the primary code, and payment for ...
February 25th, 2019
Medicare Supplemental Policies (MediGap) and Extremity Adjustments
By Wyn Staheli, Director of Research | Published February 25th, 2019
The nice thing about MediGap policies is that they pay for some of the healthcare costs that an original Medicare plan (Part B) does not cover. So when a patient has Medicare and a Medicare supplement (MediGap) and their condition is related to an extremity (a noncovered service), Medicare must ...
February 12th, 2019
Coding Medicare Initial Preventive Physical Exams (IPPE)
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 12th, 2019
The Medicare Initial Preventive Physical Exam (IPPE), also commonly referred to as the “Welcome to Medicare Physical”, may seem daunting to many, but when broken out to identify the requirements is fairly straightforward.
Purpose
An IPPE helps the Medicare beneficiary (the patient) get to know their healthcare provider at a time when they ...
February 7th, 2019
Charging Missed Appointment Fees for Medicare Patients
By Wyn Staheli, Director of Research | Published February 7th, 2019 - Last Review/Update February 8th, 2019
Some providers mistakenly think that they cannot bill a missed appointment fee for Medicare beneficiaries. You can, but Medicare has specific rules that must be followed. These rules are outlined in the Medicare Claims Policy Manual, Chapter 1, Section 30.3.13. You must have an official “Missed Appointment Policy” which is ...
February 5th, 2019
Clinical Staff vs. Healthcare Professional
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 5th, 2019
State scope of practice laws and regulations will help determine who is considered Clinical staff and Other qualified Health Care professionals.
Physician or other qualified healthcare professionals: Must have a State license, education training showing qualifications as well as facility privileges.
Examples of Qualified Healthcare professionals:
(NOTE: this list is not all-inclusive, please refer to your payer ...
February 1st, 2019
Attestations Teaching Physicians vs Split Shared Visits
By BC Advantage | Published February 1st, 2019 - Last Review/Update February 7th, 2019
Physicians often use the term "attestation" to refer to any kind of statement they insert into a progress note for an encounter involving work by a resident, non-physician practitioner (NPP), or scribe. However, for compliance and documentation purposes, "attestation" has a specific meaning and there are distinct requirements for what ...
January 28th, 2019
Empowering Medicare Beneficiaries
By Find-A-Code | Published January 28th, 2019 - Last Review/Update January 29th, 2019
BLOG: CMS announced a NEWS release today making it easier to help Medicare Beneficiaries access cost and quality information. CMS announced, "Today, the Centers for Medicare & Medicaid Services (CMS) launched a new app that gives consumers a modernized Medicare experience with direct access on a mobile device to some of ...
January 23rd, 2019
How to Report Co-Surgeons Using Modifier 62
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 23rd, 2019
Modifier 62 is appended to surgical claims to report the need for the skills of two surgeons (co-surgeons) to perform a procedure, with each surgeon performing a distinct part of the same procedure, during the same surgical session.
An easy way to explain this is to visualize a patient requiring cervical fusion where ...
January 22nd, 2019
Home Oxygen Therapy
January 10th, 2019
Are You Protecting Your Dental Practice From Fraud?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 10th, 2019
With the expansion of dental coverage through Medicaid and Medicare Advantage plans, an ever-increasing number of dental claims have come under scrutiny for fraud. One such payer, Aetna, is actively pursuing dental fraud by employing their special investigative units (SIUs) to identify and investigate providers who demonstrate unusual coding and ...
January 4th, 2019
Nine New Codes for Fine Needle Aspirations (FNA) in 2019
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 4th, 2019
If your practice performs a lot of fine needle aspirations (FNA), you probably have the code options memorized (10021 without image guidance and 10022 with image guidance). However, the 2019 CPT codes now include nine (9) new FNA codes (10004-10012), one deleted FNA code (10022) and one revised FNA code ...
January 3rd, 2019
CMS Finalizes Major Changes to ACO Program
By Wyn Staheli, Director of Research | Published January 3rd, 2019
Back in August of 2018, as part of the Medicare Shared Savings Program (Shared Savings Program), CMS proposed some sweeping changes for Accountable Care Organizations (ACOs). There has been some controversy over these changes which require ACOs to move to two-sided models. In this Final Rule which was scheduled to be published in the Federal Register ...
December 18th, 2018
Medicare Advantage Providers are not Required to be Enrolled in Medicare
By Wyn Staheli, Director of Research | Published December 18th, 2018
There was a ruling that was requiring providers to be enrolled in Medicare in order to provide services for Part C (Medicare Advantage (MA)) and/or Part D. However, on April 2, 2018, CMS released the 2019 Final Rules for MA and Part D which changed this previous ruling. According to ...
November 30th, 2018
Auditing looking between the lines
By BC Advantage | Published November 30th, 2018 - Last Review/Update January 9th, 2019
When given the task of auditing a group of charts, most often the scope of the audit is well defined. For me, there are times when my natural inquisitive nature turns on and I find my noticing the "timing" of parts of documentation. These are things that you would not...
November 29th, 2018
Errors Billing Outpatient Services When Patient is also Inpatient
By Wyn Staheli, Director of Research | Published November 29th, 2018
The OIG recently reported that Medicare inappropriately paid acute-care hospitals for outpatient services provided to patients who were inpatients of another facility including long term care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, and critical access hospitals. CMS suggests using the following resources to ensure compliance:
Medicare Inappropriately Paid Acute-Care Hospitals for ...
November 26th, 2018
Allergy Immunotherapy Coding Guidelines (CMS) Effective: 01/01/2006
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 26th, 2018
Immunotherapy (Allergy Shots) is a medical treatment to used to treat and prevent reactions or desensitize the immune system to specific allergens that trigger allergy symptoms. Payers have specific coverage guidance and rules for reporting injections, the specific type of antigen(s) provided and how they should be reported.
Below are the coding guidelines from ...
November 26th, 2018
Reciprocal Billing and Locum Tenens Arrangements Changes
By Wyn Staheli, Director of Research | Published November 26th, 2018
CMS has made changes to their payment policies for reciprocal billing arrangements and Fee-For-Time compensation arrangements (formerly referred to as locum tenens arrangements). Providers need to be aware of these changes and update their policies as appropriate.
November 9th, 2018
Billing 99211 Its not a freebie
By | Published November 9th, 2018 - Last Review/Update November 29th, 2018
It seems like a simple code to bill, but CPT 99211 (established patient office visit) is by no means a freebie when it comes to documentation and compliance. This lowest level office visit code is sometimes called a "nurse visit" because CPT does not require that a physician be present...
November 7th, 2018
Are you Ready for CMS' 2019 Medicare Physician Fee Schedule Final Rule?
By Wyn Staheli, Director of Research | Published November 7th, 2018
The waiting is over, the Final Rule for CMS' 2019 Medicare Physician Fee Schedule (MPFS) is available - all 2,379 pages for those looking for a little light reading. As anticipated, there are some pretty significant changes. Most of us were carefully watching the proposed changes to the Evaluation and ...
November 1st, 2018
CMS: Medicare Diabetes Prevention Program Expanded Model
By Find-A-Code | Published November 1st, 2018
CMS announces the Medicare Diabetes prevention program is now a new covered service. Per a recent MLN news release. Medicare Beneficiaries will be notified in 2019 in a Medicare handout. Diabetes affects more than 25 percent of Americans aged 65 or older, and its prevalence is projected to increase approximately...
October 19th, 2018
We've Always Done It This Way and Other Challenges in Education
By BC Advantage | Published October 19th, 2018 - Last Review/Update November 1st, 2018
As coders, auditors, and compliance professionals, we are the provider's advocates in closing the gap between what is medically necessary and what is required for documentation. Sometimes that places us in the role where we need to save our clinicians from themselves, and the patterns they have fallen into...
October 17th, 2018
Wolters Kluwer Drug Pricing
By Find-A-Code | Published October 17th, 2018
Wolters Kluwer provides unit and package pricing for multiple drug price types: Average Wholesale Price (AWP), Wholesale Acquisition Cost (WAC), Direct Price (DP), Manufacturer's Suggested Wholesale Price (SWP), Centers for Medicare & Medicaid Services, Federal Upper Limit (CMS FUL), Average Average Wholesale Price (AAWP), Generic Equivalent Average Price (GEAP). Average...
October 5th, 2018
Prolonged Services Its Not Just About Time
By BC Advantage | Published October 5th, 2018 - Last Review/Update October 17th, 2018
Time, as it applies to E/M codes, has often been viewed as an "if/then" proposition. "If" the documentation shows that a majority of the encounter was based on counseling and/or coordination of care, "then" we choose the highest level of service based on the total time of the encounter.
However, a ...
October 1st, 2018
When to Use Modifier 25 and Modifier 57 on Physician Claims
By BC Advantage | Published October 1st, 2018 - Last Review/Update October 17th, 2018
The biggest thing modifiers 25 and 57 have in common is that they both assert that the E/M service should be payable based on documentation within the record showing the procedure should not be bundled into the E/M. After that, the similarities end, and it is important to know the...
September 26th, 2018
The Potential Impacts of a Flat Rate EM Reimbursement on our Industry
By BC Advantage | Published September 26th, 2018 - Last Review/Update October 17th, 2018
The proposed E&M changes by CMS would decrease provider administrative work burden by, per CMS, 51 hours a year; however, how will reducing documentation requirements truly affect the professionals of the healthcare industry? First, let’s discuss the 30,000-foot overview of the most impactful E&M changes—which is the change to the...
September 11th, 2018
Getting the Right Eligibility Information for Payment Your Rights and Health Plans Requirement
By BC Advantage | Published September 11th, 2018 - Last Review/Update September 24th, 2018
We need timely and accurate patient information to bill health plans and receive appropriate payment. Clinical information is, of course, important. But we also need the "administrative" data - patient demographics and especially the insurance information. Physician offices create their clinical information, but usually rely on patients for information on...
August 30th, 2018
Keys to Successful Claims Filing
By Noridian Medicare | Published August 30th, 2018
There are many factors that can contribute to your success in filing claims and getting reimbursed. The information below is from the CMS website.
Completing Item 12, Patient's or Authorized Person's Signature, on the CMS-1500 form for a non-assigned claim
A signature on file (SOF) indicates the supplier has obtained the beneficiary's one-time authorization on ...
August 20th, 2018
PSAVE Pilot Program - What Does it Mean to You?
By Wyn Staheli, Director of Research | Published August 20th, 2018
Noridian's pilot program Provider Self-Audit with Validation and Extrapolation (PSAVE) has been extended which means that it has been successful for the payer, which means that they are saving money. Historically, when a pilot program is proven to be successful, it isn’t too long before other MACs follow. Before signing up to participate, providers need to carefully evaluate the program. Are the benefits worth the costs?
August 16th, 2018
Medicare Timed Codes Guidelines
By Wyn Staheli, Director of Research | Published August 16th, 2018
Medicare's guidelines for reporting of timed codes is found in Medicare Claims Processing Manual Chapter 5, Section 20.2. Also known as the '8 minute' rule, it describes how to calculate time for appropriate reporting when more than one timed code is performed at the same time.
It should be noted that while ...
August 15th, 2018
BREAKING NEWS: CMS Proposes to Change E&M Coding
By | Published August 15th, 2018
On July 16th 2018, anyone subscribed to the CMS Quality Payment Program received an e-mail containing a letter to doctors from Seem Verma, Administrator of the Centers for Medicare and Medicaid Services (CMS). There are some widespread changes proposed in this letter of which you need to be aware.
Where ...
August 3rd, 2018
Q/A: Is it Legal to Shred Archived Patient Records After a Certain Amount of Time?
By Wyn Staheli, Director of Research | Published August 3rd, 2018 - Last Review/Update January 28th, 2019
Shredding patient records. When is it appropriate? Read more to find out.
August 3rd, 2018
When Medical Necessity and Medical Decision Making Don't Match
By BC Advantage | Published August 3rd, 2018 - Last Review/Update September 24th, 2018
As coders and auditors, we are taught the documentation guidelines on how to determine medical decision making. However, Medicare is clear that medical necessity is what determines the overall payment. In order to know what to do when medical necessity and medical decision making do not line up, you must...
July 25th, 2018
CMS Proposes Changes to Evaluation & Management Requirements
By Wyn Staheli, Director of Research | Published July 25th, 2018
It is no secret that providers have long argued that E/M coding is burdensome and does not truly reflect the services provided. This fact is acknowledged by CMS with the following statement "Prior attempts to revise the E/M guidelines were unsuccessful or resulted in additional complexity due to lack of ...
July 18th, 2018
Provider-Based Facilities and Split Billing: Is Your Facility Being Reimbursed for All Work Performed?
By | Published July 18th, 2018
Are you stumped by billing guidelines for provider-based facilities? Who bills for what and why? Read on to hear how a little extra time and effort spent on researching split billing coding guidelines can greatly impact your facility, and even your budget ensuring reimbursement for all services performed.
For ...
July 12th, 2018
Dual Medicare-Medicaid Billing Problems
By Wyn Staheli, Director of Research | Published July 12th, 2018
It is important to keep in mind that Medicaid is run at a state level so there can be some differences when it comes to coverage. However, the rules regarding balance billing of covered services is set at the federal level. The law states (emphasis added):
A state plan must provide ...
July 9th, 2018
ESRD Claims Error: Transitional Drug Adjustment Add-On Payment Adjustment
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 9th, 2018
Medicare sent out a news release to inform of incorrect reimbursement and correction.
"End Stage Renal Disease (ESRD) claims are incorrectly reimbursed if they:
Are eligible for Transitional Drug Adjustment Add-On Payment Adjustment and
Contain non-covered charges
After we fix the system on January 1, 2019, your Medicare Administrative Contractor will mass adjust claims ...
June 22nd, 2018
Q/A: Do I Have a Patient with Part C sign an ABN if we are Out-of-Network?
By Wyn Staheli, Director of Research | Published June 22nd, 2018 - Last Review/Update January 28th, 2019
Do we need an ABN if the patient has Part C and we are out-of-network? Read More.
June 18th, 2018
Medicare Claim Submission Exceptions
By Wyn Staheli, Director of Research | Published June 18th, 2018 - Last Review/Update January 28th, 2019
There are several exceptions to the Medicare "Mandatory Claim Submission Rule." What are they?
June 18th, 2018
Q/A: Can a PT Assistant Perform Physical Therapy Modalities?
By Wyn Staheli, Director of Research | Published June 18th, 2018 - Last Review/Update January 30th, 2019
Whether or not a physical therapy assistant (PTA) may perform physical therapy modalities depends on two factors: state law and payer policies. Read here for more.
June 14th, 2018
Home Oxygen Therapy -- CMN for Oxygen
By Raquel Shumway | Published June 14th, 2018
The Certificate of Medical Necessity (CMN) for Oxygen is a required form that helps to document the medical necessity for oxygen therapy. It also documents other coverage criteria for the oxygen use. For payment on a home oxygen claim, the information in the supplier’s records or the patient’s medical record must be substantiated with the information in the CMN.
June 12th, 2018
Will Medicare's Proposed Reformations Affect Your Practice?
By Wyn Staheli, Director of Research | Published June 12th, 2018
Recently, Medicare's Innovation Center released an informal Request for Information (RFI) seeking input on several different system reformation proposals. As the market moves towards more value based payment systems, innovation and new models are being sought to both reduce costs and increase quality. This article outlines the ideas presented in the ...
June 11th, 2018
Inappropriate Use of Units Costs Practice Over $800,000
By Wyn Staheli, Director of Research & Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT | Published June 11th, 2018
A recent OIG enforcement action emphasizes the need to understand the proper use of units. A healthcare provider in Connecticut improperly submitted multiple units for drug screening urine tests. The proper billing of units has proven to be problematic for more than just lab tests. Is your billing of drugs & biologicals, injections and timed codes appropriate?
June 8th, 2018
Provider-Based Facilities and Split Billing Is Your Facility Being Reimbursed for All Work Performed?
By Sharon Hoglund, CPC, CPMA, CEMC, CEMA | Published June 8th, 2018 - Last Review/Update July 3rd, 2018
Are you stumped by billing guidelines for provider-based facilities? Who bills for what and why? Read on to hear how a little extra time and effort spent on researching split billing coding guidelines can greatly impact your facility, and even your budget ensuring reimbursement for all services performed...
June 7th, 2018
The Range of Motion Conundrum
By Gregg Friedman, DC, CCSP | Published June 7th, 2018 - Last Review/Update January 30th, 2019
As both a chiropractor for 31 years and one who reviews a lot of medical records for the medicolegal arena and has been teaching documentation for many years, the range of motion question comes up frequently. Although we used to get reimbursed very well for a specific range of motion code back in ...
June 4th, 2018
Auditing Therapy Evaluation Codes - Not So Quick!
By Nancy J Beckley, MS, MBA, CHC | Published June 4th, 2018
New evaluation codes for physical therapy (PT) and occupational therapy (OT) codes were made effective 1/1/2017. Three new physical therapy evaluation codes replaced 97001, and three new occupational evaluation codes replaced 97003. Chart 1 - Short Code Descriptors The PT and OT reevaluation codes remain the same but were...
May 30th, 2018
Creating a Culture of Compliance in 2018
By Sean M. Weiss & Frank Cohen | Published May 30th, 2018 - Last Review/Update June 4th, 2018
This year (2018), healthcare organizations (Hospitals, Health Systems, and Physician Groups/Practices) must focus on the criticality of creating a culture of compliance to ensure effectiveness and efficiency. Focusing on "compliance"-only approaches leaves healthcare organizations exposed to areas of liability oftentimes far more than what they could ever imagine or even...
May 22nd, 2018
Q/A: Am I Supposed to List the Frequency and Duration on the ABN?
By Wyn Staheli, Director of Research | Published May 22nd, 2018 - Last Review/Update January 28th, 2019
How to fill out Box D (Services) on the ABN form. What information is required?
May 14th, 2018
TKAs to Outpatient What We Have Learned with Q1
By Shannon Cameron, MBA, MHIIM, CPC | Published May 14th, 2018 - Last Review/Update May 24th, 2018
The release of the 2018 Final Rule for the Outpatient Prospective Payment System (OPPS) in November 2017 has created quite a stir across the orthopedic healthcare community. In what has been deemed a questionable decision, the Centers for Medicare and Medicaid Services (CMS) decided to remove Total Knee Arthroplasty...
May 4th, 2018
The Devil is in the Data Details
By J. Paul Spencer, CPC, COC | Published May 4th, 2018 - Last Review/Update May 24th, 2018
As an auditor who has reviewed thousands and thousands of encounter documents for level of service, a predictable pattern has merged when it comes to the Medical Decision Making (MDM) component that has attracted my attention.
April 26th, 2018
Documenting DMEs
By Find-A-Code | Published April 26th, 2018
As per MLN MM8304,
This article is based on Change Request (CR) 8304, which instructs DME MACs to implement requirements, which are effective July 1, 2013, for detailed written orders for face-to-face encounters conducted by the physician, PA, NP or CNS for certain DME items as defined in 42 CFR 410.38(g).
Due to concerns ...
April 23rd, 2018
Critical Care Documentation
By Scott Kraft, CPC, CPMA | Published April 23rd, 2018 - Last Review/Update May 2nd, 2018
Critical care documentation should show critical need for the patient AND immediate action by the provider....
April 20th, 2018
The PSAVE Pilot Program: Should You Self-Audit Your Medicare Claims?
By Robert Liles, JD, MBA, MS | Published April 20th, 2018 - Last Review/Update April 25th, 2018
As the Medicare program has grown, the Centers for Medicare and Medicaid Services (CMS) has employed a variety of different claims audit mechanisms to better ensure that the Medicare Trust Fund is protected from waste, fraud and abuse....
April 16th, 2018
Indications for Serotypes A and B Botulinum Toxins
By Find-A-Code | Published April 16th, 2018
According to Novitas LCD L27476, the following indications apply:
1. Blepharospasm and strabismus2. Spastic dystonia or focal dystonias to relieve pain, to assist posturing and walking, to increase range of motion, to assist in the outcome of physical therapy, and/or to reduce spasm thus allowing adequate perineal hygiene.3. Spasmodic dysphonia4. Achalasia and cardiospasm when ...
March 27th, 2018
Maximizing Resources for ICD-10 Coding Audits
By BC Advantage | Published March 27th, 2018 - Last Review/Update April 12th, 2018
From internal reviews to external inpatient coding audits, healthcare organizations nationwide are revisiting tried-and-true audit practices with ICD-10 coding quality in mind....
March 9th, 2018
The Comprehensive Error Rate Testing Program
By Frank Cohen, MBA, MPA | Published March 9th, 2018 - Last Review/Update April 12th, 2018
With nearly a million physicians in this country, how do auditing organizations determine whom to audit?
February 26th, 2018
Q/A: With a Maintenance Patient of Medicare age that has a Medicare Replacement Plan (Part C), do They Need to Fill out an ABN?
By Wyn Staheli, Director of Research | Published February 26th, 2018 - Last Review/Update February 4th, 2019
Q/A: With a maintenance patient of medicare age that has a medicare replacement plan (Part C), do they need to fill out an ABN?
February 23rd, 2018
The Comprehensive Error Rate Testing Program
By Frank Cohen, MBA, MPA | Published February 23rd, 2018 - Last Review/Update February 26th, 2018
With nearly a million physicians in this country, how do auditing organizations determine whom to audit?
February 6th, 2018
Medicare Using Private Payor Prices to Set Payment Rates for Clinical Diagnostic Laboratory Tests Starting January 2018
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 6th, 2018
On June 17, 2016, CMS announced the release of its final rule implementing section 216(a) of the Protecting Access to Medicare Act of 2014 (PAMA). This final rule requires reporting entities to report private payor rates paid to laboratories for lab tests, which will be used to calculate Medicare payment ...
February 2nd, 2018
Scoring & Reporting Your Audit Findings
By Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT | Published February 2nd, 2018 - Last Review/Update February 7th, 2018
This week we had a great question posted to our online forum, and I thought it would be a nice thought- provoking question for our auditing and compliance tip of the week.
February 1st, 2018
OIG Reviews Medicare Advantage Claims
By Wyn Staheli, Director of Research | Published February 1st, 2018
On January 16, 2018, the OIG released a report of their findings on claims data for Medicare Advantage plans. While it appears that there were not significant issues, they did find that:
"Types of potential errors included inactive or invalid billing provider identifiers; duplicated service lines; missing required data; inconsistent dates; ...
January 31st, 2018
Developing Coding Policies for Compliance
By Marge McQuade, CMSCS, CHCI, CPOM | Published January 31st, 2018
Every physician practice depends upon correct coding and billing for their financial success. Coding drives reimbursement. All of the resources available for coding information and guidance are meaningless without the practice manager translating it into provider-specific coding policies and compliance plan. As a practice manager, you need to develop a ...
January 25th, 2018
Psychiatric Partial Hospitalization Programs
By Wyn Staheli, Director of Research | Published January 25th, 2018
Psychiatric Partial Hospitalization Programs (PHPs) are a more comprehensive level of care than Intensive Outpatient Programs (IOPs - click here to read more about IOPs). When the patient requires a minimum of 20 hours per week and hospitalization is not clinically indicated, a PHP can be the most effective type of ...
January 23rd, 2018
NEW on Find-A-Code...National Coverage Determinations (NCDs)
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 23rd, 2018 - Last Review/Update January 25th, 2018
Medicare limits its coverage of services to those considered to be reasonable and necessary for the diagnosis and treatment of an injury or illness based on coverage guidelines. National Coverage Determinations (NCDs) are created based on research, evidence-based processes, public participation, and other resources, and made available to the public. ...
January 15th, 2018
Medicare Requiring Specific Modifiers on Therapy Services
By Wyn Staheli, Director of Research | Published January 15th, 2018
Medicare's MLN Matters Number: MM10176 was recently revised to identify services subject to their therapy cap. The revision became effective on January 1, 2018 and some providers have begun to receive claim rejections because they are not using the appropriate modifier. The article states the following:
Services furnished under the Outpatient ...
January 15th, 2018
Billing with a GP Modifier
By Wyn Staheli, Director of Research | Published January 15th, 2018 - Last Review/Update January 30th, 2019
Q: When patients have a true Medicare secondary insurance we've always billed other Medicare non-covered codes such as G0283 for electric stimulation with modifier GY because we are aware Medicare will not pay for that service but the secondary insurance does. We just were notified by our MAC that GY is not a valid modifier and I have to enter a GP or other therapy modifier. What is the new proper modifier to enter?
January 2nd, 2018
Quality Payment Program in 2018
By Wyn Staheli, Director of Research | Published January 2nd, 2018 - Last Review/Update January 30th, 2019
I checked the government website to see if I am an eligible clinician and it says that I am not. I just don't want to get blindsided with a letter saying I will be penalized. Is there anything you would suggest or recommend that I do now to protect myself from future penalties. Thank you
December 15th, 2017
Is Your Practice in Need of a Wellness Visit?
By Valora Gurganious, MBA, CHBC | Published December 15th, 2017 - Last Review/Update January 31st, 2018
Is your practice busier than ever, but net practice income continues to drop?
December 13th, 2017
AT and GA Modifiers When Billing CMT and Non-covered Codes to Medicare
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published December 13th, 2017 - Last Review/Update February 5th, 2019
Questions regarding using modifiers when billing CMT and non-covered codes to Medicare. We have used AT (Active) and GA (signed ABN) when billing active care for CMT codes 98940-98942 (e.g., 98941-ATGA) in the past. Currently we are told not to bill GA with AT. How do we bill?
December 12th, 2017
Medicare Diabetes Prevention Program (MDPP) Expanded Model Information
By Jared Staheli | Published December 12th, 2017
Diabetes treatment places an ever-increasing strain on the resources of the U.S. healthcare system. CMS estimated that in 2016 alone, Medicare incurred an additional $42 billion in costs due to the number of beneficiaries with diabetes. The best way to keep these costs down in the future is by preventing ...
December 4th, 2017
Revised ABN and Non-Participating Providers
By Wyn Staheli, Director of Research | Published December 4th, 2017
Non-participating providers have the option to strikeout part of the ABN form.
December 1st, 2017
Auditing the Use of a Scribe
By Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT | Published December 1st, 2017 - Last Review/Update January 31st, 2018
A scribe is someone that can act as a walking transcriptionist on behalf of a medical provider......
November 24th, 2017
Inpatient critical care: When is it ok to question the medical necessity?
By Stephanie Allard, CPC, CEMA, RHIT | Published November 24th, 2017 - Last Review/Update January 31st, 2018
While critical care may be easily identifiable within documentation it is not always clear if it is medically necessary.....
November 22nd, 2017
Understanding ASC Pricing
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 22nd, 2017
ASCs (Ambulatory Surgical Centers) have a separate fee schedule with a base allowed amount that is adjusted for each state using Core Based Statistical Areas (CBSA). Under the ASC payment system, Medicare pays facilities for specific ASC covered surgical procedures, however, there are only certain types of procedures that are eligible for payment ...
November 17th, 2017
Fear Factor: "The Unethical Business of Medicine"
By Sean Weiss, CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC | Published November 17th, 2017 - Last Review/Update January 31st, 2018
I want this story that I am about to share with you to fit with the majority of clients that I represent and work with because I have represented clients with refund demands as small as $1,000 and clients who had demands greater than $30 million. This year has been ...
October 31st, 2017
Correct Coding for Group Therapy
By David Klein CPC, CPMA, CHC | Published October 31st, 2017 - Last Review/Update February 5th, 2019
Recent events regarding delegation of services to ancillary personnel have given rise to concerns regarding the delivery of outpatient physical medicine by Chiropractors, specifically regarding the appropriate use of one-on-one codes as opposed to group therapy code CPT 97150 - Therapeutic procedure(s), group (2 or more individuals). This advisory provides guidance on how to properly use one-on-one and group therapy codes, both independently and together.
October 23rd, 2017
Summary of OIG Reports for Chiropractic
By | Published October 23rd, 2017
The Office of the Inspector General was created to protect the integrity of the U.S. Department of Health and Human Services. They investigate fraud, waste, and abuse in HHS programs and make recommendations to various enforcement agencies. Every few years they investigate chiropractic services. Here is a summary of the reports the ...
October 20th, 2017
PFSH Documentation: Q and A
By Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT | Published October 20th, 2017 - Last Review/Update January 31st, 2018
When coding an E/M visit in the emergency department, would you count all PFSH listed even if they don't pertain to the indication as to why the patient arrived?
October 13th, 2017
Can Chiropractors Opt-out of Medicare?
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published October 13th, 2017 - Last Review/Update February 5th, 2019
Chiropractors cannot opt-opt of Medicare. Does that only refer to chiropractors that see Medicare patients? Do all Florida chiropractors have to complete Medicare enrollment/credentialing? Bottom line- do ALL chiropractors, no matter where or who, have to complete Medicare enrollment since they cannot Opt-out?
October 13th, 2017
So, How Do You Decide if a Service was Provided?
By David Glaser, JD | Published October 13th, 2017 - Last Review/Update January 31st, 2018
An earlier coding tip explained that the oft-repeated "if it isn't written, it wasn't done" is good risk management advice, but not a legal truism.....
October 6th, 2017
Your NAMAS Weekly Auditing & Compliance Tip for October 6, 2017
By NAMAS | Published October 6th, 2017 - Last Review/Update October 16th, 2017
October 6, 2017
Acronyms and Abbreviations: When You Fall Into The Grey Area
We've all been there... you are coding or auditing, and then a note comes up that is not like the ones you've reviewed before.
The language is unclear, the acronym(s) could mean so many different things, and it's hard to get ...
October 6th, 2017
Acronyms and Abbreviations: When You Fall into the Grey Area
By Omega Renne, CPC, CPMA, CPCO, CEMC, CIMC | Published October 6th, 2017 - Last Review/Update February 1st, 2018
We've all been there... you are coding or auditing, and then a note comes up that is not like the ones you've reviewed before. The language is unclear, the acronym(s) could mean so many different things, and it's hard to get a straight answer about whether or not it's supported higher or lower....
October 5th, 2017
Q/A: Do we Need to Charge for Non-covered Services Performed Under a Maintenance Visit if we Use the S8990 Code When Billing Medicare?
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published October 5th, 2017 - Last Review/Update February 5th, 2019
Do we need to charge for non-covered services performed under a maintenance visit if we use the S8990 code when billing Medicare?
September 29th, 2017
Big Data & Facility Audit Complex Reviews
By Shannon Cameron, MBA, MHIIM, CPC | Published September 29th, 2017 - Last Review/Update January 31st, 2018
Big data and its use in the healthcare spectrum has proven to be an incredible source of the knowledge and has rapidly abetted progress in seemingly all areas of healthcare......
September 25th, 2017
Last Chance to Start Reporting MIPS
By ChiroCode | Published September 25th, 2017 - Last Review/Update February 5th, 2019
MIPS is a program that allows Medicare to collect data from providers about high quality low cost care that uses technology effectively. There are four categories and providers need to learn about the available measures so that they can pick the ones that make them look the best.
September 15th, 2017
Copy and Paste: The Real Rules Prevail
By Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA, CEMA | Published September 15th, 2017 - Last Review/Update January 31st, 2018
Have you looked for published guidance on cloning/copying and pasting from the Centers for Medicare & Medicaid Services (CMS)? There is one published resource that provides rudimentary guidance.....
September 14th, 2017
Double Dipping in the History of the Evaluation and Management Note
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published September 14th, 2017
There are many rules and guidelines a coder must be aware of when it comes to appropriately selecting an Evaluation and Management (EM) code and avoiding doubling dipping is one of them. Double dipping occurs when the same information is used in more than one of the subcomponents of history.
The subcomponents of history include:
Chief Complaint ...
September 1st, 2017
Medicare Improper Payment Report for Chiropractic (2016)
By Wyn Staheli, Director of Research | Published September 1st, 2017 - Last Review/Update October 16th, 2017
The Medicare Improper Payment Report for 2016 has been released by the OIG. Please note that the improper payment rate does not measure fraud. Rather, it estimates the payments that did not meet Medicare coverage, coding, and billing rules. The estimated Medicare FFS payment accuracy rate (claims paid correctly) from ...
September 1st, 2017
Medicare Improper Payment Report for Behavioral Health Services (2016)
By Wyn Staheli, Director of Research | Published September 1st, 2017 - Last Review/Update October 16th, 2017
The Medicare Improper Payment Report for 2016 has been released by the OIG. Please note that the improper payment rate does not measure fraud. Rather, it estimates the payments that did not meet Medicare coverage, coding, and billing rules. The estimated Medicare FFS payment accuracy rate (claims paid correctly) from ...
September 1st, 2017
Medicare Improper Payment Report (2016)
By Wyn Staheli, Director of Research | Published September 1st, 2017 - Last Review/Update October 16th, 2017
The Medicare Improper Payment Report for 2016 has been released by the OIG. Please note that the improper payment rate does not measure fraud. Rather, it estimates the payments that did not meet Medicare coverage, coding, and billing rules. The estimated Medicare FFS payment accuracy rate (claims paid correctly) from ...
September 1st, 2017
2017 Physical Therapy Evaluation & Management Codes
By Kathy Price, RHIT, CPC, CCS-P, CPMA | Published September 1st, 2017 - Last Review/Update January 31st, 2018
As you know, 2017 brought us new evaluation and management codes for physical and occupational therapy....
August 25th, 2017
Changes to the Medicare Appeals Process
By Sean Weiss, CHC, CMCO, CEMC, CPMA, CMPE, CPC-P, CPC | Published August 25th, 2017 - Last Review/Update January 31st, 2018
On June 29th, The Centers for Medicare and Medicaid (CMS) issued the Medicare Program: "Changes to the Medicare Claims and Entitlement, Medicare Advantage and Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedures final rule."
August 16th, 2017
If It’s Not a Consultation, What Is It?
By Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC | Published August 16th, 2017
You thought you had a consultation supported in your documentation, and now you find out that you cannot bill the consultation codes (99241-99245, 99251- 99255). So, what are the top reasons for a consultation not to be supported?
If the payer does not support these codes
If the documentation does not support ...
August 11th, 2017
Chart Auditing For Beginners
By Michelle West, CPC, CEMC, CPMA, CRC | Published August 11th, 2017
In the new year, have you found yourself in the new role of performing internal chart audits for your organization? Are you often finding yourself saying "Now What?!" First, take a deep breath and start with the basics. In this week's tip, I will review the very basic tips and ...
August 4th, 2017
Increased Medicare payment rates for FY 2018!
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 4th, 2017
We can look forward to a few prospective payments for Skilled Nursing Facilities, Hospice and Inpatient Rehab; CMS released their final rule and reported on key highlights of the new FY 2018 Medicare payment rules.
CMS States, “The 2018 Skilled Nursing Facility (SNF) Prospective Payment System Final Rule increases Medicare payment rates ...
August 4th, 2017
Proposed Telehealth Changes for 2018
By Wyn Staheli | Published August 4th, 2017 - Last Review/Update October 4th, 2017
Medicare has proposed making some changes to policies regarding telehealth services. They are adding some new codes to their covered list of telehealth services and propose eliminating the requirement to use the GT modifier. Since many payers adopt similar policies, watch for further announcements from other third-party payers.
Proposed Codes
HCPCS code G0296 ...
July 28th, 2017
Auditing Vaccines
By Paul Chandler | Published July 28th, 2017 - Last Review/Update January 31st, 2018
Auditing vaccines can be difficult, as precise attention needs to be paid to the documentation to extract all variables needed for proper coding.
July 14th, 2017
Don’t Overlook Diagnosis Codes During Coding Audits
By Betty Stump, MHA, RHIT, CPC, CCS-P, CPMA, CDIP | Published July 14th, 2017
Coding auditors focus much of their attention exclusively on C.P.T. codes during the review process. After all, codes reported for E and M visits, surgical procedures, and diagnostic services are what generate revenue to the provider or facility. Even more importantly, errors in reporting these services are frequently what give ...
July 13th, 2017
Our Claims are Being Rejected
By ChiroCode | Published July 13th, 2017 - Last Review/Update February 8th, 2019
Question: Our claims are being rejected. We think it is related to our diagnosis codes. What is the reason for this?
June 30th, 2017
Focus Audit Results on the Documentation, Not the Encounter
By Scott Kraft, CPC, CPMA | Published June 30th, 2017
As an auditor, your job is to assess the quality of the documentation created by the provider to determine whether it meets the requirements to bill the code assigned to the service. This task often set us up a potentially adversarial role with the provider, particularly when it comes to ...
June 30th, 2017
Documentation: Carrying Forward or Ineffective Use of Templates
By Shannon DeConda | Published June 30th, 2017
I often receive questions such as the below from our members regarding E&M scoring:
"I have heard that if information is 'cloned' or 'moved forward' from a previous visit, we should not count that info in scoring. However, I have also read that if a provider moves the info forward and ...
June 30th, 2017
Penalties Under the False Claims Act Have Risen for the Second Time Within the Last 12 Months
By Robert Liles, JD, MBA, MS | Published June 30th, 2017
The False Claims Act is the primary civil enforcement tool utilized by the U.S. Department of Justice (DOJ) to address false claims submitted to government programs and contracts by individuals and entities. The statute was first passed during the Civil War in 1863 in an effort to address the wrongful ...
June 30th, 2017
Auditing Neurologic Exams: Tips for Success
By Laurie Oestreich | Published June 30th, 2017
As an auditor, you may be asked to audit encounters that occur in various multi-specialties. It can be difficult to remember the ins and outs of each specialty, especially if you do not consistently work in a particular specialty. Neurology is one of those specialties that can appear daunting due ...
June 30th, 2017
Getting Serious About Your Practice’s Compliance
By Jesse Overbay, JD | Published June 30th, 2017
By now, hopefully most (if not all) practices know that the Office of Inspector General (OIG) has been stressing the importance of creating and abiding by a compliance plan for most of this decade. In its own words, the OIG believes "that a healthcare provider can use internal controls to ...
June 30th, 2017
Ashby’s Law of Requisite Variety; A Lesson in Preparedness
By Frank Cohen, MBA, MPA | Published June 30th, 2017
Have you ever wondered why grandparents have so much more fun with their grandchildren than they did with their children? Or why they have so much more fun than their children have with their children? It's the same reason why some organizations move through crises like a knife through butter ...
June 30th, 2017
Consultation or Transfer of Care, What are the Differences?
By Dee MiMauro, CPC, COC, CPMA | Published June 30th, 2017
According to 2017 Current Procedural Terminology (CPT), a Consultation is a type of E&M service provided by a physician at the request of another physician or other appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of ...
June 30th, 2017
The Difference Between Leadership and Management
By Kelly Ogle, BSDH, MIOP, CMPM, CHOP | Published June 30th, 2017
"The best leader is the one who has sense enough to pick good men to do what he wants done, and the self-restraint to keep from meddling with them while they do it." -Theodore Roosevelt
When a person wants to secure a topnotch position in their company, are they willing to ...
June 30th, 2017
Laceration Repairs
By Michael Loss, CPC, CPMA | Published June 30th, 2017
Auditing laceration repair is generally an adventure. Most of my auditing work is reviewing the work of our coders rather than providers, but I have audited physicians as well. My present position has limited communication with providers, however we do attempt to get important information back to our clients for ...
June 30th, 2017
Sanction Screening and Evaluating Employee Suitability: The New “Seventh Element” of Compliance
By Paul Weidenfeld, JD | Published June 30th, 2017
The recently issued Resource Guide for Measuring Compliance Program Effectiveness, the product of roundtable discussions by Office of Inspector General staff and compliance professionals, emphasizes the importance that the OIG places critical role of exclusion screening and background checks in compliance. Issued in March, the Resource Guide re configures the ...
June 30th, 2017
Neck: Supple
By Shannon DeConda | Published June 30th, 2017
I am allowed the opportunity, through our wonderful NAMAS members and bootcamp and conference attendees, to educate all walks of auditors and compliance professionals. These include not just compliance auditors and divisions in healthcare, but also auditors on the carrier side. As I do, I see the good fights on ...
June 30th, 2017
Diagnosing, Documenting, and Coding for Radiculopathy
By Evan Gwilliam, DC, MBA, BS, CPC, CCPC, CPC-I, CPMA, NCICS, MCS-P, QCC, CMHP | Published June 30th, 2017
Radiculopathy can be an unpleasant condition, but diagnosing, documenting and coding for it does not have to be. It just takes a little research. The brain communicates with the body via the spinal cord which is protected by the bones of the spinal column, called vertebrae. Nerve roots exit in ...
June 30th, 2017
Outpatient Physical Therapy Changes Effective June 13th, 2017
By Shannon DeConda | Published June 30th, 2017
Our friends in clinics operating in Health Professional Shortage Area (HPSA), a Medically Underserved Area (MUA), or in a rural area have long struggled with how to cover Physical Therapy services when a therapist is on leave, vacation, or in event of medical leave. The Centers for Medicare and Medicaid ...
June 30th, 2017
The Big Myth: “If it Isn’t Written, it Wasn’t Done” Documentation is NOT a Requirement for Most Medicare Claims
By David Glaser, JD | Published June 30th, 2017
This tip may contradict everything you've heard before. However, if you consider it with an open mind, you will see that it is an accurate characterization of the law, and it is also consistent with common sense. The phrase "If it isn't written, it wasn't done" is repeated so commonly ...
June 30th, 2017
Treating Diabetic Patients in Your Office?
By Shannon DeConda | Published June 30th, 2017
CMS will be rolling out an Expanded Diabetes Prevention Plan January 1, 2018 as well as new Durable Medical Equipment (DME) supply codes for Continuous Glucose Monitors (CGM) July 1, 2017. These services will offer your practice the opportunity to better assist your diabetic patient's needs.
Remember that prior to providing ...
June 30th, 2017
Wanna Cry?
By Ann Bachman, BS MT(ASCP), CLC(AMT) | Published June 30th, 2017 - Last Review/Update August 16th, 2017
The WannaCry (short for WannaCrypt) ransomware* attack experienced worldwide in mid-May 2017 affected some 300,000 computers running Microsoft Windows operating systems in more than 150 countries. It affected healthcare institutions, communications providers, gas stations, and banks.
The attack began on Friday, May 12, 2017, encrypting data and demanding ransom payments in ...
June 29th, 2017
Think Outside the Box When Auditing Physical Exams
By NAMAS: Betty Stump, RHIT, CPC, CCS-P, CPMA | Published June 29th, 2017
CMS guidelines instruct coding and auditing professionals they may use either the 1995 or 1997 documentation guidelines when coding or auditing provider documentation. The restriction, of course, is the two guidelines cannot be combined- auditors must use either 1995 OR 1997 for any single episode of care. The two guidelines, ...
June 29th, 2017
To Disclose or Not to Disclose… That is the Question
By Sean Weiss | Published June 29th, 2017
The biggest questions I receive these days are in regard to handling potential overpayments regarding internal or external audits is whether or not the errors constitute a self-disclosure protocol. The short answer is, avoid this process unless you have verifiable fraudulent activity to report. Section 1128J(d) of the Act created ...
June 29th, 2017
NAMAS Announced New Auditing Credential!
By Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA | Published June 29th, 2017
At NAMAS, we strive to be the industry expert in auditing and compliance education. Each year, we carefully select our weekly webinar topics, annual conference sessions, and speakers to provide you with the type of training and education you need to succeed in your role. We are excited to share ...
June 29th, 2017
Focus on Clinical Documentation to Improve Coding and Audit Results
By Betty Stump, MHS, RHIT, CPC, CCS-P, CPMA, CDIP | Published June 29th, 2017
Auditors spend their day surrounded by the end product of the health care process. Those CPT, HCPCS and ICD-10-CM codes generated as a result of services provided to the patient. Our work is focused on determining if those codes have been correctly assigned based on the content of the medical ...
June 29th, 2017
Prescription Drug Management: Is it a Level 3 or a Level 4?
By J. Paul Spencer, CPC, COC | Published June 29th, 2017
If you place four auditors around a table and place a typical established patient visit in front of them, what tends to follow is a scene that resembles less about building consensus and more along the lines of a National Geographic special regarding the hunting habits of hyenas. Perhaps no ...
June 29th, 2017
Profit Depends on Efficiency
By NAMAS | Published June 29th, 2017
To us, the most fascinating thing about process improvement within a medical practice is how it has a clear clinical counterpart: differential diagnoses. In a typical scenario, a patient presents with a chief complaint ("I don't feel well"), and it's the provider's job to figure out just what is wrong ...
June 28th, 2017
Medicare Announces New Cards to Be Issued
By Dr. Mario Fucinari, Author & Member of the Carrier Advisory Committee for Medicare | Published June 28th, 2017 - Last Review/Update February 8th, 2019
Identity theft has become a major problem in the United States. As a prevention measure, the Centers for Medicare& Medicaid Services (CMS) is readying a fraud prevention initiative that removes Social Security numbers from Medicare cards to help combat identity theft, and safeguard taxpayer dollars.
June 23rd, 2017
Inpatient Compliance: Split-Shared Services
By Grant Huang | Published June 23rd, 2017 - Last Review/Update August 16th, 2017
In the inpatient setting, a physician can combine his or her documentation with that of a non-physician provider (N.P.P.) to support an E and M service while billing the resulting code under the physician. This is called a “split-shared” service and allows physicians to bill at 100% of the fee ...
June 16th, 2017
Auditing Incident-to Services
By Michael Miscoe, Esq. | Published June 16th, 2017 - Last Review/Update August 16th, 2017
To effectively audit incident-to services under Medicare, the auditor must first have an operational understanding of the rule. Unfortunately, this is not as easy as it sounds. Auditors must also understand that the incident-to rule is a Medicare only rule. This is one area where the maxim "if you are ...
May 5th, 2017
Your MIPS Resources
By Evan Gwilliam, DC, MBA, BS, CPC, CCPC, CPC-I, CPMA, NCICS, MCS-P, QCC, CMHP | Published May 5th, 2017 - Last Review/Update March 5th, 2019
What is MIPS and what now?
May 2nd, 2017
Plain Film Xray Penalty 2017
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published May 2nd, 2017 - Last Review/Update January 31st, 2019
Watch Another quick tip from the ChiroCode HelpDesk - Plain Film Xray Penalty 2017. Even though this news comes from Medicare, who does not reimburse chiropractic physicians for x-rays, private payers nearly always follow their example. This represents the trend of X-ray reimbursement for all of healthcare.
April 24th, 2017
The Quality Payment Programs
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 24th, 2017
Medicare has given the option for participation in the Quality Payment Program offering two tracks you can choose from as well as the option to pick your pace. You can choose to start anytime between January 1 and October 2, 2017:
Advanced Alternative Payment Models (APMs) or
The Merit-based Incentive Payment System ...
April 14th, 2017
New ABN Form 2017
By ChiroCode | Published April 14th, 2017 - Last Review/Update January 31st, 2019
New ABN form for 2017. Watch this video to learn more and download a copy of the new form.
February 27th, 2017
Opting Out of MIPS & MACRA
By ChiroCode | Published February 27th, 2017 - Last Review/Update February 8th, 2019
Question: Is it true that I can opt out of MIPS & MACRA if my part B charges are less than or equal to $30,000? If so, are the charges based on covered Medicare charges (98940, 98941, 98942) or all charges sent to Medicare? Some patients want non-covered charges sent to Medicare too.
February 8th, 2017
Medicare Conversion Factor
By Wyn Staheli, Director of Research | Published February 8th, 2017
In April of 2015, the Sustainable Growth Rate (SGR) formula which is used to calculate the Medicare Physician Fee Schedule (MPFS) Conversion Factor was repealed as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The conversion factor will increase by 0.5% each year until 2019 and ...
February 6th, 2017
Medicare Revises their Appeals Process
By Wyn Staheli, Director of Research | Published February 6th, 2017
On January 17, 2017, a Final Rule was published in the Federal Register outlining changes to the Medicare Appeals process in an order to streamline procedures and reduce the current backlog of appeals at the third and fourth levels of appeal. This new policy takes effect on March 20, 3017. ...
February 6th, 2017
Q/A: Would Leaving Box 14 on the 1500 Claim Form Blank Cause Denials?
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published February 6th, 2017 - Last Review/Update February 8th, 2019
We have been leaving box 14 on the 1500 claim form blank for Medicare claims and are getting denials. Could this be why?
February 1st, 2017
Medicare Coverage of Behavioral Health Services
January 24th, 2017
Code Sets - Health Care Provider Taxonomy Code Set Link
By Raquel Shumway | Published January 24th, 2017
Every Provider needs to know their Health Care Provider Taxonomy Codes. The Taxonomy Codes define the provider type, classification, and area of specialization. We have provided a link and instructions to help you locate your code.
January 23rd, 2017
Virtual Groups and MIPS
By Wyn Staheli, Director of Research | Published January 23rd, 2017
During the comment period of the MIPS Proposed Rule (Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models), there were some concerns about NPI and TIN usage for MIPS reporting for smaller organizations.
The following statements are from the MIPS Final ...
January 23rd, 2017
Why Should I Document a Differential Diagnosis?
By Evan M. Gwilliam, DC MBA BS CPC CCPC CPC-I QCC MCS-P CPMA CMHP | Published January 23rd, 2017 - Last Review/Update February 8th, 2019
Generating a differential diagnosis — that is, developing a list of the possible conditions that might produce a patient's symptoms and signs — is an important part of clinical reasoning. It allows a provider to perform appropriate testing to rule out possibilities and confirm a final diagnosis.
Courts view the formulation and documentation of a differential diagnosis as evidence of a physician's competence, prudence, and thoughtfulness.
January 16th, 2017
Alternative Payment Models (APMs) and Advanced APMs
By Wyn Staheli, Director of Research | Published January 16th, 2017
When CMS Released the NPRM regarding the Quality Payment Program (QPP), it included two payment tracks: MIPS and Advanced Alternative Payment Models (APMs). Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and bundled payment models are some examples of APMs. So how do these payment models differ?
According to a fact sheet ...
December 30th, 2016
DOJ Announces $4.7 Billion in False Claims Act Recoveries: But What Does That Really Mean?
By Paul Weidenfeld | Published December 30th, 2016 - Last Review/Update August 17th, 2017
The Department of Justice (DOJ) recently announced that it had recovered $4.7 billion in False Claims settlements and judgments making it the "third best year" in "False Claims Act History." Trumpeted by many as a return to DOJ's record setting years, an examination of the numbers over time reveals that ...
December 28th, 2016
Medicare’s Quality Payment Program: Getting Paid for Value Instead of Volume
By ChiroCode | Published December 28th, 2016 - Last Review/Update February 8th, 2019
The government has become increasingly concerned with how they spend money in the healthcare sector. As part of the latest proposal to fix this, the Medicare Access and CHIP Reauthorization Act (MACRA) was passed in 2015. This law changes reimbursement to remunerate providers more when they provide high quality care rather than just more care. It rewards value over volume. It also ends the flawed Sustainable Growth Rate (SGR) formula that had been in use to determine Medicare payment for many years. And, it combines three other quality-based programs into one. It’s biggest and lasting impact may be how it influences the way that patients select the provider they choose to see.
December 20th, 2016
ABN FAQs
By | Published December 20th, 2016 - Last Review/Update November 29th, 2017
This handy FAQ addresses the uses and mis-uses of the ABN form.
December 19th, 2016
Benchmarks
By Wyn Staheli, Director of Research | Published December 19th, 2016
Benchmarking is simply a standard or point of reference against which things may be compared or assessed. For all businesses, it is a way of comparing your business processes to another business in the same industry to determine where shortfalls exist or improvements can be made to maintain profitability.
December 16th, 2016
VACCINE AND VACCINE ADMINISTRATION PAYMENTS UNDER MEDICARE PART D
By Brittney Murdock, QCC, CMCS, CPC | Published December 16th, 2016
Please note: The information in this publication applies only to Medicare Part D; the Prescription Drug Benefit.
Except for vaccines covered under Medicare Part B, Medicare Part D plans cover all commercially available vaccines as long as the vaccine is reasonable and necessary to prevent illness.
Health care professionals (sometimes known as ...
December 15th, 2016
How do I Determine who is a Business Associate to Our Practice?
By ChiroCode | Published December 15th, 2016 - Last Review/Update March 5th, 2019
How do I determine who is a Business Associate?
December 12th, 2016
60 Day Final Rule
By Wyn Staheli, Director of Research | Published December 12th, 2016
Effective March 14, 2016, the CMS Final Rule clarifying the standards for handling
overpayments for both Medicare and Medicaid takes effect. Failure to report and
subsequently return an overpayment within 60 days after the overpayment was
“identified” is a violation of the False Claims Act.
December 4th, 2016
2017 CPT Updates Bring Big Changes to Physical Therapy
By Misty Tinch, RHIT, CPC, CPMA | Published December 4th, 2016 - Last Review/Update August 17th, 2017
For 2017, the new physical therapy (PT), occupational therapy (OT), and athletic training (AT) evaluation codes are the first major changes to the physical medicine and rehab codes in over twenty years. The new evaluation codes (97161-97168) replace the current PT and OT evaluation codes 97001 and 97003. The new ...
December 2nd, 2016
Risk Adjustment and Hierarchical Condition Category Coding and Auditing
By Michelle West, CPC, CEMC, CPMA, CRC | Published December 2nd, 2016 - Last Review/Update August 17th, 2017
Risk Adjustment (RA) and Hierarchical Condition Category (HCC) coding is a payment model mandated by CMS in 1997, which was implemented in 2003. This model identifies individuals with serious or chronic illness and assigns a risk factor score to the person based upon a combination of the individual's health conditions ...
November 25th, 2016
PAMA
By M. Ann Bachman, BSMT (ASCP), CLC (AMT), CMPM | Published November 25th, 2016 - Last Review/Update August 17th, 2017
The Clinical Laboratory Fee Schedule (CLFS) final rule, "Medicare Program: Medicare Clinical Diagnostic Laboratory Tests Payment System" (CMS-16F) implements PAMA, the Protecting Access to Medicare Act of 2014. The purpose of this rule is to more closely align CLFS payments under Medicare with payments made by private payers. CMS perceives ...
November 22nd, 2016
What is the Quality Payment Program?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 22nd, 2016
If you are a part of the team of Medicare’s Part B clinicians, Medicare is providing you with a new quality payment program. You will get to chose from Advanced Alternative Payment Models (APMs or Merit-Based incentive Payment system (MIPS). The MIPS is a new program that combines parts of ...
November 19th, 2016
Lack of Medical Necessity
By ChiroCode | Published November 19th, 2016 - Last Review/Update March 5th, 2019
(from page 210 in chapter 3.5 of the 2017 DeskBook) One of the biggest problems providers face when audited is that many services are deemed not medically necessary and are routinely denied. Much of the proof falls back on the medical record.
Here are some specific situations as they may ...
November 18th, 2016
Preventive Medical Services
By Shannon DeConda | Published November 18th, 2016 - Last Review/Update August 17th, 2017
The guidelines for PMS (Preventive Medicine Services), like those of regular E&M services are gray and leave many puzzling questions to the auditor regarding what is exactly is REQUIRED according to guidelines. In this tip, I will try to address the areas of documentation and provide a relatively concise statement ...
November 4th, 2016
The “APSO” Note: Changes and Challenges with the Modern Patient Record
By J. Paul Spencer, CPC, COC | Published November 4th, 2016 - Last Review/Update August 17th, 2017
Thirty years before the first set of evaluation and management , or E&M guidelines was released, Dr. Lawrence Weed developed a format for the improvement of what was then a segmented medical record into a problem-oriented medical record for patients. This format evolved into the "SOAP" note, representing an acronym ...
November 3rd, 2016
Medical Cloning in EHRs
By McKenzie Harrison, CPMA | Published November 3rd, 2016 - Last Review/Update August 17th, 2017
When an entry in the medical record is worded similar to or exactly as previous records, or when parts of the medical record are exactly the same from patient to patient, this is called Medical Cloning. When this occurs, the documentation does not meet the requirements of medical necessity due ...
October 28th, 2016
Auditing Same Day Psychotherapy and E&M Services: The Time Trap
By Scott Kraft, CPC, CPMA | Published October 28th, 2016 - Last Review/Update August 17th, 2017
A problem-focused E/M service and the provision of psychotherapy on the same date of service are both separately payable, when medically necessary. A typical scenario is when the
provider treats the patient's diagnoses by documenting the appropriate level of history, exam and medical decision making - such as a decision to ...
October 22nd, 2016
Think Outside the Box When Auditing Physical Exams
By Betty Stump, RHIT, CPC, CCS-P, CPMA | Published October 22nd, 2016 - Last Review/Update October 24th, 2017
CMS guidelines instruct coding and auditing professionals they may use either the 1995 or 1997 documentation guidelines when coding or auditing provider documentation. The restriction, of course, is the two guidelines cannot be combined- auditors must use either 1995 OR 1997 for any single episode of care. The two guidelines, ...
October 21st, 2016
First Listed Diagnosis and Episode of Care
By Aimee Wilcox, MA, CST, CCS-P, CPMA | Published October 21st, 2016 - Last Review/Update August 17th, 2017
Since ICD-10-CM implementation, there has been some confusion and incorrect information disseminated about how the first-listed diagnosis code should be determined for outpatient physical therapy services. To clear up the confusion, the American Physical Therapy Association (APTA) recently reported they had contacted the ICD-10 Cooperating Parties (AHA, AHIMA, CMS, and ...
October 17th, 2016
CMS Finalizes the New Medicare Quality Payment Program
By ChiroCode | Published October 17th, 2016 - Last Review/Update March 5th, 2019
On October 14, HHS finalized its policy implementing the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM) incentive payment provisions in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), collectively referred to as the Quality Payment Program.
October 14th, 2016
Injections and Infusions
By Jessica Franzese, CPC, CPMA | Published October 14th, 2016 - Last Review/Update August 17th, 2017
Injection and infusion codes can be tricky. In this auditing tip, we'll break them down and help to make them a little easier to understand. Let's start first with the basics. Injections and infusion codes can be found in the medicine section of the CPT® book, codes 96360-96549. They are ...
October 7th, 2016
Is Your Practice in Need of a Wellness Visit?
By Valora Gurganious, MBA, CHBC | Published October 7th, 2016 - Last Review/Update August 17th, 2017
Are you finding yourself frustrated that you are working harder than ever but your practice income continues to drop? Are patients expressing greater frustration with longer wait times at your office? Is your staff morale declining and your own stress level is rising each day in the face of increasingly ...
September 30th, 2016
Medicare Condition Code 44
By Jeanette Anderson, CPC, CPMA | Published September 30th, 2016 - Last Review/Update August 17th, 2017
Medicare Condition Code 44 is used when an inpatient admission needs to be changed to outpatient status. There are some instances where a Medicare patient was admitted to the hospital with an inpatient status, but upon review it is deemed more appropriate for the entire encounter to be an outpatient ...
September 24th, 2016
Medicare Improper Payment Report for Behavioral Health Services (2015)
By Wyn Staheli, Director of Research | Published September 24th, 2016
Medicare claims review sheds light on problem areas for behavioral health providers.
September 23rd, 2016
Documentation Rules vs. Guidelines – Is it Just Semantics, or Something More?
By Shannon DeConda | Published September 23rd, 2016 - Last Review/Update August 17th, 2017
This article was previously published in BCAdvantage Issue 11.5- September/October 2016
Most of us learned at a young age that rules are set in stone. Guidelines, on the other hand, are open to interpretation. Consider the last time you-or someone you know-was stopped by a police officer for speeding. Do you ...
September 17th, 2016
Government Healthcare Programs
By Wyn Staheli, Director of Research | Published September 17th, 2016
The Department of Health and Human Services (HHS) oversees all government health care programs. They are administered by various agencies such as the Centers for Medicare & Medicaid Services (CMS), the Veterans Administration (VA) and even at the state level. Here are the basic government programs:
Medicare
Federal Workers’ Compensation
Military and Veterans
Medicaid
Federal ...
September 16th, 2016
Measure Up: Wound Measurements & Debridement Auditing
By Grant Huang, CPC, CPMA | Published September 16th, 2016 - Last Review/Update August 17th, 2017
Wound care can be a tricky arena for auditors, but if there's any one element that providers tend to skimp on, it's wound measurements. Getting wound measurements right is crucial, but providers can sometimes be slapdash with documenting their measurements. Let's review what's required in terms of measurements for the ...
September 9th, 2016
CMS offering options for MACRA Participation. You Choose - Be prepared!
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 9th, 2016
The most recent Blog Post from CMS has given a new update on The bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). CMS states they will allow providers four options of reporting for the first year of the program stating they can pick their pace of participation for the ...
September 9th, 2016
Who Can It Be Knocking at Your Door? Are You Prepared?
By Sean Weiss | Published September 9th, 2016 - Last Review/Update August 17th, 2017
The truth is you can never be fully prepared when a Special Investigative Unit (SIU) from Medicare or Medicaid shows up unannounced. With that said, you can use this tip to help understand what your obligations are and how to act to ensure it is as smooth a process as ...
September 2nd, 2016
Little Things People Hate About Their Colleagues – Are You Guilty?
By Bernard Marr | Published September 2nd, 2016 - Last Review/Update August 17th, 2017
Article was republished with permission from author.
It's true that we can't choose our families, but in most cases, we also don't get to choose our work colleagues - and many of us spend more time with the people at work than we do with our blood kin! According to a ...
August 19th, 2016
Chief Complaint
By Shannon DeConda | Published August 19th, 2016 - Last Review/Update August 17th, 2017
What do you do when you come across an E&M encounter that has no chief complaint? Do you deem the encounter non-billable?
For years, I have heard it said that EVERY encounter MUST have a chief complaint, bus is that really what documentation guidelines have to say? The only guidance we ...
August 11th, 2016
When the Government Tries to Change the Rules
By Sean Weiss | Published August 11th, 2016 - Last Review/Update August 17th, 2017
We all know that the government doesn't fight fair. This is why it is so critical for healthcare professionals to understand their recourse when the government does not follow
their own guidelines. Providing audit appeal defense services to clients all over the country, we are seeing MACs and ZPICs making determinations ...
August 7th, 2016
Don’t Undervalue Patient Complexity
By Robin Sewell, CCS, CPC, CHTS-PW | Published August 7th, 2016 - Last Review/Update August 17th, 2017
Healthcare professionals can readily discern the acuity and severity of a patient's illness based on the presentation of the patient and objective data at their disposal. Although it is the responsibility of the clinician to convey the complexity of the case, it is not always easy for an auditor to ...
August 5th, 2016
History of Present Illness
By Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC | Published August 5th, 2016 - Last Review/Update August 17th, 2017
Per Medicare's 1995 and 1997 documentation guidelines, "HPI is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present." The History of Present Illness (HPI) is the story that explains the progress of the condition ...
July 29th, 2016
Modifier 22
By J. Paul Spencer, CPC, COC | Published July 29th, 2016 - Last Review/Update August 17th, 2017
Depending on a surgeon's area of expertise, documentation becomes an important tool not simply as a marker of care quality, but for the proper capture of charges and reimbursement. This past January 1st marked the 20th anniversary of CMS' adoption of Correct Coding Initiative (CCI) bundling edits, which have over ...
July 22nd, 2016
MACRA & MIPS Explained
By James Goosie | Published July 22nd, 2016 - Last Review/Update August 17th, 2017
You may have already heard that on April 16, 2015, the bipartisan legislation signed into law the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA was created to repeal the sustainable growth formula, change the way physicians are paid by going to a value- based system instead of ...
July 15th, 2016
Compliance Plans: The Truth About Templates
By Sean Weiss, VP and Chief Compliance Officer at DoctorsManagement | Published July 15th, 2016 - Last Review/Update August 17th, 2017
This is not an article about building an effective compliance plan. It is about the most efficient and accurate way to build it and some of the nuances to be aware of when using a template to build your plan. As a compliance officer and someone that spends my days ...
July 8th, 2016
What You Need to Know About 2017 ICD-10 Updates
By Jessica Franzese, CPC, CPMA | Published July 8th, 2016 - Last Review/Update August 17th, 2017
October 2016 brought us the implementation of ICD-10-CM. The switch from ICD-9-CM to ICD-10- CM brought with it a level of uncertainty and maybe even a little panic. With a great deal of preparation and planning in place, the implementation came and went without too much trouble. Now that we've ...
July 1st, 2016
Demystifying the 7th Character in ICD-10-CM
By Aimee Wilcox, MA, CST, CCS-P, CPMA | Published July 1st, 2016 - Last Review/Update August 17th, 2017
Since implementation of ICD-10-CM on October 1, 2016, the proper application of the 7th character has caused confusion and subsequent claims denials. ICD-9-CM, 'aftercare' codes have been replaced by 7th character codes in ICD-10-CM. The 7th characters identify active treatment, healing phase, and sequale (all healed up but the patient's ...
June 28th, 2016
NAMAS - Study the Rules Before Auditing E&M Services by Teaching Physicians
By Find-A-Code | Published June 28th, 2016
If you work for a facility that utilizes residents, then you will need to understand the requirements for reporting teaching physician services. The Office of Inspector General (OIG) has had hospital teaching physician activities on their work plan repeatedly, and therefore it should be on your radar as well to ...
June 24th, 2016
Study the Rules Before Auditing E&M Services by Teaching Physicians
By Sara San Pedro, CPC, CEMC, CPMA | Published June 24th, 2016 - Last Review/Update August 17th, 2017
If you work for a facility that utilizes residents, then you will need to understand the requirements for reporting teaching physician services. The Office of Inspector General (OIG) has had hospital teaching physician activities on their work plan repeatedly, and therefore it should be on your radar as well to ...
June 21st, 2016
Voluntary Overpayments
By Wyn Staheli, Director of Research | Published June 21st, 2016
When a claim has been determined to be paid more than the allowed amount, it is considered an overpayment. The action to be taken depends on how the overpayment is discovered. This article covers voluntary overpayment refund procedures as well as a Voluntary Overpayment Form.
June 17th, 2016
Comparative Billing Reports (CBRs): The Truth About Your Numbers
By Sean M. Weiss, VP and Chief Compliance Officer at DoctorsManagement | Published June 17th, 2016 - Last Review/Update August 17th, 2017
More and more I am receiving calls from clients and their attorneys from around the country asking what these CBRs mean and whether they should be concerned. The answer is simple: any time a payor or one of their contracted "Bounty Hunters" sends you a letter stating you're an outlier ...
June 16th, 2016
Q&A: Will Using Lower Level Codes Reduce Our Chances of Being Audited?
By ChiroCode | Published June 16th, 2016 - Last Review/Update March 5th, 2019
Q&A: If we use low level codes on each visit (such as 98940, 99212, 99202), will our chances of being audited be less than if we billed higher level codes?
June 15th, 2016
Mastering Medicare: When Opting Out is not an Option
By Dr. Ray Foxworth, Certified Medical Compliance Specialist and President of ChiroHealthUSA | Published June 15th, 2016 - Last Review/Update March 5th, 2019
Unlike MDs and DOs, chiropractors may not opt out of Medicare.
When it comes to Medicare, providers and patients alike feel like beating their heads against the wall. Signing up to be a provider or a patient is confusing, understanding what is covered is confusing and just about the time you think you have it figured out, you receive a notice that suggests you don’t.
The hassles of Medicare certainly validate any sane person questioning whether they should see a Medicare patient, but with the rising number of Medicare patients in the US do you really want to limit your patient base?
June 10th, 2016
Medical Necessity & Its Impact on E/M Services: Ensure You Always Land on the Correct Level of Service
By McKenzie Harrison, CPMA | Published June 10th, 2016 - Last Review/Update August 17th, 2017
One of the areas dating back to the first change in how providers select codes for visits is still causing problems today and at almost the same rate. The high rate of improper Evaluation and Management (E&M) levels and the failure to adequately demonstrate medical necessity (nature of presenting problem) ...
June 7th, 2016
Q/A: Do you Have any Recommendations for Audit Prevention?
By ChiroCode | Published June 7th, 2016 - Last Review/Update March 5th, 2019
Q: Do you have any recommendations for audit prevention?
June 7th, 2016
HIPAA Helps and FAQs
By Raquel Shumway | Published June 7th, 2016
The Health Insurance Portability and Accountability Act (HIPAA) has been around for quite some time. There are many misconceptions about HIPAA compliance that our office still gets calls about. This page is to help clear up some of these misconceptions.
June 3rd, 2016
Electronic Medical Records: Is Your EMR Making You Look Like a Bad Doctor?
By Betty Stump, RHIT, CPC, CCS-P, CPMA | Published June 3rd, 2016 - Last Review/Update August 17th, 2017
"As of the end of 2015, 56 percent of all U.S. office-based physicians (MD/DO) have demonstrated meaningful use of certified health IT in the Centers for Medicare and Medicaid Services (CMS) Electronic Health Record (EHR) Incentive Programs." [1]
More than half of the physicians in practice in the United States currently ...
May 27th, 2016
Documentation Criteria: Medicare Physicals
By Jeanette Anderson, CPC, CPMA | Published May 27th, 2016 - Last Review/Update August 16th, 2017
When billing annual Medicare physicals, it's very important to know the status of the patient, determining when they became eligible, and/or if they've seen another provider for any of these services as the initial visit codes are once in a lifetime codes and will be denied if they have already ...
May 20th, 2016
Pass-Through Billing and Shared Labs
By Ann Bachman, CLC (AMT), MT (ASCP) | Published May 20th, 2016 - Last Review/Update August 16th, 2017
Pass-through billing has mostly passed on.
Pass-through billing is an arrangement between a physician practice and a reference laboratory that allows the physician practice to submit specimens to the reference lab for testing, pay that laboratory directly, and then bill the payer (insurance or patient) for the test, usually at a ...
May 19th, 2016
Skilled nursing facilities paid for participating in new program, starting the summer of 2016
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 19th, 2016
Medicare plans to start a Skilled Nursing Facility Value-Based Purchasing Program (SNFVBP), beginning fiscal year 2019. This program will be used to promote better clinical outcomes for skilled nursing facility patients and improve care during their stay at a skilled nursing facility. Skilled nursing facilities will be paid for participating. ...
May 13th, 2016
Using the Right Diagnosis
By Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC | Published May 13th, 2016 - Last Review/Update August 16th, 2017
One of the hardest parts when reviewing a medical record for coding or auditing is the determination of what conditions were addressed. Any condition that is taking into account or affects patient care, treatment or management should be documented and ultimately coded. However, the documentation still needs to support that ...
May 6th, 2016
This Week’s Auditing & Compliance Tip Comes from a Recent NAMAS Q&A
By Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA | Published May 6th, 2016 - Last Review/Update August 16th, 2017
In the setting of incident-to billing, if an established patient presents with a known history of benign lesions including actinic keratosis previously treated by cryo, would the presence of new skin lesions be considered a 'new problem' that requires physician involvement OR is the previous history and treatment plan sufficient ...
May 3rd, 2016
CMS Publishes Final Rule on Fire Safety Requirements for Certain Health Care Facilities
By Brittney Murdock, QCC, CMCS, CPC | Published May 3rd, 2016
Today, the Centers for Medicare & Medicaid Services (CMS) announced a final rule (https://www.federalregister.gov/public-inspection) to update health care facilities’ fire protection guidelines to improve protections for all Medicare beneficiaries in facilities from fire.
The new guidelines apply to hospitals; long term care (LTC) facilities; critical access hospitals (CAHs); inpatient hospice facilities; ...
May 3rd, 2016
CMS Finalizes its Quality Measure Development Plan
By Kate Goodrich, M.D., M.H.S., Director, Center for Clinical Standards & Quality, CMS | Published May 3rd, 2016
On December 18, 2015, we posted our draft Quality Measure Development Plan, a strategic framework for clinician quality measurement development to support the new Merit-based Incentive Payment System (MIPS) and advanced alternative payment models (APMs). Through March 1, 2016, we asked for stakeholder feedback and received responses from 60 individuals ...
April 29th, 2016
Auditing Exams: Detailed Exams
By Grant Huang, CPC, CPMA | Published April 29th, 2016 - Last Review/Update August 16th, 2017
You might think the physical exam portion of an E/M note is one of the simplest areas to audit. After all, you don't have to worry about all the possible words a physician might use in the history that you'll need to qualify as elements of the history of present ...
April 8th, 2016
Amending the Medical Record
By Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA | Published April 8th, 2016 - Last Review/Update August 16th, 2017
A medical record is a legal document and therefore there is a right way to modify a record and certainly a wrong way as well. All modifications and addendums must follow the guidelines whether it is the provider or ancillary staff that are modifying their own entries. Addendums may be ...
April 5th, 2016
Voluntary Disclosure - Look Before You Leap
By ChiroCode | Published April 5th, 2016
Occasionally providers are faced with the need to assess the option of making a voluntary disclosure to the government. Here are steps that every provider should consider before disclosing information to the government.
April 1st, 2016
Who Audits the Auditor?
By Michelle West, CPC, CEMC, CPMA | Published April 1st, 2016 - Last Review/Update August 16th, 2017
Does your facility have a policy in place which addresses quality assurance? It is vital to ensure that regulatory and internal compliance plan policies are being followed by those who are responsible for internal chart audits.
Even before you review internal audits, here are some tips to ensure their quality:
Is your ...
March 25th, 2016
Auditing Smoking Cessation Services
By John Burns, CPC, CPC-I, CEMC, CPMA | Published March 25th, 2016 - Last Review/Update August 16th, 2017
Most payers do indeed recognize smoking and tobacco cessation services as a covered health insurance benefit. We have found that some providers perform these services without fully understanding the reimbursement opportunities, while others claim such services without adequately documenting to support them. Medicare, for example, will pay for two (2) ...
March 18th, 2016
TCM, CCM, and Clinical Staff Members
By Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA | Published March 18th, 2016 - Last Review/Update August 16th, 2017
When auditing Transitional Care Management (TCM) and Chronic Care Management (CCM) services, you may come into a situation where services are performed by clinical staff members. What constitute as a clinical staff member, and are they allowed to perform such services? What if they are not licensed?
CMS is vague about ...
March 11th, 2016
The Importance of Verifying Regulatory Guidance
By Jessica Franzese, CPC, CPMA | Published March 11th, 2016 - Last Review/Update August 16th, 2017
In the world of medical documentation, things are constantly changing. As medical coding and auditing professionals, we know that CPT and ICD-10 CM codes change annually. We are quick to keep up with these changes, ensuring such things as software updates and the purchase of new manuals. But are we ...
March 4th, 2016
Medicare Improper Payment Report for Behavioral Health Services (2014)
By Wyn Staheli, Director of Research | Published March 4th, 2016
Medicare Improper Payment Report information regarding Behavioral Health Services
March 4th, 2016
Guidance for Modifier 24 Usage
By Sara San Pedro, CPC, CEMC, CPMA | Published March 4th, 2016 - Last Review/Update August 16th, 2017
Modifier 24 (Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period) has generated more scrutiny lately because of the attention it is receiving from Recovery Auditors and payors. An assignment of modifier 24 will oftentimes trigger a medical record request, so we must be confident when ...
February 26th, 2016
Auditing for Cerumen Removal Codes 69209, 69210
By Scott Kraft | Published February 26th, 2016 - Last Review/Update August 16th, 2017
2016 brings changes to how physician practices bill for the removal of impacted cerumen, including a new CPT code. The rules that apply to the two cerumen removal codes now available for use mean that auditors will need to scrutinize the documentation closely in order to ensure codes are being ...
February 24th, 2016
Employee Exclusions Screenings Must be High Priority
By Wyn Staheli | Published February 24th, 2016
Many healthcare organizations are not aware of how critically important it is to screen their employees against ALL state and federal exclusions databases. This article has important information for organization to ensure compliance.
February 19th, 2016
Is Your Patient PHI Fully Protected?
By Kelly Ogle, BSDH, MIOP, CHOP, CMPM | Published February 19th, 2016 - Last Review/Update August 16th, 2017
As you probably know, HIPAA stands for the Health Insurance Portability and Accountability Act. This means that as healthcare professionals, we must hold ourselves accountable when handling patient information. This goes beyond having conversations with unauthorized people about what we see or hear in the office. Unlike OSHA, patients, employees, ...
February 15th, 2016
Unified Program Integrity Contractors (UPIC)
By InstaCode Institute | Published February 15th, 2016
CMS is developing a new Unified Program Integrity Contractor (UPIC) program to consolidate Medicare and Medicaid reviews. This consolidation of the Medicaid Integrity Contractors (MICs) and the Medicare Zone Program Integrity Contractors (ZPICs) could relieve some of the overlap and burdens under the current systems.
February 12th, 2016
Patient Status: Hospital Inpatient vs. Observation
By Jeanette Anderson, CPC, CPMA | Published February 12th, 2016 - Last Review/Update August 16th, 2017
As an auditor, we must ensure that the documentation supports the selected use of codes for reimbursement. When auditing hospital encounters, the patient status serves as the basis for the code selection and therefore must be clearly documented. This ensures that the hospital is able to collect appropriate reimbursement.
During an ...
February 5th, 2016
The Assurance of Quality Assurance
By Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA | Published February 5th, 2016 - Last Review/Update August 16th, 2017
Does your organization have a Quality Assurance (QA) plan in place? Does it contain policies for escalations or what to do when certain issues arise? Even organizations with the most experienced of auditors on staff can find extreme value in creating - and following - an effective quality assurance plan.
Many ...
February 1st, 2016
Will Incident-To in Your Organization Pass a Compliance Audit?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 1st, 2016
Practices that bill incident to services need to periodically audit compliance with Medicare and private payor guidelines to avoid potential denials or third-party audits.
January 29th, 2016
What is MIPS?
By Wyn Staheli, Director of Research | Published January 29th, 2016
The Merit-Based Incentive Payment System (MIPS) combines PQRS, VM, and EHR into a single Medicare pay-for-performance quality payment system scheduled to begin in 2019.
January 29th, 2016
Opioid Abuse and House It Will Impact Physicians
By James Goosie, MBA | Published January 29th, 2016 - Last Review/Update August 16th, 2017
One of the largest issues that the healthcare industry is facing, which no one wants to really deal with, is the addiction to opioids in the United States. In 2014, an estimated 2 million people in the United States were addicted to opioids. In 2013, the United States became the ...
January 22nd, 2016
Think Outside the Box When Auditing Physical Exams
By Betty Stump, RHIT, CPC, CCS-P, CPMA | Published January 22nd, 2016 - Last Review/Update August 16th, 2017
CMS guidelines instruct coding and auditing professionals they may use either the 1995 or 1997 documentation guidelines when coding or auditing provider documentation. The restriction, of course, is the two guidelines cannot be combined- auditors must use either 1995 OR 1997 for any single episode of care. The two guidelines, ...
December 21st, 2015
ROS Checklist
By | Published December 21st, 2015
Review of Systems CHECKLIST: -General- ? Weight loss or gain ? Fatigue ? Fever or chills ? Weakness ? Trouble sleeping ----------------------------------------------------------------------------------- -Skin- ? Rashes ? Lumps ? Itching ? Dryness ? Color changes ? Hair and nail changes ----------------------------------------------------------------------------------- -Head- ? Headache ? Head...
December 3rd, 2015
Hospital Observation Services
By Codapedia | Published December 3rd, 2015
Hospital observation services are considered outpatient services. They are typically used when a period of time is needed to evaluate the progress or regression. This may include effectiveness of medication/ infusions, results of diagnostic results or other reasons deemed as medically necessary. This period of time...
December 3rd, 2015
Why Get Into Medical Billing?
By Codapedia | Published December 3rd, 2015
I am asked alot or read alot where people want to get into medical billing. Some have gone to school and some haven't. Either way, there is more to it than just saying, I want to do that. I've been in this field for over...
December 3rd, 2015
Interval History
By Codapedia | Published December 3rd, 2015
In the CPT® book, some E/M codes are described as requiring an "expanded problem focused history" or a "detailed history." Others require "an expanded problem focused interval" history or a "detailed interval history." What's the difference? Past medical, family and social history. These three are not...
December 2nd, 2015
99212--established patient visit - Sample audited notes
By | Published December 2nd, 2015
Established patient visits all require 2 out of 3 of history, exam, medical decision making 99212: History required is problem focused: 1-3 HPI elements Exam required is problem focused: 1 body area/organ system examined from the 1995 exam, or one bullet from the multi-specialty exam...
December 2nd, 2015
Chief Complaint - Rules related to the Chief Complaint in the D.G.
By | Published December 2nd, 2015
The guidelines go on to read, "The medical record should clearly reflect the chief complaint." This leaves physicians to ask the question, does the chief complaint need to be listed separately from the history of the present illness or the rest of the rest of the...
December 2nd, 2015
Past medical, family and social history - Documenting and auditing the history section of an E/M service
By | Published December 2nd, 2015
When an Evaluation and Management service requires past medical, family and social history, (or one or two of those) here is what needs to be documented, and the rules around using one that is previously documented. Past medical history includes the patient's chronic illnesses, previous...
December 2nd, 2015
History of the present illness - HPI Rules from the Documentation Guidelines
By | Published December 2nd, 2015
Here are the elements of the HPI: Location: Where do the patient's symptoms occur? In order to use location, it should be a place on the body that you could point to or touch and that the physician describes as the place where the patient's symptoms occur. Head, shoulders, knees...
December 2nd, 2015
It’s a home health crackdown, but your phone’s going to ring
By Codapedia | Published December 2nd, 2015
Don’t be surprised if you suddenly start to get persistent calls from home health agencies concerning patients you’ve referred for home health care. Medicare has directed its supplemental medical review contractors (SMRCs) to crack down on the face-to-face visit rules required to certify home health care by...
December 2nd, 2015
Yet another new auditor looking at Part B claims
By Codapedia | Published December 2nd, 2015
Recovery Audit Contractors (RACs) may be about to take a break while CMS awards new contracts, but don’t rest on your laurels. CMS has handed out yet another auditor contract for a single auditor, known as a Supplemental Medical Review Contractor (SMRC) to do nationwide claims...
December 2nd, 2015
CMS puts the brakes on RAC audits for now, and implements changes for when they return
By Codapedia | Published December 2nd, 2015
Good news for physician practices that don’t like getting demand letters and record requests from Recovery Audit Contractors (RACs). All those requests will stop by Feb. 28 on orders from CMS. RACs will be back once CMS awards new RAC contracts, but those awards may...
December 2nd, 2015
CMS looking for ways to boot providers who don’t correct repeated billing problems
By Codapedia | Published December 2nd, 2015
Providers with a history of making the same mistakes over and over again may find themselves on the outside of the Medicare program looking in, if CMS has its way. The agency has formalized a policy to use existing regulations to identify these providers and be...
December 2nd, 2015
CMS clarifies the ways physician practices can respond to additional documentation requests
By | Published December 2nd, 2015
It’s one of the inevitabilities of running a physician practices that never happens at a good time and seems to rarely go very smoothly. You see an additional documentation request – known as an ADR – from either your Medicare Administrative Contractor (MAC) or one of...
December 2nd, 2015
Will the RACs audit E/M services?
By Codapedia | Published December 2nd, 2015
This is the $10,000 question: will the RAC auditors, now in place throughout the country, look at E/M services? Here is what CMS says in its FAQ on the topic: From their website: Will the Recovery Audit Contractors (RAC) review evaluation and management (E&M) services on...
December 2nd, 2015
Do headings matter in an E/M note?
By Codapedia | Published December 2nd, 2015
When documenting the history components in an Evaluation and Management service, the clinician is not required to use the headings that the Documentation Guidelines define. That is, the history section does not need to be labeled: History of the Present Illness, Review of Systems, and past...
November 24th, 2015
You do not need to change or rewrite your original orders
By Find-A-Code | Published November 24th, 2015
CMS wants to remind you not to change or rewrite your original orders for any service or product due to the change of code sets from ICD-9-CM to ICD-10-CM.
For any type of product or service prior to October 1, 2015, do not change the order, even if it will be ...
November 19th, 2015
Review of Systems - ROS Rules for Auditing
By | Published November 19th, 2015
Sometimes one symptom can be used in more than one system. For example, dizziness. Although we typically think of this as a neurological symptom, sometimes cardiologists ask about dizziness and relate it to the cardiovascular system.
In the citations section of this entry, there are references for symptoms ...
August 19th, 2015
Chiropractic Listed as Focal Point in 2015 OIG Work Plan
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published August 19th, 2015 - Last Review/Update January 30th, 2017
With the recent release of the 2015 OIG Work Plan, many providers and facilities are reviewing the content to learn which areas of interest pertaining to their specialty will be points of interest for federal auditing programs for the 2015 Fiscal Year. The information contained in this Work Plan addresses the ...
August 19th, 2015
What to Do When a Payer Audits You
By | Published August 19th, 2015 - Last Review/Update January 27th, 2017
When a payer audits you the first thing to do is respond to the audit. Do not ignore it; it won’t go away. In the initial stage of the audit, they will probably ask you to send them your notes on approximately 5-10 patients. Either have a health care attorney or yourself send ...
August 10th, 2015
Audit Fighting Tactics
By Tom Necela, DC, CPC, CPMA, CCP-P | Published August 10th, 2015 - Last Review/Update January 27th, 2017
Four Tactics or tips to help you fight back when you are audited or have your claims reviewed. They are effective and easy to use.
August 10th, 2015
Alphabet Soup for Waste and Fraud Inspectors
By ChiroCode | Published August 10th, 2015 - Last Review/Update January 27th, 2017
The following are some of the acronyms you would need to know when communicating with auditors:
National Correct Coding Initiative (NCCI) Edits: Use of codes that should not occur on the same day, effectively treating the same area twice.
Medically Unlikely Edits (MUE): Exceeding the anticipated units of service (time spent) for a given HCPCS or CPT code.
Office of the ...
July 20th, 2015
Formats for Submitting Claims to Medicare - Electronic Submission Requirements
By Find-A-Code | Published July 20th, 2015
(Rev. 3086, Issued: 10-03-14, Effective: ICD-10: Upon Implementation of ICD-10, ASC X12: January 1, 2012, Implementation ICD-10: Upon Implementation of ICD- 10; ASC X12: November 4, 2014)
The Administrative Simplification Compliance Act (ASCA) requires that claims be submitted to Medicare electronically unless certain exceptions are met. In addition, the Health Insurance ...
July 10th, 2015
Carrier Claims Processing - Reporting of Pricing Localities for Clinical Laboratory Services (Rev. 85, 02-06-04)
By Jared Staheli | Published July 10th, 2015
Carriers shall report to the common working file (CWF) new State pricing localities (positions 58 and 59 on the carrier record) indicated on the Clinical Diagnostic Laboratory fee schedule for any reference laboratory service billed with a HCPCS 90 modifier. If the laboratory test billed is not a reference laboratory ...
July 10th, 2015
Specimen Collection Fee (Rev. 1, 10-01-03)
By Jared Staheli | Published July 10th, 2015
In addition to the amounts provided under the fee schedules, the Secretary shall provide for and establish a nominal fee to cover the appropriate costs of collecting the sample on which a clinical laboratory test was performed and for which payment is made with respect to samples collected in the ...
July 10th, 2015
Independent Laboratory Specimen Drawing (Rev. 3071, 12-22-14)
By Jared Staheli | Published July 10th, 2015
Medicare allows separate charges made by laboratories for drawing or collecting specimens whether or not the specimens are referred to hospitals or independent laboratories. The laboratory does not bill for routine handling charges where a specimen is referred by one laboratory to another.
Medicare allows payment for a specimen collection fee ...
July 10th, 2015
Specimen Drawing for Dialysis Patients (Rev. 3056, 12-01-14)
By Jared Staheli | Published July 10th, 2015
See the Medicare Benefit Policy Manual, Chapter 11, for a description of laboratory services included in the composite rate. With the implementation of the ESRD PPS, effective for claims with dates of service on or after January 1, 2011, all ESRD-related laboratory services are included in the ESRD PPS base ...
July 10th, 2015
Laboratory Tests Utilizing Automated Equipment (Rev. 1, 10-01-03)
By Jared Staheli | Published July 10th, 2015
Clinical laboratory tests are covered under Medicare if they are reasonable and necessary for the diagnosis or treatment of an illness or injury. Because of the numerous technological advances and innovations in the clinical laboratory field and the increased availability of automated testing equipment, no distinction is generally made in ...
July 10th, 2015
Automated Test Listing (Rev. 1, 10-01-03)
By Jared Staheli | Published July 10th, 2015
Profiles are specific groupings of blood chemistries that enable physicians to more accurately diagnose their patients’ medical problems. While the component tests in automated profiles may vary somewhat from one laboratory to another, or from one physician’s office or clinic to another, in order to develop appropriate payment amounts, contractors ...
July 10th, 2015
History Display (Rev. 372, 04-04-05)
By Jared Staheli | Published July 10th, 2015
When displaying claims payment for each CPT code in history, contractors apply the following rules:
1. If all component tests of any panel are allowed because the individual line item comparison is less than the fee (as determined in item C above), record the panel codes as determined on the line-by-line ...
July 9th, 2015
The Competitive Acquisition Program (CAP) for Drugs and Biologicals Not Paid on a Cost or Prospective Payment Basis (Rev. 3085, Effective: Upon Implementation of ICD-10)
By Jared Staheli | Published July 9th, 2015
Section 303 (d) of the Medicare Prescription Improvement and Modernization Act (MMA) of 2003 requires the implementation of a competitive acquisition program (CAP) for Medicare Part B drugs and biologicals not paid on a cost or prospective payment system basis. Beginning with drugs administered on or after July 1, 2006, ...
July 9th, 2015
Application of Local Medical Review Policies (Rev. 866, 07-03-06) - Competitive Acquisition Program
By Jared Staheli | Published July 9th, 2015
Carriers and/or Program Safeguard Contractors shall apply all Local Coverage Determination (LCD) policies and National Coverage Determination (NCD) policies to the administration and no-pay drug code lines on the CAP claims.
Should it be determined that a drug administration or drug code service line does not meet the requirements of the ...
July 9th, 2015
Creation of Internal Vendor Provider Files (Rev. 866, 07-03-06) - Competitive Acquisition Program
By Jared Staheli | Published July 9th, 2015
The designated carrier shall create an internal provider file for each vendor which includes the names, addresses, and UPINs, (NPI when effective), of those physicians who have elected that vendor.
The designated carrier shall edit incoming vendor claims to verify that the UPIN number on the claim for the ordering physician ...
July 9th, 2015
Background (Rev. 1, 10-01-03) - Laboratory Services
By Jared Staheli | Published July 9th, 2015
Diagnostic X-ray, laboratory, and other diagnostic tests, including materials and the services of technicians, are covered under the Medicare program. Some clinical laboratory procedures or tests require Food and Drug Administration (FDA) approval before coverage is provided.
A diagnostic laboratory test is considered a laboratory service for billing purposes, regardless of ...
July 9th, 2015
Definitions (Rev. 85, 02-06-04) - Laboratory Services
By Jared Staheli | Published July 9th, 2015
“Independent Laboratory” - An independent laboratory is one that is independent both of an attending or consulting physician’s office and of a hospital that meets at least the requirements to qualify as an emergency hospital as defined in §1861(e) of the Social Security Act (the Act.) (See the Medicare Benefits ...
July 9th, 2015
General Explanation of Payment (Rev. 2581, 04-01-13) - Laboratory Services
By Jared Staheli | Published July 9th, 2015
Outpatient laboratory services can be paid in different ways:
• Physician Fee Schedule;
• 101 percent of reasonable cost (critical access hospitals (CAH) only);
NOTE: When the CAH bills a 14X bill type for a non-patient laboratory specimen, the CAH is paid under the fee schedule.
• Laboratory Fee Schedule;
• Outpatient Prospective Payment System, ...
July 9th, 2015
Calculation of Payment Rates - Clinical Laboratory Test Fee Schedules (Rev. 1, 10-01-03)
By Jared Staheli | Published July 9th, 2015
Under Part B, for services rendered on or after July 1, 1984, clinical laboratory tests performed in a physician’s office, by an independent laboratory, or by a hospital laboratory for its outpatients are reimbursed on the basis of fee schedules. Current exceptions to this rule are CAH laboratory services as ...
July 9th, 2015
Initial Development of Laboratory Fee Schedules (Rev. 1, 10-01-03)
By Jared Staheli | Published July 9th, 2015
Initially, each carrier established the fee schedules on a carrier-wide basis (not to exceed a statewide basis). If a carrier’s area includes more than one State, the carrier established a separate fee schedule for each State. The carrier determined the fee schedule amount based on prevailing charges for laboratory billings ...
July 9th, 2015
Annual Fee Schedule Updates (Rev. 2106, 01-03-11) - Laboratory Services
By Jared Staheli | Published July 9th, 2015
The CMS adjusts the fee schedule amounts annually to reflect changes in the Consumer Price Index for all urban consumers (CPI-U) (U.S. city average) and the 10-year moving average of changes in annual economy-wide private nonfarm business multi-factor productivity, unless alternative updates are specified by legislation. The CMS communicates this ...
July 9th, 2015
Mandatory Assignment for Laboratory Tests (Rev. 1, 10-01-03)
By Jared Staheli | Published July 9th, 2015
Unless a laboratory, physician, or medical group accepts assignment, the carrier makes no Part B payment for laboratory tests paid on the laboratory fee schedule. Laboratories, physicians, or medical groups that have entered into a participation agreement must accept assignment. Sanctions of double the violation charges, civil money penalties (up ...
July 9th, 2015
Rural Health Clinics (Rev. 1, 10-01-03) - Laboratory Services
By Jared Staheli | Published July 9th, 2015
Rural Health Clinics (RHCs) must furnish the following laboratory services to be approved as an RHC. However, these and other laboratory services that may be furnished are not included in the encounter rate and must be billed separately:
• Chemical examinations of urine by stick or tablet method or both;
• Hemoglobin ...
July 9th, 2015
Deductible and Coinsurance Application for Laboratory Tests (Rev. 2581, 04-01-13)
By Jared Staheli | Published July 9th, 2015
Neither the annual cash deductible nor the 20 percent coinsurance apply to:
• Clinical laboratory tests performed by a physician, laboratory, or other entity paid on an assigned basis;
• Specimen collection fees; or
• Travel allowance related to laboratory tests (e.g., collecting specimen).
Codes on the physician fee schedule are generally subject to ...
July 9th, 2015
Method of Payment for Clinical Laboratory Tests - Place of Service Variation (Rev. 2971, 07-07-14)
By Jared Staheli | Published July 9th, 2015
The following apply in determining the amount of Part B payment for clinical laboratory tests:
Laboratory tests not payable on the Clinical Diagnostic Laboratory Fee Schedule (CLFS) will be based on OPPS (for hospitals subject to OPPS) and current methodology for hospitals not subject to OPPS.
Independent laboratory or a physician or ...
July 9th, 2015
Payment for Review of Laboratory Test Results by Physician (Rev. 1, 10-01-03)
By Jared Staheli | Published July 9th, 2015
Reviewing results of laboratory tests, phoning results to patients, filing such results, etc., are Medicare covered services. Payment is included in the physician fee schedule payment for the evaluation and management (E and M) services to the patient. Visit services entail a wide range of components and activities that may ...
July 9th, 2015
Which Contractor to Bill for Laboratory Services Furnished to a Medicare Beneficiary in a Skilled Nursing Facility (SNF) (Rev. 1, 10-01-03)
By Jared Staheli | Published July 9th, 2015
Inpatient Part A beneficiary - SNF bills the FI under Part A. The service is included in SNF PPS payment.
Inpatient Part B beneficiary (benefits exhausted or no Part A entitlement) - SNFs may provide the service and bill the FI, may obtain the service under arrangement and bill the ...
July 9th, 2015
Date of Service (DOS) for Clinical Laboratory and Pathology Specimens (Rev. 1515, 01-05-09)
By Jared Staheli | Published July 9th, 2015
The DOS policy for either a clinical laboratory test or the technical component of physician pathology service is as follows:
General Rule: The DOS of the test/service must be the date the specimen was collected.
Variation: If a specimen is collected over a period that spans two calendar days, then the DOS ...
July 9th, 2015
Clotting Factor Furnishing Fee (Rev. 3055, 01-05-15)
By Jared Staheli | Published July 9th, 2015
The Medicare Modernization Act section 303(e)(1) added section 1842(o)(5)(C) of the Social Security Act which requires that, beginning January 1, 2005, a furnishing fee will be paid for items and services associated with clotting factor.
Beginning January 1, 2005, a clotting factor furnishing fee is separately payable to entities that furnish ...
July 9th, 2015
Intravenous Immune Globulin (Rev. 3085, Effective: Upon Implementation of ICD-10)
By Jared Staheli | Published July 9th, 2015
Beginning for dates of service on or after January 1, 2004, Medicare pays for intravenous immune globulin administered in the home. (See the Medicare Benefit Policy Manual, Chapter 15 for coverage requirements.) Contractors pay for the drug, but not the items or services related to the administration of the drug ...
July 9th, 2015
Requirement for Providing Route of Administration Codes for Erythropoiesis Stimulating Agents (ESAs) (Rev. 1212; 06-29-07)
By Jared Staheli | Published July 9th, 2015
Patients with end stage renal disease (ESRD) receiving administrations of erythropoiesis stimulating agents (ESA), such as epoetin alfa (EPO) and Darbepoetin alfa (Aranesp) for the treatment of anemia may receive intravenous administration or subcutaneous administrations of the ESA.
Effective for claims submitted on or after February 1, 2007 with dates of ...
July 8th, 2015
Exceptions to Average Sales Price (ASP) Payment Methodology (Rev. 2437, 01-01-13) Medicare Pub 100-04 Drugs and Biologicals
By Jared Staheli | Published July 8th, 2015
The payment allowance limits for blood and blood products (other than blood clotting factors) that are not paid on a reasonable charge or prospective payment basis, are determined in the same manner the payment allowance limits were determined on October 1, 2003. Specifically, the payment allowance limits for blood and ...
July 8th, 2015
Calculation of the AWP (Rev. 397, 01-03-05) Medicare Pub 100-04 Drugs and Biologicals
By Jared Staheli | Published July 8th, 2015
See Business Requirements and Excel Spreadsheets at http://www.medicaid.com/manuals/pm_trans/R54CP.pdf http://www.medicaid.com/manuals/pm_trans/R55CP.pdf
Carriers must ensure that if any NDCs are added or deleted, the formulae are applied appropriately.
A separate AWP is calculated for each drug as defined by a HCPCS code. Within each HCPCS code there may be a single source or there may ...
July 8th, 2015
Carrier Distribution of Limit Amounts (Rev. 1, 10-01-03) Medicare Pub 100-04 Drugs and Biologicals
By Jared Staheli | Published July 8th, 2015
The FIs get drug prices from the carrier for drugs not listed on the SDP.
Carriers prepare a list of the drug payment allowance limits updates (or new file depending upon local requirements) to the claims system.
Carriers distribute, free of charge, the updated limits in an agreed upon format directly to ...
July 8th, 2015
Discarded Drugs and Biologicals (Rev. 1962, 07-30-10)
By Jared Staheli | Published July 8th, 2015
The CMS encourages physicians, hospitals and other providers and suppliers to care for and administer to patients in such a way that they can use drugs or biologicals most efficiently, in a clinically appropriate manner.
When a physician, hospital or other provider or supplier must discard the remainder of a single ...
July 8th, 2015
Discarded Erythropoietin Stimulating Agents for Home Dialysis (Rev. 1581; 12-01-08)
By Jared Staheli | Published July 8th, 2015
Multiuse vials are not subject to payment for discarded amounts of drug or biological, with the exception of self administered erythropoietin stimulating agents (ESAs) by Method I home dialysis patients. The renal facility must bill the program using the modifier JW for the amount of ESAs appropriately discarded if the ...
July 8th, 2015
Assignment Required for Drugs and Biologicals (Rev. 1, 10-01-03)
By Jared Staheli | Published July 8th, 2015
A. Local Carriers
Under §114 of the Benefits Improvement Act of 2000, effective for claims with dates of service on or after February 1, 2001, payment for any drug or biological covered under Part B of Medicare may be made only on an assignment-related basis. Therefore, no charge or bill may ...
July 8th, 2015
DMEPOS Suppliers Require a License to Dispense Drugs (Rev. 1, 10-01-03)
By Jared Staheli | Published July 8th, 2015
Regulations at 42 CFR 424.57(b)(4) (supplier standards) state that a “supplier that furnishes a drug used as a Medicare-covered supply with durable medical equipment or prosthetic devices must be licensed by the State to dispense drugs. (A supplier of drugs must bill and receive payment for the drug in its ...
July 8th, 2015
Prescription Drugs Billed by Suppliers Not Licensed to Dispense Them (Rev. 1, 10-01-03)
By Jared Staheli | Published July 8th, 2015
Medicare does not cover a drug used as a supply with DME or a prosthetic device if the drug is dispensed by an entity that is not licensed to dispense the drug. The drug is not considered to be reasonable and necessary because CMS cannot be assured of its safety ...
July 8th, 2015
Reporting Modifiers in the Compound Drug Segment (Rev. 1, 10-01-03)
By Jared Staheli | Published July 8th, 2015
Certain informational modifiers are required on compound ingredients. The NCPDP format does not currently support reporting modifiers in the compound segment. Therefore, the narrative portion in the prior authorization segment must be used to report these modifiers. The following must be entered in positions 001-003 of the narrative (Example, MMN ...
July 8th, 2015
Oral Anti-Emetic Drugs Used as Full Replacement for Intravenous Anti-Emetic Drugs as Part of a Cancer Chemotherapeutic Regimen (Rev. 2931, 07-07-14)
By Jared Staheli | Published July 8th, 2015
See the Medicare Benefit Policy Manual, Chapter 15, and the National Coverage Determination (NCD) Manual, Section 110.18, for detailed coverage requirements.
Effective for dates of service on or after January 1, 1998, Medicare Part B (including (institutional claims processed by Part A Medicare Administrative Contractors (MACs) and physician/supplier claims processed by ...
July 7th, 2015
Screening for Depression in Adults (Rev. 2431,10-14-11)
By Jared Staheli | Published July 7th, 2015
A. Coverage Requirements
Effective October 14, 2011, the Centers for Medicare & Medicaid Services (CMS) will cover annual screening up to 15 minutes for Medicare beneficiaries in primary care settings that have staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment, and follow-up. Various screening tools are ...
July 7th, 2015
Intensive Behavioral Therapy for Obesity (Effective November 29, 2011) (Rev. 2421, 11-29-11)
By Jared Staheli | Published July 7th, 2015
The United States Preventive Services Task Force (USPSTF) found good evidence that body mass index (BMI) is a reliable and valid indicator for identifying adults at increased risk for mortality and morbidity due to overweight and obesity. It also good evidence that high intensity counseling combined with behavioral interventions in ...
July 7th, 2015
Payment Rules for Drugs and Biologicals (Rev. 2437, 01-01-13)
By Jared Staheli | Published July 7th, 2015
Drugs for inpatient hospital and inpatient skilled nursing facility (SNF) beneficiaries are included in the respective prospective payment system (PPS) rates, except for hemophilia clotting factors for hospital inpatients under Part A.
All hospital outpatient drugs are excluded from SDP because the payment allowance for such drugs is determined by a ...
July 7th, 2015
MMA Drug Pricing – Average Sales Price (Rev. 1513, 06-23-08)
By Jared Staheli | Published July 7th, 2015
In general, CMS establishes a single, national payment limit for FI, carrier, DME MAC, and A/B MAC payment for each Medicare-covered drug whose payment is determined based on the methodology described above. Drugs billed to DME MACs are still priced locally, albeit under the new statutory formula, as applicable. The ...
July 7th, 2015
Average Sales Price (ASP) Payment Methodology (Rev. 1513, 06-23-08) Medicare Pub 100-04 Drugs and Biologicals
By Jared Staheli | Published July 7th, 2015
Section 303(c) of the Medicare Modernization Act of 2003 (MMA) revised the payment methodology for Part B covered drugs and biologicals that are not priced on a cost or prospective payment basis. Per the MMA, beginning January 1, 2005, the vast majority of drugs and biologicals not priced on a ...
July 6th, 2015
A/B MAC and Fiscal Intermediary (FI) Billing Requirements for the IPPE (Rev. 2159, 04-04-11)
By Jared Staheli | Published July 6th, 2015
Contractors will pay for IPPE or EKG only when the services are submitted on one of the following TOBs: 12X, 13X, 22X, 71X, 73X and 85X.
Type of facility and setting determines the basis of payment:
• For the IPPE or the screening EKG tracing only performed on a 12X and 13X ...
July 6th, 2015
Remittance Advice Remark Codes for the IPPE (Rev. 1615, 01-05-09)
By Jared Staheli | Published July 6th, 2015
Contractors shall use the appropriate claim Remittance Advice Remark code, such as N117 (This service is paid only once in a patient’s lifetime) when denying additional claims for an IPPE and/or a screening EKG.
...
July 6th, 2015
Claims Adjustment Reason Codes for the IPPE (Rev. 1615, 01-05-09)
By Jared Staheli | Published July 6th, 2015
Contractors shall use the appropriate Claim Adjustment Reason code, such as 149 (Lifetime benefit maximum has been reached for this service/benefit category) when denying additional claims for an IPPE and/or a screening EKG.
...
July 6th, 2015
Advanced Beneficiary Notice (ABN) as Applied to the IPPE (Rev. 1615, 01-05-09)
By Jared Staheli | Published July 6th, 2015
If a second IPPE is billed for the same beneficiary, it would be denied based on Section 1861(s)(2) of the Act, since the IPPE is a one-time benefit, and an ABN would not be required in order to hold the beneficiary liable for the cost of the second IPPE. However, ...
July 6th, 2015
Ultrasound Screening for Abdominal Aortic Aneurysm (AAA) (Rev. 3096, 11-18-14)
By Jared Staheli | Published July 6th, 2015
Section 1861(s)(2)(AA) and 1861(bbb) of the Social Security Act and implementing regulations at 42 CFR 410.19 authorize coverage under Medicare Part B for a one-time ultrasound screening for abdominal aortic aneurysm (AAA), effective January 1, 2007.
...
July 6th, 2015
Definitions for Ultrasound Screening for Abdominal Aortic Aneurysm (AAA) (Rev. 3096, 11-18-14)
By Jared Staheli | Published July 6th, 2015
The term “ultrasound screening for abdominal aortic aneurysm” means the following services furnished to an asymptomatic individual for the early detection of an abdominal aortic aneurysm—
(1) a procedure using sound waves (or such other procedures using alternative technologies, of commensurate accuracy and cost, as specified by the Secretary of Health ...
July 6th, 2015
Coverage for Ultrasound Screening for Abdominal Aortic Aneurysm (Rev. 3096, 11-18-14)
By Jared Staheli | Published July 6th, 2015
Payment may be made for a one-time ultrasound screening for AAA for beneficiaries who meet the following criteria:
(i) receives a referral for such an ultrasound screening from the beneficiary’s attending physician, physician assistant, nurse practitioner or clinical nurse specialist;
(ii) receives such ultrasound screening from a provider or supplier who is ...
July 6th, 2015
Payment for Ultrasound Screening for Abdominal Aortic Aneurysm (Rev. 1113, 01-02-07)
By Jared Staheli | Published July 6th, 2015
If the screening is provided in a physician office, the service is billed to the carrier using the HCPCS code identified in section 110.3.2 below. Payment is under the Medicare Physicians Fee Schedule (MPFS).
Fiscal Intermediaries (FIs) shall pay for the AAA screening only when the services are performed in a ...
July 6th, 2015
Payment Method for HIV Screening Tests (Rev. 2199, 07-06-10)
By Jared Staheli | Published July 6th, 2015
Payment for HIV screening is under the Medicare Clinical Laboratory Fee Schedule for TOBs 12X, 13X, 14X, 22X, and 23X beginning January 1, 2011. For TOB 85X payment is based on reasonable cost. Deductible and coinsurance do not apply. Between December 8, 2009, and April 4, 2010, these services can ...
July 6th, 2015
Annual Wellness Visit (AWV) (Rev. 2159, 04-04-11)
By Jared Staheli | Published July 6th, 2015
Pursuant to section 4103 of the Affordable Care Act of 2010, the Centers for Medicare & Medicaid Services (CMS) amended section 411.15(a)(1) and 411.15(k)(15) of 42 CFR (list of examples of routine physical examinations excluded from coverage) effective for services furnished on or after January 1, 2011. This expanded coverage ...
July 6th, 2015
Counseling to Prevent Tobacco Use (Rev. 2058, 01-03-11)
By Jared Staheli | Published July 6th, 2015
Effective for claims with dates of service on and after August 25, 2010, the Centers for Medicare & Medicaid Services (CMS) will cover counseling to prevent tobacco use services for outpatient and hospitalized Medicare beneficiaries:
1. Who use tobacco, regardless of whether they have signs or symptoms of tobaccorelated disease;
2. Who ...
July 6th, 2015
Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD) (Rev. 2432, 11-08-11)
By Jared Staheli | Published July 6th, 2015
For services furnished on or after November 8, 2011, the Centers for Medicare & Medicaid Services (CMS) covers intensive behavioral therapy (IBT) for cardiovascular disease (CVD). See National Coverage Determinations (NCD) Manual (Pub. 100-03) §210.11 for complete coverage guidelines.
...
July 6th, 2015
Specialty Codes and Place of Service (POS) for Screening for STIs and HIBC to Prevent STIs (Rev. 2476, 02-27-12)
By Jared Staheli | Published July 6th, 2015
Medicare provides coverage for screening for chlamydia, gonorrhea, syphilis, and/or hepatitis B and HIBC to prevent STIs only when ordered by a primary care practitioner (physician or non-physician) with any of the following specialty codes:
• 01 – General Practice
• 08 – Family Practice
• 11 – Internal Medicine
• 16 – Obstetrics/Gynecology
• ...
July 5th, 2015
Calculating Frequency for Prostate Cancer Screening Tests and Procedures (Rev. 1, 10-01-03)
July 5th, 2015
MSN Messages for Prostate Cancer Screening Tests and Procedures (Rev. 1, 10-01-03)
By Jared Staheli | Published July 5th, 2015
If a claim for screening prostate specific antigen test or a screening digital rectal examination is being denied because of the age of the beneficiary, FIs use MSN message 18.13:
This service is not covered for patients under 50 years of age.
The Spanish version of this MSN message should read:
Este servicio ...
July 5th, 2015
Colorectal Cancer Screening (Rev. 52, 12-19-03)
By Jared Staheli | Published July 5th, 2015
See the Medicare Benefit Policy Manual, Chapter 1, for Medicare Part B coverage and effective dates of colorectal rectal screening services.
Effective for services furnished on or after January 1, 1998, payment may be made for colorectal cancer screening for the early detection of cancer. For screening colonoscopy services (one of ...
July 5th, 2015
Determining Frequency Standards for Colorectal Cancer Screening (Rev. 1, 10-01-03)
By Jared Staheli | Published July 5th, 2015
To determine the 11, 23, 47, and 119 month periods, start counts beginning with the month after the month in which a previous test/procedure was performed.
EXAMPLE: The beneficiary received a fecal-occult blood test in January 2000. Start counts beginning with February 2000. The beneficiary is eligible to receive another blood ...
July 5th, 2015
Glaucoma Screening Services (Rev. 1, 10-01-03)
By Jared Staheli | Published July 5th, 2015
Conditions of Medicare Part B coverage for glaucoma screening are located in the Medicare Benefit Policy Manual, Chapter 15.
...
July 5th, 2015
Claims Submission Requirements and Applicable HCPCS Codes for Glaucoma Screening Services (Rev. 1, 10-01-03)
By Jared Staheli | Published July 5th, 2015
Claims for screening for glaucoma should be submitted on Form CMS-1500 to carriers and Form CMS-1450 to FIs or their electronic equivalents. Claims must be prepared and submitted by physicians and providers to the carrier in accordance with the general instructions in Chapter 26. Claims submitted to FIs must be ...
July 5th, 2015
Additional Coding Applicable to Claims Submitted to FIs for Glaucoma Screening Services (Rev. 371, 04-04-05)
By Jared Staheli | Published July 5th, 2015
A. Type of Bill The applicable FI claim bill types for screening glaucoma services are 13X, 22X, 23X, 71X, 73X, 75X, and 85X. (See instructions below for rural health clinics (RHCs) and federally qualified health centers (FQHCs).)
B. Revenue Coding The following revenue codes should be reported when billing for screening ...
July 5th, 2015
Special Billing Instructions for RHCs and FQHCs for Glaucoma Screening Services (Rev. 371, 04-04-05)
By Jared Staheli | Published July 5th, 2015
Screening glaucoma services are considered RHC/FQHC services. For claims with dates of service before April 1, 2005, RHCs and FQHCs bill the FI under bill type 71X or 73X along with revenue code 0770 and HCPCS codes G0117 or G0118 and RHC/FQHC revenue code 0520 or 0521 to report the ...
July 5th, 2015
Payment Methodology for Glaucoma Screening Services (Rev. 1, 10-01-03)
By Jared Staheli | Published July 5th, 2015
Carriers pay for glaucoma screening based on the Medicare Physician Fee Schedule. Deductible and coinsurance apply. Claims from physicians or other providers where assignment was not taken are subject to the Medicare limiting charge, which means they cannot charge the beneficiary more than 115 percent of the allowed amount.
FI pay ...
July 5th, 2015
Determining the 11-Month Period for Glaucoma Screening Services (Rev. 1, 10-01-03)
By Jared Staheli | Published July 5th, 2015
Once a beneficiary has received a covered glaucoma screening procedure, the beneficiary may receive another procedure after 11 full months have passed. To determine the 11- month period, start counts beginning with the month after the month in which the previous covered screening procedure was performed.
...
July 5th, 2015
Remittance Advice Notices for Glaucoma Screening Services (Rev. 895, 04-03-06)
By Jared Staheli | Published July 5th, 2015
Appropriate remittance advice(s) must be used by fiscal intermediaries and carriers when denying payment for glaucoma screening. The following messages are used where applicable:
• If the services were furnished before January 1, 2002, use existing ANSI X12N 835 remittance advice claim adjustment reason code 26 “Expenses incurred prior to coverage” ...
July 5th, 2015
MSN Messages for Glaucoma Screening Services (Rev. 895, 04-03-06)
By Jared Staheli | Published July 5th, 2015
The following MSN messages where appropriate must be used.
If a claim for a screening for glaucoma is being denied because the service was performed prior to January 1, 2002, use the MSN message:
MSN Message 16.54:
This service is not covered prior to January 1, 2002.
The Spanish version of the MSN message ...
July 5th, 2015
Initial Preventive Physical Examination (IPPE) (Rev. 3096, 11-18-14)
By Jared Staheli | Published July 5th, 2015
(NOTE: For billing and payment requirements for the Annual Wellness Visit, see chapter 18, section 140, of this chapter.)
Background: Sections 1861(s)(2)(w) and 1861(ww) of the Social Security Act (and implementing regulations at 42 CFR 410.16, 411.15(a)(1), and 411.15(k)(11)) authorize coverage under Part B for a one-time initial preventive physical examination ...
June 29th, 2015
MSN Messages for Screening Pap Smears (Rev. 1, 10-01-03)
By Jared Staheli | Published June 29th, 2015
If there are no high risk factors, and the screening Pap smear and/or screening pelvic examination is being denied because the procedure/examination is performed more frequently than allowed use MSN 18.17:
Medicare pays for a screening Pap smear and/or screening pelvic examination only once every (2, 3) years unless high risk ...
June 29th, 2015
Remittance Advice Codes for Screening Pap Smears
By Jared Staheli | Published June 29th, 2015
If high risk factors are not present, and the screening Pap smear and/or screening pelvic examination is being denied because the procedure/examination is performed more frequently than allowed, use existing ANSI X12N 835:
• Claim adjustment reason code 119 - “Benefit maximum for this time period has been reached” at the ...
June 29th, 2015
Screening Pelvic Examinations (Rev. 1541, 09-23-08)
By Jared Staheli | Published June 29th, 2015
Section 4102 of the BBA of 1997 (P.L. 105-33) amended §1861(nn) of the Act (42 USC 1395X(nn)) to include Medicare Part B coverage of screening pelvic examinations (including a clinical breast examination) for all female beneficiaries for services provided January 1, 1998 and later. Effective July 1, 2001, the Consolidated ...
June 29th, 2015
MSN Messages for Screening Pelvic Examinations (Rev. 440, 07-05-05)
By Jared Staheli | Published June 29th, 2015
If there are no high risk factors, and the screening Pap smear and/or screening pelvic examination is being denied because the procedure/examination is performed more frequently than allowed, contractors use MSN 18-17:
• Medicare pays for a screening Pap smear and/or screening pelvic examination only once every (2, 3) years unless ...
June 29th, 2015
Remittance Advice Codes for Screening Pelvic Examinations (Rev. 440, 07-05-05)
By Jared Staheli | Published June 29th, 2015
If high risk factors are not present, and the screening Pap smear and/or screening pelvic examination is being denied because the procedure/examination is performed more frequently than allowed, use existing ANSI X12N 835:
• Claim adjustment reason code 119 - “Benefit maximum for this time period has been reached” at the ...
June 26th, 2015
MSN Messages (Rev. 298, 09-25-04)
By Jared Staheli | Published June 26th, 2015
The following messages are used on the MSN.
If the claim is denied because the beneficiary is under 35 years of age, use the following MSN:
MSN 18.3:
Screening mammography is not covered for women under 35 years of age.
The Spanish version of this MSN message should read:
Las pruebas de mamografía para mujeres ...
June 26th, 2015
Remittance Advice Messages (Rev. 1387, 04-07-08)
By Jared Staheli | Published June 26th, 2015
If the claim is denied because the beneficiary is under 35 years of age, contractors must use existing ASC X12N 835 claim adjustment reason code/message 6, “The procedure/revenue code is inconsistent with the patient’s age” along with the remark code M37 (at the line item level), “Service is not covered ...
June 26th, 2015
Screening Pap Smears (Rev. 1, 10-01-03)
By Jared Staheli | Published June 26th, 2015
Effective January 1, 1998, §1861(nn) of the Act (42 USC 1395x(nn)) provides Medicare Part B coverage for a screening Pap smear for women under certain conditions. See the Medicare Benefit Policy Manual, Chapter 15, for coverage of screening PAP smears.
To be covered screening Pap smears must be ordered and collected ...
June 26th, 2015
Pap Smears On and After July 1, 2001 (Rev. 1, 10-01-03)
By Jared Staheli | Published June 26th, 2015
The following requirements must be met.
1. The beneficiary has not had a screening Pap smear test during the preceding three years (i.e., 35 months have passed following the month that the woman had the last covered Pap smear. Use one of the following ICD-9-CM codes V76.2, V76.47, or V76.49; or
2. ...
June 26th, 2015
Payment Method for RHCs and FQHCs for Screening Pap Smears (Rev. 795, 04-03-06)
By Jared Staheli | Published June 26th, 2015
The professional component of a screening Pap smear furnished within an RHC/FQHC by a physician or non physician is considered an RHC/FQHC service. RHCs and FQHCs bill the FI under bill type 71X or 73X for the professional component along with revenue code 052X. See Chapter 9, for RHC and ...
June 25th, 2015
FI – Telehealth Originating Site Facility Fee – Medicare Part B – Payment Policy for Indian Health Services (Rev. 1776, 01-04-10)
By Jared Staheli | Published June 25th, 2015
Effective January 1, 2009, IHS providers, including CAHs are paid separately from the AIR for the Telehealth Originating Site Facility Fee. HCPCS code Q3014 (“telehealth originating site facility fee”) is a Part B benefit. The fee is updated each calendar year by the Medicare Economic Index announced in the annual ...
June 25th, 2015
FI – Telehealth Originating Site Facility Fee – Medicare Part B – Claims Processing for Indian Health Services (Rev. 1776, 01-04-10)
By Jared Staheli | Published June 25th, 2015
The Telehealth Originating Site Facility Fee is reported on TOB 12X, 13X or 85X along with the revenue code 0780 and HCPCS code Q3014 as described in Chapter 12, Section 190 of Pub. 100-04, Medicare Claims Processing Manual.
No clinic visit shall be billed if this is the only service received. ...
June 25th, 2015
FI -- Payment for Distant Site Practitioner Services for Indian Health Services (Rev. 1776, 01-04-10)
By Jared Staheli | Published June 25th, 2015
Distant site services are listed in §190.3 in Chapter 12 of this manual. These services are payable only by the FI to a Method II CAH. Payment is based on 80 percent of the MPFS. Deductible and coinsurance apply, but are waived by IHS.
The MSN is suppressed.
...
June 25th, 2015
Audit of IHS Cost Reports (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
All IHS hospitals that convert to CAH status are subject to audit by the FI. CMS’ audit policy can be found in Chapter 8, Contractor Procedures for Provider Audit, of Pub. 100- 06, Medicare Financial Management Manual.
The CAHs are reimbursed under the Medicare Principles of Reasonable Costs. These principles are ...
June 25th, 2015
Method E Cost Reports for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The IHS has used the Method E cost report since it began filing cost reports with CMS in 1998. Method E is the method of cost apportionment which is used to calculate the all inclusive outpatient per visit rate and the all inclusive inpatient ancillary per diem rate. Both of ...
June 25th, 2015
Critical Access Hospitals for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
All IHS hospitals that elect CAH status, and are certified as such, are reimbursed under the reasonable cost method of reimbursement. The all inclusive inpatient per diem rate, the all inclusive outpatient per visit rate, and the all inclusive inpatient ancillary per diem rate are calculated based upon the individual ...
June 25th, 2015
Payment to Non-Indian Health Service Physicians by Indian Health Service (IHS) Providers for Teleradiology Interpretations (Rev. 1643, 03-09-09)
By Jared Staheli | Published June 25th, 2015
The IHS providers may choose to purchase or otherwise contract for teleradiology interpretation from non-IHS practitioners. Two options are available for payment for these services.
(1) Contractual Reassignment – Under this provision, non-IHS physicians can reassign their benefits to the IHS hospital where the technical component is performed. Non-IHS practitioners providing ...
June 25th, 2015
Medicare Preventive and Screening Services (Rev. 2233, 06-28-11)
By Jared Staheli | Published June 25th, 2015
The Patient Protection and Affordable Care Act (ACA) amended the definition of “Preventive Services” available in Medicare and included two additional preventive physical examination services: the initial preventive physical examination (IPPE) and the annual wellness visit (AWV).
The definition of preventive services and the corresponding table of services are reflective of ...
June 25th, 2015
Definition of Preventive Services (Rev. 2233, 06-28-11)
By Jared Staheli | Published June 25th, 2015
Section 4104 of the ACA revised section 1861(ddd) of the Social Security Act (the Act) to add subsection (3), which defines the term “preventive services” as follows:
• The specific services currently listed in section 1861(ww)(2) of the Act with the explicit exclusion of electrocardiograms (as specified in section 1861(ww)(2)(M) of ...
June 25th, 2015
Waiver of Cost Sharing Requirements of Coinsurance, Copayment and Deductible for Furnished Preventive Services Available in Medicare (Rev. 2233, 06-28-11)
By Jared Staheli | Published June 25th, 2015
Section 4104(b)(4) of the ACA, amends section 1833(a)(1) of the Act, by requiring 100 percent payment for the IPPE, AWV and for those preventive services recommended by the United States Preventive Services Task Force (USPSTF) with a grade of A or B for any indication or population and that are ...
June 25th, 2015
Pneumococcal Pneumonia, Influenza Virus, and Hepatitis B Vaccines (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
For Carriers/AB MACs, Part B of Medicare pays 100 percent of the Medicare allowed amount for pneumococcal vaccines and influenza virus vaccines and their administration.
Part B deductible and coinsurance do not apply for pneumococcal and influenza virus vaccine.
Part B of Medicare also covers the hepatitis B vaccine and its administration. ...
June 25th, 2015
Coverage Requirements (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
Pneumococcal vaccine, influenza virus vaccine, and hepatitis B vaccine and their administration are covered only under Medicare Part B, regardless of the setting in which they are furnished, even when provided to an inpatient during a hospital stay covered under Part A.
See Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, ...
June 25th, 2015
Pneumococcal Vaccine (Rev. 3159, 02-02-15)
By Jared Staheli | Published June 25th, 2015
Section 1861(s)(10)(A) of the Social Security Act and regulations at 42 CFR 410.57 authorize Medicare coverage under Part B for pneumococcal vaccine and its administration. Medicare does not require for coverage purposes, that a doctor of medicine or osteopathy order the pneumococcal vaccine and its administration. Therefore, the beneficiary may ...
June 25th, 2015
Influenza Virus Vaccine (Rev. 2253, 08-08-11)
By Jared Staheli | Published June 25th, 2015
Effective for services furnished on or after May 1, 1993, the influenza virus vaccine and its administration is covered when furnished in compliance with any applicable State law. Typically, this vaccine is administered once a flu season. Medicare does not require for coverage purposes that a doctor of medicine or ...
June 25th, 2015
Hepatitis B Vaccine (Rev. 1, 10-01-03)
By Jared Staheli | Published June 25th, 2015
Effective for services furnished on or after September 1, 1984, the hepatitis B vaccine and its administration is covered if it is ordered by a doctor of medicine or osteopathy and is available to Medicare beneficiaries who are at high or intermediate risk of contracting hepatitis B, e.g., exposed to ...
June 25th, 2015
Billing Requirements (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
A. Edits Not Applicable to Pneumococcal or Influenza Virus Vaccine Bills and Their Administration
The Common Working File (CWF) and shared systems bypass all Medicare Secondary Payer (MSP) utilization edits in CWF on all claims when the only service provided is pneumococcal or influenza virus vaccine and/or their administration. This ...
June 25th, 2015
Bills Submitted to FIs/AB MACs (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
The applicable types of bills acceptable when billing for influenza virus and pneumococcal vaccines are 12X, 13X, 22X, 23X, 34X, 72X, 75X, 83X and 85X.
The following revenue codes are used for reporting vaccines and administration of the vaccines for all providers except RHCs and FQHCs. Independent and provider based RHCs ...
June 25th, 2015
FI/AB MAC Payment for Pneumococcal Pneumonia Virus, Influenza Virus, and Hepatitis B Virus Vaccines and Their Administration (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
Payment for Vaccines
Payment for all of these vaccines is on a reasonable cost basis for hospitals, home health agencies (HHAs), skilled nursing facilities (SNFs), critical access hospitals (CAHs), and hospital-based renal dialysis facilities (RDFs). Payment for comprehensive outpatient rehabilitation facilities (CORFs), Indian Health Service hospitals (IHS), IHS CAHs and ...
June 25th, 2015
Special Instructions for Independent and Provider-Based Rural Health Clinics/Federally Qualified Health Center (RHCs/FQHCs) (Rev. 1586,10-06-08)
By Jared Staheli | Published June 25th, 2015
Independent and provider-based RHCs and FQHCs do not include charges for influenza virus and pneumococcal vaccines on Form CMS-1450. Administration of these vaccines does not count as a visit when the only service involved is the administration of influenza virus and/or pneumococcal vaccine(s). If there was another reason for the ...
June 25th, 2015
Bills Submitted to Regional Home Health Intermediaries (RHHIs) (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
The following provides billing instructions for Home Health Agency (HHAs) in various situations:
• Where the sole purpose for an HHA visit is to administer a vaccine (influenza virus, pneumococcal, or hepatitis B), Medicare will not pay for a skilled nursing visit by an HHA nurse under the HHA benefit. However, ...
June 25th, 2015
Bills Submitted by Hospices and Payment Procedures for Renal Dialysis Facilities (RDF) (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
Hospices can provide the influenza virus, pneumococcal, and hepatitis B vaccines to those beneficiaries who request them including those who have elected the hospice benefit. These services may be covered when furnished by the hospice. Services for the vaccines should be billed to the local carrier/AB MAC on the Form ...
June 25th, 2015
Hepatitis B Vaccine Furnished to ESRD Patients (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
Hepatitis B vaccine and its administration (including staff time and supplies such as syringes) are paid to ESRD facilities in addition to, and separately from, the dialysis composite rate payment.
Payment for the hepatitis B vaccine for ESRD patients follows the same general principles that are applicable to any injectable drug ...
June 25th, 2015
Claims Submitted to Carriers/AB MACs (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
Medicare does not require that the influenza virus vaccine be administered under a physician’s order or supervision. Effective for claims with dates of service on or after July 1, 2000, Medicare does not require that pneumococcal vaccinations be administered under a physician’s order or supervision. Medicare still requires that the ...
June 25th, 2015
Carrier/AB MAC Indicators for the Common Working File (CWF) (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
The carrier/AB MAC record submitted to CWF must contain the following indicators:
Description
Payment Indicator
Payment
Deductible Indicator
Deductible
Type of Service
Pneumococcal
“1”
100 percent
“1”
Zero deductible
“V”
Influenza
“1”
100 percent
“1”
Zero deductible
“V”
Hepatitis B
“0”
80 percent
“0”
Deductible applies
"1"
A payment indicator of “1” represents 100 percent payment. A deductible indicator of “1” represents a zero deductible. A payment indicator of “0” represents 80 percent payment. A ...
June 25th, 2015
Carrier/AB MAC Payment Requirements (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
Payment for pneumococcal, influenza virus, and hepatitis B vaccines follows the same standard rules that are applicable to any injectable drug or biological. (See chapter 17 for procedures for determining the payment rates for pneumococcal and influenza virus vaccines.)
Effective for claims with dates of service on or after February 1, ...
June 25th, 2015
Simplified Roster Claims for Mass Immunizers (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
The simplified roster billing process was developed to enable Medicare beneficiaries to participate in mass pneumococcal and influenza virus vaccination programs offered by PHCs and other individuals and entities that give the vaccine to a group of beneficiaries, e.g. at PHCs, shopping malls, grocery stores, senior citizen homes, and health ...
June 25th, 2015
Roster Claims Submitted to AB MACs for Mass Immunization (Rev. 3159, 02-02-15)
By Jared Staheli | Published June 25th, 2015
If the PHC or other individual or entity qualifies to submit roster claims, it may use a preprinted Form CMS-1500 that contains standardized information about the entity and the benefit. Key information from the beneficiary roster list and the abbreviated Form CMS-1500 is used to process pneumococcal and influenza virus ...
June 25th, 2015
Centralized Billing for Influenza Virus and Pneumococcal Vaccines to Medicare Carriers/AB MACs (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
The CMS currently authorizes a limited number of providers to centrally bill for influenza virus and pneumococcal immunization claims. Centralized billing is an optional program available to providers who qualify to enroll with Medicare as the provider type “Mass Immunization Roster Biller,” as well as to other individuals and entities ...
June 25th, 2015
Claims Submitted to FIs/AB MACs for Mass Immunizations of Influenza Virus and Pneumococcal Vaccinations (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
Some potential "mass immunizers," such as hospital outpatient departments and HHAs, have expressed concern about the complexity of billing for the influenza virus vaccine and its administration. Consequently, to increase the number of beneficiaries who obtain needed preventive immunizations, simplified (roster) billing procedures are available to mass immunizers. The simplified ...
June 25th, 2015
Simplified Billing for Influenza Virus and Pneumococcal Vaccine Services by HHAs (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
The following billing instructions apply to HHAs that roster bill for influenza virus and pneumococcal vaccines.
• When an HHA provides the influenza virus vaccine or the pneumococcal vaccine in a mass immunization setting, it does not have the option to pick and choose whom to bill for this service. If ...
June 25th, 2015
CWF Edits (Rev. 1617, 04-06-09)
By Jared Staheli | Published June 25th, 2015
In order to prevent duplicate payments for influenza virus and pneumococcal vaccination claims by the local contractor/AB MAC and the centralized billing contractor, effective for claims received on or after July 1, 2002, CWF has implemented a number of edits.
NOTE: 90659 was discontinued December 31, 2003.
CWF returns information in Trailer ...
June 25th, 2015
CWF Edits on Carrier/AB MAC Claims (Rev. 2824, 04-07-14)
By Jared Staheli | Published June 25th, 2015
In order to prevent duplicate payment by the same carrier/AB MAC, CWF will edit by line item on the carrier/AB MAC number, the HIC number, the date of service, the influenza virus procedure codes 90653, 90654, 90655, 90656, 90657, 90660, 90661, 90662, 90672, 90673, 90685, 90686, 90687, or 90688; the ...
June 25th, 2015
CWF A/B Crossover Edits for FI/AB MAC and Carrier/AB MAC Claims (Rev. 2824, 04-07-14)
By Jared Staheli | Published June 25th, 2015
When CWF receives a claim from the carrier/AB MAC, it will review Part B outpatient claims history to verify that a duplicate claim has not already been posted.
CWF will edit on the beneficiary HIC number; the date of service; the influenza virus procedure codes 90653, 90654, 90655, 90656, 90657, 90660, ...
June 25th, 2015
Medicare Summary Notice (MSN) (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
Contractors must generate a Medicare Summary Notice (MSN) for the pneumococcal, influenza virus, hepatitis B vaccines, and their administration.
For vaccines rendered to beneficiaries other than pneumococcal, influenza virus or hepatitis B, which are not covered by Medicare, they must send the following MSN message.
MSN: 18.2:
This immunization and/or preventive care is ...
June 25th, 2015
FDA Certification Data (Rev. 1387, 04-07-08)
By Jared Staheli | Published June 25th, 2015
The FDA furnishes data to CMS on a weekly basis, which specify the certification of facilities under the MQSA. This data are contained in a “MQSA file.”
Prior to April 1, 2003, the MQSA file showed all facilities that are certified to perform film screening and diagnostic mammograms. After April 1, ...
June 25th, 2015
Mammography Services (Screening and Diagnostic) Payment (Rev. 1931, 06-14-10)
By Jared Staheli | Published June 25th, 2015
There is no Part B deductible for screening mammographies, however, coinsurance is applicable. The anti-markup payment limitation on physician billing for diagnostic tests does not apply to these services. Following are three categories of billing for mammography services:
• Professional component of mammography services (that is the physician’s interpretation of the ...
June 25th, 2015
Payment for Screening Mammography Services Provided On and After January 1, 2002 (Rev. 1070, 01-02-07)
By Jared Staheli | Published June 25th, 2015
The payment limitation methodology does not apply to claims with dates of service on or after January 1, 2002.
FI Claims
For claims with dates of service on or after January 1, 2002, §104 of the Benefits Improvement and Protection Act (BIPA) 2000, provides for payment of screening mammography under the ...
June 25th, 2015
Durable Medical Equipment Medicare Administrative Contractors (DME MAC) Designation for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
There are four DME MACs assigned to geographical regions. Jurisdiction for DME claims is based upon the permanent residence of the beneficiary, regardless of the location of the supplier submitting the claim. The IHS facilities shall enroll with the National Supplier Clearinghouse (NSC) to obtain a supplier number for billing ...
June 25th, 2015
Overview of Medicare Part B Services for Indian Health Services (Rev. 2075, 01-28-11)
By Jared Staheli | Published June 25th, 2015
Section 630 of the MMA, indefinitely extended by §2902 of the ACA, extended to IHS providers, suppliers, physicians and practitioners, independent ambulance suppliers, hospital based ambulance providers and clinical laboratory service suppliers the ability to bill for all Medicare Part B covered services and items which were not covered under ...
June 25th, 2015
Medicare Part B Services for Indian Health Services (Rev. 2075, 01-28-11)
By Jared Staheli | Published June 25th, 2015
Effective July 1, 2001, §432 BIPA extended payment for the services of physician and non-physician practitioners furnished in hospitals and ambulatory care clinics (services paid under the MPFS, §1848 of the Act). Clinics associated with hospitals or which are freestanding that are owned and operated by IHS or tribally owned ...
June 25th, 2015
Provider Enrollment with Carrier for Indian Health Services (Rev. 1027, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The designated carrier shall designate a consistent method of labeling all IHS-related enrollment applications. For Form CMS-855B (11/01) submission, under item 2.A.1 Supplier Identification, check the “Other” box and manually indicate IHS, tribes or tribal organization on the line provided.
The designated carrier shall follow these enrollment requirements:
• All applications are ...
June 25th, 2015
Entities Enrollment for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
In order to enroll IHS clinics that are currently provider-based (and use the hospital’s tax identification number (TIN)) and that wish to bill the designated Medicare Part B carrier, the hospital must complete a Form CMS-855B and enroll as a “group”. Each clinic would be reflected on the Form CMS-855 ...
June 25th, 2015
Individual Practitioners Enrollment for Indian Health Services (Rev. 1643, 03-09-09)
By Jared Staheli | Published June 25th, 2015
For those eligible practitioners already working in or for hospitals or freestanding ambulatory care clinics, whether operated by the Indian Health Service (IHS) or by an Indian tribe or tribal organization, enroll and process requests for reassignment of benefits following the current individual practitioner enrollment and verification instructions. For practitioners ...
June 25th, 2015
Multiple Sites Enrollment for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Multiple clinics utilizing the same TIN can be enrolled as practice locations under the “owner” of the TIN (i.e., the hospital). Each clinic will be assigned a separate PIN. If the clinic has a separate TIN, then the clinic would have to enroll separately. Payment is made to the name ...
June 25th, 2015
Reassignment for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
For those individual practitioners who are employees of the IHS, tribe or tribal facility that provides offsite care to the IHS, tribe or tribal Medicare Part B beneficiary, the facility can bill under reassignment from the employee. With regard to contract practitioners, the IHS, tribe, or tribal facility can accept ...
June 25th, 2015
Mobile Units for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The entity providing the service must bill for the service unless the service is provided under contractual arrangements. If the contracted entity performs services on space that the IHS facility owns or leases, the IHS facility can bill under arrangements.
In order to purchase a professional test interpretation, the IHS physician ...
June 25th, 2015
Mobile Mammography Units for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
With respect to mobile mammography units, the law provides specific standards regarding those qualified to perform mammograms and how they should be certified. The Mammography Quality Standards Act (MQSA) requires the Secretary to ensure that all facilities that provide mammography services meet national quality standards. Effective October 1, 1994, all ...
June 25th, 2015
Clinical Laboratory, Ambulance and Medicare Part B Drugs for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Enrollment of IHS, tribe and tribal organization facilities providing clinical laboratory, ambulance services and Medicare Part B drugs must be provided through the designated carrier. These IHS, tribe and tribal organization facilities must meet all the usual enrollment requirements for the designated carrier. The designated carrier started accepting enrollment applications ...
June 25th, 2015
Provider Enrollment with FI for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
New IHS providers, including Critical Access Hospitals (CAHs) follow the same application process as any other provider enrolling in Medicare with the designated FI. Instructions for completing the Form CMS-855A, Application for Health Care Providers that will bill Medicare FIs are found in Pub. 100-08, Medicare Program Integrity Manual, Chapter ...
June 25th, 2015
Provider Enrollment with FI - Ambulatory Surgical Services for Indian Health Services(Rev. 1325; 01-07-08)
By Jared Staheli | Published June 25th, 2015
For dates of service prior to January 1, 2008, IHS providers that want to bill for surgeries on the ambulatory surgical center (ASC) list and receive the ASC rate must contact their designated FI. IHS providers are certified by one of several national accrediting organizations recognized by the Centers for ...
June 25th, 2015
Provider Enrollment with FI - Services Under Arrangements for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
If an IHS provider is unable to provide all the services a beneficiary that is a registered outpatient of the provider needs, the provider may provide those services “under arrangements”, via a contract with another entity. Section 1862(a)(14) of the Social Security Act prohibits payment for nonphysician services furnished to ...
June 25th, 2015
Provider Enrollment with DME MAC for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
All IHS providers and suppliers that do not currently have a supplier number and want to bill for DMEPOS items must enroll with the NSC.
Beginning July 1, 2005, IHS providers (including CAHs) and pharmacies were eligible to begin billing for DME. The NSC must accept enrollment applications from IHS and ...
June 25th, 2015
NSC Supplier Number for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
To enable direct billing of DMEPOS, an IHS supplier must enroll with the NSC as a “DME Supplier”, secure a Medicare supplier billing number and comply with the supplier standards specified in 42 CFR §424.57, and submit all DME claims to the appropriate DME MAC based on current DME jurisdiction ...
June 25th, 2015
Reporting Requirements and Specifications for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
In order to facilitate report generation and data collection regarding IHS physicians, practitioners and services, the designated carrier shall assign PINs to each IHS physician and practitioner in a manner that will allow the designated carrier to ascertain which facilities are IHS, Indian tribe or tribal organization. For example, the ...
June 25th, 2015
Incentive Payments for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
In accordance with §1833(m) of the Act, IHS physicians who provide covered professional services in any rural or urban health professional shortage area (HPSA) are entitled to an incentive payment. IHS physicians providing services in either a rural or urban HPSA are eligible for a 10 percent incentive payment. It ...
June 25th, 2015
Covered Medicare Part B Services That May Be Paid to IHS Providers, Physicians and Practitioners (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Medicare Part B covers medically necessary expenses incurred for the following medical and other health services:
• Diagnostic x-ray tests, and other diagnostic tests;
• Physician services;
• Anesthesia services (anesthesiologist, certified registered nurse anesthetist);
• Practitioner services (clinical nurse specialist, clinical psychologist, clinical social worker, nurse mid-wife, nurse practitioner, physician assistant);
• Drugs and ...
June 25th, 2015
Carrier - Medicare Part B Physician and Practitioner Services Paid Under the Medicare Physician Fee Schedule (MPFS) - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Prior to the enactment of BIPA, reimbursement for Medicare services provided in IHS facilities was limited to services provided in hospitals and SNFs. Effective July 1, 2001, §432 BIPA extended payment to services of IHS physicians and practitioners furnished in hospitals and ambulatory care clinics.
The services that may be paid ...
June 25th, 2015
Carrier - Claims Processing Requirements for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
1. Claims will be submitted by IHS physicians and practitioners using either the American National Standards Institute Accredited Standards Committee (ANSI ASC) 837P or Form CMS-1500.
2. The designated carrier shall supply IHS physicians and practitioners with any billing software that would normally be given to physician and non-physician practitioners.
3. The ...
June 25th, 2015
Carrier - Ambulance Services - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Effective July 1, 2005, Medicare Part B payment may be made to IHS independent ambulance suppliers that furnish ambulance services. IHS independent ambulance suppliers bill the designated carrier for services.
Payment for independent ambulance supplier claims shall be based on the ambulance fee schedule and processed based on point of pickup ...
June 25th, 2015
Carrier – Ambulance Services - Claims Processing (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Medically necessary ambulances provided by an IHS ambulance supplier are paid based upon Chapter 15 of Pub. 100-04, Medicare Claims Processing Manual. Suppliers must report an origin and destination code for each ambulance service billed.
Modifier Reporting –
Origin and destination modifiers used for ambulance services are created by combining two alpha ...
June 25th, 2015
Carrier - Vaccines and Vaccine Administration - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Medicare Part B payment may be made to IHS physicians and practitioners that furnish vaccines including pneumococcal pneumonia virus (PPV), influenza virus and hepatitis B virus. Medicare Part B payment may be made to IHS physicians and practitioners for the administration of these vaccines. Payment for the administration of the ...
June 25th, 2015
Carrier - Vaccines and Vaccine Administration - Coverage Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Pneumococcal Pneumonia Vaccinations
The Medicare Part B program covers PPV and its administration when furnished in compliance with any applicable State law by any provider of services or any entity or individual with a supplier number. This includes revaccination of patients at highest risk of pneumococcal infection. Typically, these vaccines ...
June 25th, 2015
Carrier - Screening and Preventive Services for Indian Health Services (Rev. 2075, 01-28-11)
By Jared Staheli | Published June 25th, 2015
Medicare Part B makes payment for the following screening and preventive services:
• Pelvic exam;
• Glaucoma screening;
• Bone mass measurements;
• Prostate cancer screening;
• Colorectal cancer screening;
• Screening pap smear;
• Screening mammography;
• Cardiovascular screening blood tests;
• Diabetes screening tests;
• DSMT;
• Influenza virus vaccine and its administration, pneumococcal vaccine and its administration; hepatitis ...
June 25th, 2015
Carrier - Clinical Laboratory Services - Payment Policy for Indian Health Services (Rev. 2075, 01-28-11)
By Jared Staheli | Published June 25th, 2015
Medicare Part B payment may be made to freestanding facilities for covered clinical laboratory tests. Freestanding facilities are paid for clinical laboratory tests covered as a result of §630 MMA, indefinitely extended by §2902 of the ACA, based on the clinical laboratory fee schedule.
...
June 25th, 2015
Carrier - Clinical Laboratory Services - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Some clinical laboratory procedures or tests require FDA approval before coverage is provided. Laboratory services furnished by a freestanding facility are covered under Medicare Part B if the laboratory is an approved independent clinical laboratory. However, as is the case of all diagnostic services, in order to be covered these ...
June 25th, 2015
Carrier – Medical Nutrition Therapy (MNT) - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Section 105 of BIPA permits Medicare coverage of MNT when furnished by a registered dietician (RD) meeting certain requirements. See Chapter 4, §§300 through 300.6 of Pub. 100-04, Medicare Claims Processing Manual, for more information on these requirements.
Medical nutrition therapy services rendered by an RD who is an individual practitioner ...
June 25th, 2015
Carrier – MNT - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
If the RD providing the services is an employee of an independent or free standing clinic and the services are provided in the clinic, the services are billed to the designated carrier.
See Chapter 4, §§300 through 300.6 of Pub. 100-04, Medicare Claims Processing Manual, for more information on the Healthcare ...
June 25th, 2015
Dual Eligibility for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The Omnibus Budget Reconciliation Act of 1989 requires mandatory assignment of claims for physician services furnished to individuals who are eligible for Medicaid, including those individuals eligible as qualified Medicare beneficiaries. Therefore, claims for services to dual eligibles are paid as assigned claims.
...
June 25th, 2015
Carrier Claims Processing and Payment Policy for ASC Claims for Indian Health Services (Rev. 1325; 01-07-08)
By Jared Staheli | Published June 25th, 2015
Effective for services on or after January 1, 2008, the designated IHS carrier shall accept and pay for claims submitted by IHS and tribal hospitals that elect to enroll as ASC facilities. See Pub. 100-04, Medicare Claims Processing Manual, Chapter 14, for information on ASC claims processing. See Pub. 100-02, ...
June 25th, 2015
DME General Information for Indian Health Services (Rev.2075, 01-28-11)
By Jared Staheli | Published June 25th, 2015
The DME MACs process claims for items of DMEPOS for use in the beneficiary’s home. Beginning January 1, 2005, Medicare Part B makes payment for medically necessary items of DME, prosthetics, orthotics, and supplies to IHS suppliers that furnish DME for use in the beneficiary’s home. See Pub. 100-02, Medicare ...
June 25th, 2015
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Payment Policy for Indian Health Services (Rev. 2075, 01-28-11)
By Jared Staheli | Published June 25th, 2015
Section 630 of the MMA, indefinitely extended by §2902 of the ACA, permits IHS suppliers to directly bill for itemized DMEPOS with dates of service (DOS) on or after January 1, 2005. Previously IHS suppliers could not directly bill Medicare for DMEPOS.
...
June 25th, 2015
Licensure to Dispense Drugs for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
In order to bill drugs to the DME MACs, the supplier must be a pharmacy. States may not regulate the qualifications of Federal employees who are carrying out their authorized Federal activities within the scope of their employment. However, IHS employees are not subject to state licensure laws and IHS ...
June 25th, 2015
Payment for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Surgical dressings, splints, casts, DME and other devices used for reductions of fractures and dislocations are paid based on the DMEPOS fee schedule. Claims will be priced using the appropriate DMEPOS fee schedule based on the beneficiary’s address.
Payment for DME MAC-covered drug claims shall be based on the ASP fee ...
June 25th, 2015
Services Billed to the DME MAC for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Effective July 1, 2005, IHS suppliers and IHS providers (including CAHs) shall bill the appropriate DME MAC for DME.
Although, parenteral and enteral nutrients, equipment, and supplies meet the definition of the prosthetic benefit, they are separately billable to the DME MAC for home use. Ostomy, tracheostomy, and urological supplies meet ...
June 25th, 2015
Prosthetics, Orthotics and Supplies Billed to the A/B MAC for Indian Health Services (Rev. 1957; 10- 04-10)
By Jared Staheli | Published June 25th, 2015
Effective for dates of service on or after July 1, 2005, IHS providers, including CAHs shall bill the designated A/B MAC for prosthetics and orthotics under revenue code 0274 (prosthetic/orthotic devices) on type of bill (TOB) 12X (hospital inpatient part B), 13X (hospital outpatient) or 85X (Critical Access Hospital (CAH). ...
June 25th, 2015
General Claims Processing Rules for DMEPOS for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The DME MACs may only be billed for surgical dressings, splints, casts and for prosthetics and orthotics by IHS suppliers, not by IHS providers. The Region D DME MAC shall accept all DMEPOS claims submitted by IHS suppliers and shall forward electronic media claims to the appropriate DME MAC for ...
June 25th, 2015
A/B MAC (A) Payment Policy and Claims Processing for Indian Health Services (Rev. 3049, 09-23-14)
By Jared Staheli | Published June 25th, 2015
Bills are submitted to the A/B MAC (A) by IHS providers (including CAHs) using the ASC-X12 837 institutional claim format. In exceptional circumstances, a hardcopy Form CMS-1450 may be accepted by the designated A/B MAC (A).
The IHS providers are identified by Provider Type 08 in the Provider Specific File in ...
June 25th, 2015
FI - Medicare Part B Services Paid Under Various Fee Schedules for Indian Health Services (Rev. 2075, 01-28-11)
By Jared Staheli | Published June 25th, 2015
The legislative change in MMA §630 of 2003, which was effective January 1, 2005, and indefinitely extended by §2902 of the ACA, allows IHS providers to bill for other Medicare Part B services, not covered under §1848 of the Act. In an effort to clarify that these charges are not ...
June 25th, 2015
FI - Medicare Part B Services Included in the All Inclusive Rate (AIR) for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Unless otherwise specified in this chapter, payment to IHS providers is made based on the AIR. To understand how payment is made for IHS services, it is recommended that Chapter 19 be reviewed in its entirety. Services provided in IHS providers that are considered part of the AIR include:
• Diagnostic ...
June 25th, 2015
FI - Inpatient Acute Care - Medicare Part A - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Medicare Part A provides payment to IHS providers for up to 90 days of covered inpatient hospital services in a benefit period. These services are subject to Medicare Part A inpatient deductible and coinsurance. Each beneficiary also has 60 lifetime reserve days (LTR) of inpatient hospital services to draw upon ...
June 25th, 2015
A/B MAC (A) - Inpatient Acute Care - Medicare Part A - Claims Processing for Indian Health Services (Rev. 3049, 09-23-14)
By Jared Staheli | Published June 25th, 2015
All charges are combined and reported under revenue code 0100 (all-inclusive room and board plus ancillary) on type of bill (TOB) 11X (hospital inpatient). Inpatient services are billed from admission through discharge. Interim billing is not allowed.
See Chapter 1, §50.2 of Pub. 100-04, Medicare Claims Processing Manual, for more information ...
June 25th, 2015
FI - Physician Acknowledgement Statement for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Section 42 CFR 412.46 requires hospitals to obtain only one signed acknowledgment from physicians who are being granted admitting privileges at a particular IHS provider. The physician must complete the acknowledgment at the time that he/she is granted admitting privileges at the hospital or before, or at the time the ...
June 25th, 2015
FI - Social Admissions for Indian Health Services (Rev. 1446, 07-07-08)
By Jared Staheli | Published June 25th, 2015
Social admissions for patient and family convenience are not covered by Medicare. They are not billable to Medicare by IHS providers (including CAHs) on either TOB 11X (hospital inpatient) or 12X (hospital inpatient Part B). For admissions before surgery, only the scheduled surgery and related services may be billed on ...
June 25th, 2015
FI - Inpatient Ancillary Services - Medicare Part B - Payment Policy for Indian Health Services (Rev. 1511; 06-23-08)
By Jared Staheli | Published June 25th, 2015
Certain inpatient hospital ancillary services are covered under Medicare Part B when coverage is no longer provided under Medicare Part A due to benefits exhausted, the beneficiary is determined to be receiving a non-covered level of care, or is not eligible for Medicare Part A benefits. Chapter 4, §240 of ...
June 25th, 2015
FI - Inpatient Ancillary Services - Medicare Part B - Claims Processing for Indian Health Services (Rev. 1776, 01-04-10)
By Jared Staheli | Published June 25th, 2015
All charges, except therapies, telehealth originating site facility fee, PPV, influenza virus and hepatitis B vaccines are combined and reported under revenue code 024X (allinclusive ancillary) on TOB 12X (hospital inpatient Part B). Medicare Part B deductible and coinsurance amounts are applied to inpatient Medicare Part B ancillary services, but ...
June 25th, 2015
FI - Swing-bed for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Under §1880 of the Act, Medicare Part A provides payment for hospitalization and post hospitalization extended care in SNFs, including swing-bed SNFs.
A beneficiary is entitled to 100 days of skilled nursing care in a SNF or the swing-bed unit of an acute care hospital or CAH during each benefit period. ...
June 25th, 2015
Swing-bed – Medicare Part A - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Effective July 2002, IHS hospital swing-bed services began being paid according to the SNF prospective payment system (PPS) payment methodology. See Chapter 6, §30.6 in Pub. 100-04, Medicare Claims Processing Manual for information on SNF PPS payment methodology.
Medicare Part A coinsurance is applied to IHS swing-bed inpatient bills, but is ...
June 25th, 2015
Swing-bed – Medicare Part A - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Revenue code 0022 (special charges) and the Health Insurance Prospective Payment System (HIPPS) codes are reported on the bill along with the accommodation revenue codes. Services are itemized and billed with the appropriate revenue code that describes the service on TOB 18X (hospital swing bed). Medicare swing-bed bill processing instructions ...
June 25th, 2015
FI - Swing-bed - Inpatient Ancillary Claims - Medicare Part B - Payment Policy for Indian Health Services (Rev. 1511; 06- 23-08)
By Jared Staheli | Published June 25th, 2015
The IHS providers are paid for covered inpatient Medicare Part B ancillary services based upon an all inclusive inpatient ancillary per diem rate (AIR). The AIR is established by CMS and IHS based upon a review of yearly cost reports prepared by IHS’s contractor. Upon completion of the review, IHS ...
June 25th, 2015
FI - Swing-bed - Inpatient Ancillary Claims - Medicare Part B - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The IHS hospital swing-bed Medicare Part B inpatient ancillary bills revert to inpatient Medicare Part B ancillary bills and are submitted under the regular hospital (or CAH) provider number (not the swing-bed provider number) with revenue code 0240 (all inclusive ancillary) on TOB 12X (inpatient Part B). The MSN is ...
June 25th, 2015
FI - Outpatient - Medicare Part B - Payment Policy for Indian Claims Processing (Rev. 1511; 06-23-08)
By Jared Staheli | Published June 25th, 2015
The IHS providers are paid for covered outpatient services based upon an all inclusive outpatient per visit rate (AIR). The AIR is established by CMS and IHS based upon a review of yearly cost reports prepared by IHS’s contractor. Upon completion of the review, IHS submits the agreed upon rate ...
June 25th, 2015
FI - Outpatient - Medicare Part B - Claims Processing for Indian Health Services (Rev. 2075, 01-28-11)
By Jared Staheli | Published June 25th, 2015
All charges, except for therapies, telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance services are combined and reported under revenue code 0510 (clinic visit) on TOB 13X (hospital outpatient).
Regardless of the number of times a patient is seen in a given day at ...
June 25th, 2015
FI - Ambulatory Surgical Center (ASC) - Medicare Part B - Payment Policy for Indian Health Services (Rev. 1325; 01-07-08)
By Jared Staheli | Published June 25th, 2015
Qualified IHS providers are reimbursed at the ASC rates published in the Federal Register. Medicare Part B deductible and coinsurance amounts apply to ASC services, but are waived by the IHS.
See §40.2.1 of this chapter for information on enrolling with the designated FI to receive payment for ASC services based ...
June 25th, 2015
FI - ASC - Medicare Part B - Claims Processing for Indian Health Services (Rev. 1325; 01-07-08)
By Jared Staheli | Published June 25th, 2015
Charges are reported under revenue code 0360 (operating room services) or 0490 (ambulatory surgical care) on TOB 83X (ambulatory surgical center). ASC surgeries are identified with CPT codes 10000-69979 only. One bill is required for all services provided on the day a surgical procedure is performed.
*Exception: Revenue code 0276 (intraocular ...
June 25th, 2015
FI - Critical Access Hospital (CAH) Inpatient - Medicare Part A - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The IHS CAHs are paid 101 percent of the all inclusive facility specific per diem rate established on a yearly basis from the most recently filed cost report information for covered inpatient services (on and after January 1, 2004). An average of 96 hours of acute inpatient care in a ...
June 25th, 2015
FI - CAH Inpatient - Medicare Part A - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
All charges are combined and reported under revenue code 0100 (all-inclusive room and board plus ancillary) on TOB 11X (hospital inpatient). Inpatient services are billed from admission through discharge.
The MSN is suppressed.
...
June 25th, 2015
FI - CAH Ancillary Services -Medicare Part B - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Certain inpatient CAH ancillary services are covered under Medicare Part B when coverage is no longer provided under Medicare Part A due to benefits exhausted, the beneficiary is determined to be receiving a non-covered level of care, or is not eligible for Medicare Part A benefits. Chapter 4, §240 of ...
June 25th, 2015
FI - CAH Ancillary Services - Medicare Part B - Claims Processing for Indian Health Services (Rev. 1776, 01-04-10)
By Jared Staheli | Published June 25th, 2015
All charges, except therapies, telehealth originating site facility fee, PPV, influenza virus and hepatitis B vaccines are combined and reported under revenue code 024X (allinclusive ancillary) on TOB 12X (hospital inpatient Part B). The MSN is suppressed.
See §§100.10 and 100.11 of this chapter, for more information on the payment of ...
June 25th, 2015
FI - CAH Swing-bed - Medicare Part A - Payment Policy for Indian Health Services (Rev. 1325; 01-07-08)
By Jared Staheli | Published June 25th, 2015
The IHS CAH swing-bed services are paid 101 per cent of an all inclusive facility specific per diem rate. Medicare Part A coinsurance is applied to IHS CAH swing-bed inpatient bills, but is waived by the IHS.
...
June 25th, 2015
FI - CAH Swing-bed - Medicare Part A - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Services are itemized and billed with the appropriate revenue code that describes the service on TOB 18X (hospital swing-bed). Technical criteria for swing-bed admissions apply (i.e., 3 day qualifying hospital stay, 30 day transfer requirements, etc.) but CAH swing-bed providers are not required to report revenue code 0022 or HIPPS ...
June 25th, 2015
FI - CAH Swing-bed - Inpatient Ancillary Claims - Medicare Part B - Payment Policy for Indian Health Services (Rev. 1325; 01-07-08)
By Jared Staheli | Published June 25th, 2015
The IHS CAHs are paid for covered inpatient Medicare Part B ancillary services based upon 101 percent of an all inclusive facility specific per diem rate that is established on a yearly basis from prior year cost report information. Medicare Part B deductible and coinsurance amounts are applied to inpatient ...
June 25th, 2015
FI - CAH Swing-bed - Inpatient Ancillary Claims - Medicare Part B - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The IHS CAH swing-bed Medicare Part B inpatient ancillary bills revert to inpatient Medicare Part B ancillary bills and are submitted under the regular hospital (or CAH) provider number (not the swing-bed provider number) with revenue code 0240 (all inclusive ancillary) on TOB 12X (inpatient Part B). The MSN is ...
June 25th, 2015
FI - CAH Outpatient - Medicare Part B - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The IHS CAHs are paid for covered outpatient services based on 101 percent of an all inclusive facility specific per visit rate that is established on a yearly basis from prior year cost report information for both facilities electing Standard Method I and Optional Method II billing.
For services provided in ...
June 25th, 2015
FI - CAH Outpatient - Medicare Part B - Claims Processing for Indian Health Services (Rev. 1776, 01-04-10)
By Jared Staheli | Published June 25th, 2015
All charges, except therapies, telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine, and hospital-based ambulance services are combined and reported under revenue code 0510 (clinic visit) on TOB 85X (CAH).
Non-patient lab specimens are billed on TOB 14X (hospital other).
The MSN is suppressed.
See Chapter18, §10 of Pub. ...
June 25th, 2015
CAH Election of Method I or Method II for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
See Chapter 4, §250 of Pub. 100-04, Medicare Claims Processing Manual, for information on the election of Standard Method I or Optional Method II IHS CAH billing for professional services.
...
June 25th, 2015
FI - Vaccines and Vaccine Administration - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Effective January 1, 2006, IHS providers, including CAHs are paid separately from the AIR for certain vaccines and their administration. See Chapter 18 of Pub. 100-04, Medicare Claims Processing Manual for more information on the payment of PPV, influenza virus, and hepatitis B vaccines. The administration of vaccines is paid ...
June 25th, 2015
FI - Vaccines and Vaccine Administration - Claims Processing for Indian Health Services (Rev. 1325; 01-07-08)
By Jared Staheli | Published June 25th, 2015
These vaccines are reported on TOB 12X, 13X, 83X, or 85X along with the appropriate revenue codes and HCPCS codes as found in billing instructions in Chapter 18, §10.2 of Pub. 100-04, Medicare Claims Processing Manual.
No clinic visit shall be billed if vaccine and its administration are the only service ...
June 25th, 2015
FI - Physical Therapy, Occupational Therapy, SpeechLanguage Pathology and Diagnostic Audiology Services - Payment Policy for Indian Health Services (Rev. 1325; 01-07-08)
By Jared Staheli | Published June 25th, 2015
Effective January 1, 2006, IHS providers are paid separately from the AIR for physical therapy, OT, speech-language pathology and diagnostic audiology services. Payment for services to IHS providers on TOB 12X, 13X or 83X is made based on the MPFS. Payment for services to IHS CAHs on TOB 85X is ...
June 25th, 2015
FI - Physical Therapy, Occupational Therapy, SpeechLanguage Pathology and Diagnostic Audiology Services - Claims Processing for Indian Health Services (Rev. 1325; 01-07-08)
By Jared Staheli | Published June 25th, 2015
Therapy services and diagnostic audiology services are reported on TOB 12X, 13X, 83X or 85X using the appropriate revenue code and HCPCS codes.
No clinic visit shall be billed if a therapy service or a diagnostic audiology service is the only service received. These services may be billed with or without ...
June 25th, 2015
A/B MAC - Ambulance Services for Indian Health Services (Rev. 2102, 04-04-11)
By Jared Staheli | Published June 25th, 2015
Section 630 of the MMA allows for the reimbursement of ambulance services provided by IHS hospital-based ambulance providers, CAHs, and entities owned and operated by a CAH, for the 5 year period beginning January 1, 2005. Section 2902 of the Affordable Care Act indefinitely extends Section 630 of the MMA, ...
June 25th, 2015
FI - Outpatient Hospital-Based Ambulance Services - Medicare Part B - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Medically necessary ambulance services submitted by hospital-based ambulance providers are reimbursed based on the ambulance fee schedule.
The Medicare Part B deductible and coinsurance apply to ambulance services, but are waived by the IHS.
See Chapter 15, §30.2.4 of Pub. 100-04, Medicare Claims Processing Manual, for more information on the payment of ...
June 25th, 2015
FI - Outpatient Hospital-Based Ambulance Services - Medicare Part B - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Outpatient ambulance bills from hospital-based ambulance providers are submitted with revenue code 054X (ambulance) with charges for ambulance, as well as the appropriate ambulance HCPCS codes on TOB 12X or 13X.
If an outpatient encounter occurs at the same time a covered ambulance service is provided, the hospital-based ambulance providers may ...
June 25th, 2015
A/B MAC - CAH Ambulance Services - Medicare Part B - Payment Policy for Indian Health Services (Rev. 2102, 04-04-11)
By Jared Staheli | Published June 25th, 2015
For dates of service on or after December 21, 2000 and prior to January 1, 2004, medically necessary ambulance services provided by an IHS CAH or an entity that is owned and operated by the IHS CAH are paid based on 100 percent of the reasonable cost if the 35 ...
June 25th, 2015
FI - CAH Ambulance Services - Medicare Part B -Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Medically necessary ambulance services originating out of an IHS CAH with a hospitalbased ambulance service are submitted with revenue code 054X (ambulance) with charges for ambulance, as well as the appropriate ambulance HCPCS codes on TOB 85X. IHS CAHs that meet the 35 mile rule for cost based payment shall ...
June 25th, 2015
FI - Ambulance Services - Medicare Part A - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
If an inpatient is transferred to another hospital for services under arrangement, the ambulance services are not billable to Medicare. Reimbursement for such services is part of the inpatient stay and payment is included in the IPPS payment based on the DRG.
...
June 25th, 2015
FI - Other Screening and Preventive Services - Payment Policy for Indian Health Services (Rev. 2075, 01-28-11)
By Jared Staheli | Published June 25th, 2015
Effective January 1, 2005, payment is made by the FI based on the AIR to IHS providers, excluding CAHs, for screening and preventive services covered under §630 of the MMA, indefinitely extended by §2902 of the ACA. Payment is made to CAHs based on cost. Screening and preventive services covered ...
June 25th, 2015
FI - Other Screening and Preventive Services - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The screening and preventive services listed in §100.13 of this chapter are reported on TOB 12X, 13X, or 85X with revenue code 0510 (clinic visit).
Services for screening pap smears are only payable by the FI when billed with a pelvic exam. Prostate cancer screening, cardiovascular screening blood tests and screening ...
June 25th, 2015
FI - MNT - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Section 105 of BIPA permits Medicare coverage of MNT when furnished by a RD meeting certain requirements. See Chapter 4, §§300 through 300.6 of Pub. 100-04, Medicare Claims Processing Manual, for more information on these requirements.
If the RD providing the services is either an IHS hospital employee or has contracted ...
June 25th, 2015
FI - MNT - Claims Processing for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The MNT services provided under the auspices of the hospital are reported to the designated FI under revenue code 0510 (clinic visit). The current MNT HCPCS codes are required for the both the assessment and reassessment. The MSN is suppressed.
See Chapter 4, §§300 through 300.6 of Pub. 100-04, Medicare Claims ...
June 25th, 2015
FI - Laboratory Services for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
• Laboratory services furnished to IHS provider inpatients are combined with other inpatient services furnished and reported under revenue code 0100 (all-inclusive room and board plus ancillary) on TOB 11X. Payment is made for inpatient laboratory services under the PPS based upon DRGs.
• Inpatient hospital laboratory ancillary services are covered ...
June 25th, 2015
FI - Drugs for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The IHS providers, including CAHs, are paid by the FI for covered drugs and biologicals provided during a covered inpatient hospital stay. All charges are combined and reported under revenue code 0100 (all-inclusive room and board plus ancillary) on TOB 11X.
Payment is made to IHS/tribal hospitals under IPPS. IHS CAHs ...
June 25th, 2015
FI--Payment for Telehealth Services to Indian Health Service/Tribal Facilities and Practitioners for Indian Health Services (Rev. 1776, 01-04-10)
By Jared Staheli | Published June 25th, 2015
For background on the telehealth benefit, see Chapter 12, §190.1 in this manual. For more information on the payment of Telehealth services, see Chapter 15 of the Benefit Policy Manual. Telehealth services fall into two categories: an originating site facility service in which the beneficiary is presented to the distant ...
June 24th, 2015
General Information about Indian Health Services
By Jared Staheli | Published June 24th, 2015
The Indian Health Service (IHS) is the primary health care provider to the American Indian/Alaska Native (AI/AN) Medicare population. The Indian health care system, consisting of tribal, urban, and federally operated IHS health programs, delivers a spectrum of clinical and preventive health services to its beneficiaries, via a network of ...
June 24th, 2015
Carrier and FI Designation for Indian Health Services (Rev. 1325; 01-07-08)
By Jared Staheli | Published June 24th, 2015
The designated carrier and FI enroll IHS operated facilities, process IHS institutional claims, IHS physician and practitioner claims for IHS or tribally owned facilities and hospitals. The designated carrier may also enroll tribally operated facilities and process the practitioner claims for these facilities, if the tribally operated facility chooses. All ...
June 22nd, 2015
MSN - Specifications for Section 1: Summary (Page 1) (Rev. 3210, 04-16-15)
By Jared Staheli | Published June 22nd, 2015
A. Notice Title
This section names the notice, specifies the function of the notice and the Medicare program under which the notice’s claims are paid, and identifies the Federal agencies responsible for generating the notice.
GLOBAL SPECIFICATIONS
POSITION
This subsection contains information of a fixed size. It does not vary in ...
June 22nd, 2015
MSN - Specifications for Header for Other Pages (Rev. 2522, 01-03-13(Final Implementation)
By Jared Staheli | Published June 22nd, 2015
This element repeats at the top of every page of the MSN, except for the first page. It contains the beneficiary’s name, a notification, and page numbering.
POSITION
This subsection is of a fixed size. It does not vary in overall width or length.
It begins (0˝, 0˝) and is full-page or 540 ...
June 22nd, 2015
MSN - Specifications for Section 2: Making the Most of Your Medicare (Page 2) (Rev. 3210, 04-16-15)
By Jared Staheli | Published June 22nd, 2015
A. Section Title
POSITION
This subsection contains information of a fixed size. It does not vary in overall width or length.
The content area begins (0˝, 5˝), 7 points from the baseline of the Headers for Other Pages subsection. It is full-page or 540 points in width and 24 points in height.
CONTENT
Making ...
June 19th, 2015
Format Conventions for the MSN (Rev. 3210, 04-16-15)
By Jared Staheli | Published June 19th, 2015
This information describes the overall format conventions for the MSN.
MSNs are a combination of fixed and variable length sections, using a range of different typefaces and type styles, as well as a number of static graphic elements. For discussion of the display in specific areas of the notice, see the ...
June 18th, 2015
General Medicare Summary Notices (MSN) Requirements (Rev. 955, September 1, 2006)
By Jared Staheli | Published June 18th, 2015
Effective July 1, 2002, the MSN is used by all carriers and intermediaries.
The MSN is the primary vehicle by which beneficiaries are notified of decisions on their claims for Medicare benefits. The intermediary or carrier mails a single MSN at the end of the month to each beneficiary for whom ...
June 18th, 2015
General Requirements for the MSN (Rev. 1491, 05-12-08)
By Jared Staheli | Published June 18th, 2015
A. Intermediary/RHHI MSN
The MSN is used to notify Medicare beneficiaries of action taken on intermediary processed claims. MSNs are not used by RHHIs for RAPs, and RAP data are not included on the monthly MSN.
The MSN provides the beneficiary with a record of services received and the status of ...
June 18th, 2015
Correction/Reissuance of Faulty MSNs (Rev. 159, 04-30-04)
By Jared Staheli | Published June 18th, 2015
Occasionally programming errors will occur which cause inaccuracies on MSNs that do not materially affect benefits. An example of a potential programming error could be one data column writing in another data column. So long as the claims are correctly paid and the notice is intelligible, it is not necessary ...
June 18th, 2015
Basic Concepts and Approaches (Rev. 3210, 04-16-15)
By Jared Staheli | Published June 18th, 2015
A. Overview
The Medicare Summary Notice (MSN) is a printed notification, sent to Medicare beneficiaries enrolled in Original Medicare, that displays data for claims processed during a given reporting period. The MSN lists claim information in a summarized format. It also contains other helpful information for beneficiaries. Each MSN consists of ...
June 17th, 2015
Where to Bill DMEPOS and PEN Items and Services (Rev. 1603, 10-27-08)
By Jared Staheli | Published June 17th, 2015
Skilled Nursing Facilities, CORFs, OPTs, and hospitals bill the FI for prosthetic/orthotic devices, supplies, and covered outpatient DME and oxygen (refer to §40). The HHAs may bill Durable Medical Equipment (DME) to the RHHI, or may meet the requirements of a DME supplier and bill the DME MAC. This is ...
June 17th, 2015
Durable Medical Equipment (DME) (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
DME is covered under Part B as a medical or other health service (§1861(s)(6) of the Social Security Act [the Act]) and is equipment that:
a. Can withstand repeated use;
b. Is primarily and customarily used to serve a medical purpose;
c. Generally is not useful to a person in the absence of ...
June 17th, 2015
Prosthetic Devices - Coverage Definition (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
Prosthetic devices (other than dental) are covered under Part B as a medical or other health service (§1861(s)(8) of the Act) and are devices that replace all or part of an internal body organ or replace all or part of the function of a permanently inoperative or malfunctioning internal body ...
June 17th, 2015
Prosthetics and Orthotics (Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes) - Coverage Definition (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
These appliances are covered under Part B as a medical or other health service (§1861(s)(9) of the Act) when furnished incident to physicians' services or on a physician's order. A brace includes rigid and semi-rigid devices that are used for the purpose of supporting a weak or deformed body member ...
June 17th, 2015
Beneficiaries Previously Enrolled in Managed Care Who Return to Traditional Fee for Service (FFS) (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
When a beneficiary who was previously enrolled in a Medicare HMO/Managed Care program returns to traditional FFS, he or she is subject to all benefits, rules, requirements and coverage criteria as a beneficiary who has always been enrolled in FFS. When a beneficiary returns to FFS, it is as though ...
June 17th, 2015
Scenario: How Medicare Pays For Electric Wheelchairs (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
If you need an electric wheelchair prescribed by your doctor, you may already know that Medicare can help pay for it. Medicare requires (specify name of supplier) to give you the option of either renting or purchasing it. If you decide that purchase is more economical, for example, because you ...
April 15th, 2015
Medicare Updates Preventive Exam and Wellness Visit Information
By Wyn Staheli, Director of Research | Published April 15th, 2015 - Last Review/Update June 9th, 2016
Medicare has updated their provider educational tools for the Initial Preventive Physical Examination (IPPE) and the Annual Wellness Visit (AWV). These tools were designed to help providers gain a greater understanding of these services. Learn what the required elements for these services as well as important coverage and coding information.
CLICK ...
March 27th, 2015
Will the SGR be Repealed?
By Wyn Staheli, Director of Research | Published March 27th, 2015 - Last Review/Update June 9th, 2016
It appears that the repeal of the Sustainable Growth Rate formula (SGR) could finally be a real possibility. On Thursday, March 26, The U.S. House of Representatives overwhelmingly passed H.R 2, The Medicare Access and CHIP Reauthorization Act which includes both repeal and replace the flawed SGR formula that has ...
February 27th, 2015
CMS Extends EHR Attestation Deadline
By | Published February 27th, 2015 - Last Review/Update June 9th, 2016
Originally, for providers to Attest EHR/Meaningful Use for the 2014 reporting period, the attestation deadline was February 28, 2015. However, to encourage providers to start attesting for the 2014 reporting year, CMS has extended the attestation deadline for eligible professionals to March 20, 2015. CMS indicates this has been done, ...
February 26th, 2015
Avoiding Medicare and Medicaid Fraud and Abuse
By | Published February 26th, 2015 - Last Review/Update January 27th, 2017
Recently, the U.S. Department of Health and Human Services Office of Inspector General updated their booklet, “Avoiding Medicare and Medicaid Fraud and Abuse.”
In this publication, the Government agencies, including the Department of Justice, the Department of Health and Human Services office of Inspector General, and the Centers for Medicare and ...
February 26th, 2015
Levels of Supervision Required by Medicare
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 26th, 2015 - Last Review/Update March 2nd, 2016
Be sure you know and understand the levels of supervision required so as not to result in non-compliance audits, possible fines and take-backs. Supervision requirements may also affect your documentation requirements; be sure to document the presence during the procedure or performance if it requires personal supervision.
Find-A-Code has levels of supervision ...
February 23rd, 2015
Q & A: Why is Medicare Denying Claims?
By | Published February 23rd, 2015 - Last Review/Update March 9th, 2016
Q: We have recently enrolled with Medicare and treat only a few patients. However, those claims are being denied. Can you help me to understand why this might be happening?
A: First, I would recommend you carefully review your Medicare Remittance Advice as that will identify the reason Medicare is denying your ...
February 21st, 2015
Electronic Code of Federal Regulations
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 21st, 2015 - Last Review/Update March 1st, 2016
Lots of information on government regulations pertaining to Medicare is listed here:
The Electronic Code of Federal Regulations (e-CFR) is a regularly updated, unofficial editorial compilation of CFR material and Federal Register amendments produced by the National Archives and Records Administration's Office of the Federal Register (OFR) and the Government Publishing Office.
...
February 15th, 2015
CMS Opt-Out Regulations and Guidelines
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 15th, 2015 - Last Review/Update March 1st, 2016
40-Effect of Beneficiary Agreements Not to Use Medicare Coverage
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)
(Rev. 194, 09-03-14)
Normally physicians and practitioners are required to submit claims on behalf of beneficiaries for all items and services they provide for which Medicare payment may be made under Part B. Also, they are ...
February 10th, 2015
MAC Jurisdictions Resources
By | Published February 10th, 2015 - Last Review/Update February 18th, 2016
The Centers for Medicare & Medicaid Services (CMS) uses a network of contractors called Medicare Administrative Contractors (MAC) to process Medicare claims, enroll health care providers in the Medicare program and educate providers on Medicare billing requirements. MACs also handle claims appeals and answer beneficiary and provider inquiries. Even though ...
February 9th, 2015
Encryption
By Wyn Staheli, Director of Research | Published February 9th, 2015 - Last Review/Update June 9th, 2016
How secure is your computer? Do you have a password on your computer? Do you have the automatic log offs turned on? Is your computer encrypted? Are your off-site storage files encrypted?
This document is designed to give some basic information about making your office a little more secure. It is not ...
February 3rd, 2015
PPACA Provider Non-Discrimination FAQ
By | Published February 3rd, 2015 - Last Review/Update June 9th, 2016
The following information (emphasis added) is from: http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs15.html
Provider Non-Discrimination PHS Act section 2706(a), as added by the Affordable Care Act, states that a “group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against ...
January 9th, 2015
How Important is Your Fee Schedule?
By | Published January 9th, 2015 - Last Review/Update June 13th, 2016
Did you know that inconsistent and un-reviewed fee schedules can lead to some of the following occurrences:
• Prompt an audit or some level of claims review
• Cause claims delays
• Increase provider liability in case of an audit or investigation
• Potentially lead to being paid less than the actual value of ...
December 23rd, 2014
CMS Announces New HCPCS Modifiers to be Implemented January 2015
By | Published December 23rd, 2014 - Last Review/Update January 30th, 2017
Beginning January 5, 2015 CMS (Centers for Medicare and Medicaid Services) requires new HCPCS modifiers to be used in place of modifier 59 for all Medicare claims.
These new subset modifiers are known as -X{ESPU} and are defined as follows:• XE - separate encounter, a service that is distinct because it ...
December 4th, 2014
NCDs and LCDs - What Are They?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
What are NCDs and LCDs?
NCD — NATIONAL COVERAGE DETERMINATIONS
Medicare specific coverage on the national level. All Medicare carriers are required to follow the NCDs. The NCDs are developed by CMS to describe the circumstances for Medicare coverage nationwide for an item or service. NCDs generally outline the conditions for which an ...
December 1st, 2014
Q & A: Establishing a Multi-Disciplinary Practice and Being Legal
By | Published December 1st, 2014 - Last Review/Update January 30th, 2017
Q: How do you add another provider type such as a Nurse Practitioner to your practice to provide additional services to patients and legally bill for those services under their license?
A: Multi-disciplinary practices are under scrutiny at the moment by ZPIC, CMS and State Boards. For your reference, just below, there ...
November 25th, 2014
Have you checked your QRUR to find out if you qualify for a CMS bonus (or penalty)?
By | Published November 25th, 2014 - Last Review/Update January 30th, 2017
What? You've never heard of a QRUR?
You have probably heard about Meaningful Use (MU) and penalties that kick in for those who did not attest. And the Physician Quality Reporting System (PQRS) with penalties for those who did not successfully report on at least one patient. The new one ...
November 21st, 2014
Risk Adjustment, What is it?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update January 30th, 2017
Risk adjustments are used to compare Actual and Expected Mortality Rates using Risk Adjustments calculated by patient risk score.
BC Risk Adjustment — Risk Adjustment 101
WA Regence Administrative Manual
Risk adjustment is part of the Regence Medicare Program Management for Medicare Advantage plans. Commercial risk adjustment is a requirement of the U.S. Department ...
November 21st, 2014
What is an LMRP and Where Can I Find Them?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update March 1st, 2016
Local Medical Review Policies (LMRPs) were converted to LCDs. This was done as a result of the Benefits Improvement and Protection Act of 2000 (BIPA 2000). The difference between LCDs and previously written LMRPs is that LCDs contain only reasonable and necessary conditions of coverage as allowed under section 1862(a)(1)(A) ...
November 19th, 2014
Understanding ZPIC
By | Published November 19th, 2014 - Last Review/Update January 30th, 2017
The following chart identifies each of the 7 zones for ZPIC and the states/regions within each zone. Links are provided for each zone which contain information about each zone as well as activity and updates in those regions.
November 19th, 2014
Understanding RAC
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published November 19th, 2014 - Last Review/Update January 30th, 2017
Recovery Audit Contractors, also known as RAC, is a program that seeks to identify and correct improper payments for services provided to Medicare Parts A & B beneficiaries. This includes both recoupment of overpayments and corrected distribution of underpayments made by CMS.  RAC began in 2005 as a three-year demonstration project consisting ...
November 17th, 2014
Conducting a Gap Analysis for Your Documentation & Billing Systems
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published November 17th, 2014 - Last Review/Update January 30th, 2017
What is a Gap Analysis?
A Gap Analysis is a process by which a practice conducts a baseline assessment of the company's coding, billing, operations, and business practices. The objective of a Gap Analysis is to ensure that the practice is in full compliance with applicable legal and ethical requirements. This ...
November 17th, 2014
Medicare's Screening, Brief Intervention, and Referral to Treatment (SBIRT) Services
By Wyn Staheli, Director of Research | Published November 17th, 2014 - Last Review/Update January 6th, 2017
Medicare understands that there are individuals who may not meet the diagnostic criteria for substance abuse, but who are still at risk. To help identify these individuals and take steps to keep them from reaching the level of abuse, Medicare has established a program called the Screening, Brief Intervention, and ...
October 20th, 2014
PPO Plans
By | Published October 20th, 2014 - Last Review/Update January 27th, 2017
Are PPOs are affecting the value of your practice?
Did you know that taking a 20% PPO write-off on a $200 procedure with a 60% overhead cuts practice profits in half?
By participating in PPO plans, you agree to take a certain discount on fees; however, your fixed overhead costs remain the same ...
October 16th, 2014
Is Compliance a Dirty Word?
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published October 16th, 2014 - Last Review/Update January 23rd, 2017
In October of 2000 in the Federal Register the Office of the Inspector General (who investigates fraud against the federal government on behalf of the Department of Health and Human Services) offered general guidelines for health care facilities to set up a “Compliance Program”. This advice has long been pushed ...
October 16th, 2014
Chiropractic is Listed as a Priority in the 2014 OIG Work Plan...Find Out Why
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published October 16th, 2014 - Last Review/Update January 30th, 2017
Each year the Office of Inspector General (OIG) issues an updated work plan which outlines the objectives and enforcement priorities for each new year. For Medical providers, including Chiropractic, this information is necessary to review and be familiar with so we may evaluate our own practice systems to ensure compliance ...
October 16th, 2014
The Role of Statistical Analysis in Fighting Fraud
By Jared Staheli | Published October 16th, 2014 - Last Review/Update January 30th, 2017
It is common knowledge that fraud is a large problem for payers, who must spend money paying fraudulent claims as well as on recovery. New developments in statistical analysis helps to combat this.
October 16th, 2014
ABN FAQ for Chiropractic Care
By | Published October 16th, 2014 - Last Review/Update November 29th, 2017
What is the ABN form used for?
The Advanced Beneficiary Notice of Non-Coverage (ABN) is the Notice of Liability that is required to be provided to Medicare patients in the event that the service(s) rendered to them are expected to not be covered. For chiropractic, reason for non-coverage is generally due ...
October 15th, 2014
RAC Alert
By | Published October 15th, 2014 - Last Review/Update January 30th, 2017
In February, 2014, CMS announced the "pausing" of the RAC (Recovery Audit Contractors) program to allow current RAC contractors to complete remaining claim audits and related duties before CMS begins the process of reviewing RAC program contracts as well as allowing time for CMS to make improvements in the RAC program itself. ...
October 9th, 2014
Effective Billing Dates for New CMS Providers
By | Published October 9th, 2014 - Last Review/Update January 30th, 2017
As of May 14, 2012, the billing effective date can be made retroactive as far back as 30 calendar days from the date the application was received in Medicare's office.
Provider offices must submit the CMS 855 form as soon as the provider begins seeing Medicare patients to ensure their services will be ...
September 25th, 2014
Healthcare Fraud Investigations in FY 2013
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 25th, 2014 - Last Review/Update January 30th, 2017
Enforcement Actions in FY 2013: the Department of Justice (DOJ) opened 1,013 new criminal health care fraud investigations involving 1,910 potential defendants. Federal prosecutors had 2,041 health care fraud criminal investigations pending, involving 3,535 potential defendants, and filed criminal charges in 480 cases involving 843 defendants. A total of 718 ...
September 18th, 2014
PQRS Web Based Training
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 18th, 2014 - Last Review/Update January 30th, 2017
The CMS Physician Quality Reporting System (PQRS) Program: "What Medicare Eligible Professionals Need to Know in 2014” Web-Based Training Course — Released
“The CMS Physician Quality Reporting System (PQRS) Program: What Medicare Eligible Professionals Need to Know in 2014” Web-Based Training (WBT) Course was released and is now available. This WBT ...
September 15th, 2014
Medicare Definition of Timed Codes
By Wyn Staheli, Director of Research | Published September 15th, 2014 - Last Review/Update July 12th, 2016
Many procedure codes are considered "timed codes," that is, the number of units are determined by the amount of time spent performing the service. Medicare Claims Processing Manual, Chapter 5 clarification included here.
September 9th, 2014
Compliance Specialists
By | Published September 9th, 2014
Compliance specialists are responsible for monitoring health and human services program operations for compliance with federal and state regulations and standards in order to promote health and safety, assure that public services are delivered properly, or prevent fraud. Areas assessed may include service delivery, eligibility determination and payment, medical reimbursement, ...
August 27th, 2014
PQRS FAQS
By | Published August 27th, 2014 - Last Review/Update January 30th, 2017
PQRS FAQs: How do I report for the 2014 PQRS? What is the MAV and when does it apply? What happens if we report less than 9 measures across 3 domains? How does CMS apply the MAV Clinical Relation/Domain test for PQRS?
August 7th, 2014
Durable Medical Equipment, Prosthetics, Orthotics and Supplies
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 7th, 2014 - Last Review/Update January 25th, 2017
Reimbursement for most Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) is established by fee schedules. Payment is limited to the lower of the actual charge or the fee schedule amount.  We have given you some basic information to get you started including modifiers and how CMS views DMEPOS, please ...
July 24th, 2014
Are Medicare fees going up? Or down?
By | Published July 24th, 2014 - Last Review/Update January 29th, 2016
Are Medicare fees going up? Or down? Results for the following:
Sequestration
Chiropractic Demonstration Project
Electronic Health Record/Meaningful Use
Physician Quality Reporting System - PQRS
Value-Based Modifier
March 2nd, 2014
Will mandatory Medicare payment cuts (due to the SGR) get repealed?
By | Published March 2nd, 2014 - Last Review/Update January 27th, 2017
Since 2003, healthcare providers have been dealing with the the short term patches to the Medicare payment system. After all this time, it now appears that Congress is making a move to address the ongoing issues with the Sustainable Growth Rate (SGR). This is the formula that has caused the payment problems with Medicare. Many professional organizations are endorsing the SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (H.R. 4015, S. 2000) and encouraging providers to contact their congressional leaders and lend their support for this legislation. If you wish to join those lending their support CLICK HERE for a helpful tool to contact YOUR congressional leaders.
Read More
February 12th, 2014
EHR Hardship Exemption
By | Published February 12th, 2014 - Last Review/Update January 27th, 2017
The following information is from the Centers for Medicare & Medicaid Services (CMS) regarding the Electronic Health Records (EHR) payment reduction hardship exemption.
November 26th, 2013
How do I know which ICD-10 codes payers are going to like?
By | Published November 26th, 2013 - Last Review/Update January 27th, 2017
One of the biggest questions doctors have is “Which codes will I actually use when ICD-10 kicks in on October 1, 2014?” This is the great mystery. Fortunately we have access to the same code set that payers will be using as they determine which codes they like to see. ...
September 24th, 2013
Federal Health Care Fraud Summary 2012
By | Published September 24th, 2013 - Last Review/Update January 27th, 2017
Be aware of the possible monetary results and enforcement actions imposed for fraud. This is the annual report of the Department of Justice Health Care Fraud and Abuse Control Program for FY 2012
September 11th, 2013
ICD-10 Coding Possibilities for Chiropractic Physicians
By Evan M Wsilliam, DC, CPC, CCPC, NCICS, CCCPC, CPC-I, MCS-P, CPMA | Published September 11th, 2013 - Last Review/Update January 27th, 2017
Right now, it’s hard to say which ICD-10 codes third-party payers will select as medically necessary, but we can make an educated guess based on information from a few sources. More detail is expected from Medicare before the end of 2013. For doctors of chiropractic (DCs), the natural place to start is with the relatively short list of frequently used ICD-9-CM codes for submitting claims. We’ll investigate a handful of diagnosis codes that Medicare recognizes as medically necessary and explore ICD-10-CM code possibilities.
July 15th, 2013
Medicare Recruits Seniors to Fight Against Fraud
By | Published July 15th, 2013 - Last Review/Update January 27th, 2017
Recently Medicare issued a press release about their updated Medicare Summary Notice. The Obama Administration has made the elimination of fraud, waste, and abuse a top priority and the number of providers thrown out of Medicare programs has more than doubled in the last few years. The newly designed Medicare ...
August 30th, 2012
Inappropriate Medicare Payments for Chiropractic Services
By | Published August 30th, 2012 - Last Review/Update January 27th, 2017
OIG released two reports critical of the way chiropractic handled documentation and coding. Their findings are included in this article. Read further to see what documentation is needed for proper payment.
As required by the Social Security Act, Medicare pays only for reasonable and necessary chiropractic services, which are limited to active/corrective manual manipulations of the spine to correct subluxations. A chiropractic service must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function.
June 21st, 2010
Medicare Fee Alert-June 21, 2010, by Dr. Ron Short
By | Published June 21st, 2010 - Last Review/Update January 27th, 2017
Congress continues to debate the elimination of the negative update that took effect June 1, 2010. The CMS is hopeful that Congressional action will be taken to avert the negative update.
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