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General Links and Resources

CMS Noridian - Active LCDs

CMS Noridian - Active LCDs

Hospital Outpatient Regulations and Notices

Hospital Outpatient Regulations and Notices

Medicare Enrollment

PECOS- Medicare Provider Enrollment, Chain, and Ownership System

Medicare Provider/Supplier to Healthcare Provider Taxonomy

Medicare Provider/Supplier to Healthcare Provider Taxonomy

The Medicare Learning Network®

Free educational materials for health care professionals on CMS programs, policies, and initiatives.

General Billing Requirements

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Find-A-Code Links and Resources

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National Coverage Determinations

CMS|Medicare Articles

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Now That is Fraud! Genetic Testing "Public alert"

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Genetic testing is becoming very popular. In fact, so popular you might see it in places you would not expect such as a community event, fairs or any event happening in your community. Some labs may even offer FREE screening for genetic testing. Watch for FREE screening announcements or advertisements ...

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CMS says Codes are on the Move!

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Have you noticed your LCDs are missing something? CMS is moving codes out of LCDs and into Billing and Coding Articles. MACs began moving ICD-10-CM, CPT/HCPCS, Bill Type, and Revenue codes in January 2019, and will continue through January 2020. Therefore, if there is an LCD with its codes removed, you will find ...

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Why is HIPAA So Important?

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Why is HIPAA So Important? Some may think that what they do to protect patient information may be a bit extreme. Others in specialty medical fields and research understand its importance a little more. Most of that importance lies in the information being protected. Every patient has a unique set of ...

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Are You Aware of Medicare Advantage Plans Timely Filing Rules?

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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 ...

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Will Medicare Change Their Rules Regarding Coverage of Services Provided by a Chiropractor?

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Two separate pieces of legislation introduced in the House of Representatives (H.R. 2883 and H.R. 3654) have the potential to change some of Medicare’s policies regarding doctors of chiropractic. Find out what these two bills are all about and how they could affect Medicare policies.

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The Slippery Slope For CDI Specialists

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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 ...

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Anthem is Changing their Timely Filing Requirements for All Plans, Including Medicare Advantage

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Anthem has been very busy sending out notices stating that, beginning October 1, 2019, all timely filing deadlines for claims will be 90 days. We've seen this letter, or something very similar, sent to doctors and other healthcare providers from California to Kentucky. In their notice, Anthem states: "Effective for all commercial ...

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Helping Others Understand How to Apply Incident to Guidelines

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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 ...

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A United Approach

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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 ...

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Now is Your Chance to Speak Up! Tell CMS What You Think!

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CMS is asking for your input, we all have ideas on how we would change healthcare documentation requirements and get rid of the burdensome requirements and regulations if it were up to us, so go ahead, speak up! Patients over Paperwork Initiative is being looked at to help significantly cut ...

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Medicare Revises Their Appeals Process

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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 ...

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Medicare Revises Their Appeals Process

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There are policy revisions in the Medicare Claims Processing Manual (MCPM), Chapter 29 taking place June 13, 2019. This will give you a heads up on those changes.

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Auditing Chiropractic Services

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Chiropractic is unique from other types of health care and auditors need to be aware of the nuances of this field. Chiropractic has become the focus of more and more audits as doctors seem to struggle to create records that properly support the care provided to the patient throughout the entire episode.

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Q/A: What do I do When a Medicare Patient Refuses to Sign an ABN?

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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 ...

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Q/A: Can I Tell a Medicare Patient Which Option to Check on the ABN?

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Question My patient seemed confused about which of the options they should check. Can I just tell them which one they should check? Answer No! That could be construed as coercion. The official instructions state “Under no circumstances can the notifier decide for the beneficiary which of the 3 checkboxes to select.” Now, this ...

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Clearing Up Some Medicare Participation Misunderstandings

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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 ...

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Date of Service Reporting for Radiology Services

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Providers need to ensure that they are reporting radiology dates of service the way the payer has requested. Unlike other many other professional services which only have one date of service (DOS), radiology services can span multiple dates. Medicare requirements may differ from professional organization recommendations.

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Q/A: Can you Help me Understand the New Medicare Insurance Cards?

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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.

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Coding Medicare Initial Preventive Physical Exams (IPPE)

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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 ...

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HHS Proposes Significant Changes to Patient Access Rules

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In a significant announcement on February 11, 2019, HHS proposed new rules aimed at improving interoperability of electronic health information. This announcement was made in support of the MyHealthEData initiative which was announced by the Trump administration on March 6, 2018. The goal of that initiative was to break down ...

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Charging Missed Appointment Fees for Medicare Patients

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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 ...

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Attestations Teaching Physicians vs Split Shared Visits

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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 ...

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Empowering Medicare Beneficiaries

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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 ...

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Home Oxygen Therapy

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Home Oxygen Therapy Guidelines

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CMS Finalizes Major Changes to ACO Program

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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 ...

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Medicare Advantage Providers are not Required to be Enrolled in Medicare

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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 ...

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Errors Billing Outpatient Services When Patient is also Inpatient

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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 ...

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Allergy Immunotherapy Coding Guidelines (CMS) Effective: 01/01/2006

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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 ...

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CMS: Medicare Diabetes Prevention Program Expanded Model

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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...

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Wolters Kluwer Drug Pricing

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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...

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Type of Bill Codes

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Type of bill codes identifies the type of bill being submitted to a payer. Type of bill codes are four-digit alphanumeric codes that specify different pieces of information on claim form UB-04 or form CMS-1450 and is reported in box 4 on line 1. First Digit = Leading zero. Ignored by CMSSecond ...

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Keys to Successful Claims Filing

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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 ...

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BREAKING NEWS: CMS Proposes to Change E&M Coding

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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 ...

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Risky Business The CMS HCC Risk Model

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Today's catchy title may invoke memories of that risqué movie from the 80's starring a young Tom Cruise famously dancing in his "tighty whities." But today's post is not about that type of risk. Instead we are going to spend some time with a risk adjustment model that's quietly become...

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CMS Proposes Changes to Evaluation & Management Requirements

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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 ...

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Provider-Based Facilities and Split Billing: Is Your Facility Being Reimbursed for All Work Performed?

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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 ...

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Patients Over Paperwork?! We have Great News!

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Spend more time with patients and less time documenting? Great Concept! Document meaningful information? Sound good? CMS is proposing just that! CMS released a new proposal July 12, 2018, focused on streamlining clinician billing and expanding access to high-quality care. The goal is to improve and restore the doctor-patient relationship, modernize Medicare ...

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Attention Providers - Please Make Time to Read this Letter

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In an effort to show CMS is committed to changing the rules to accommodate their providers CMS released a letter to Doctors of Medicare Beneficiaries. The letter offers encouragement and a promise to reduce the burden of unnecessary rules and requirements. The letter states “President Trump has made it clear that ...

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CMS Proposed New E/M Codes for Podiatry

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According to CMS changes are coming for E/M codes.  A recent proposal from CMS stated: "The E/M visit code set is outdated and needs to be revised and revalued." Since podiatry tends to furnish a lower level of E/M visits, CMS is proposing new G-codes to report E/M office/outpatient visits. The proposed ...

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Dual Medicare-Medicaid Billing Problems

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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 ...

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ESRD Claims Error: Transitional Drug Adjustment Add-On Payment Adjustment

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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 ...

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How Does the Physician Compare Website Affect You?

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The physician compare website may not be working quite the way you think it is. Not all providers will have rankings showing up for them. Physician compare lists basic information, but quality measure information was not added until this year (2018) and not all quality measures are included in the ...

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Q/A: Do I Have a Patient with Part C sign an ABN if we are Out-of-Network?

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Do we need an ABN if the patient has Part C and we are out-of-network? Read More.

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Home Oxygen Therapy -- CMN for Oxygen

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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.

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Why Is Medicare Denying My Claims for Mammography and Breast Biopsies?

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When Medicare updated their systems with the updates to mammography and breast biopsy policies some ICD-10-CM codes were inadvertently left out. The omitted new codes are N63.11-N63.14, N63.21-N63.24, N63.31, N63.32, N63.41, and N63.42, which will replace the truncated ICD-10 diagnosis N63. The Centers for Medicare & Medicaid Services (CMS) will...

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Creating a Culture of Compliance in 2018

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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...

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TKAs to Outpatient What We Have Learned with Q1

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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...

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Webinar: Basic E&M Avoiding Common Errors

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Join us for AAPC CEU approved Education and Outreach with Noridian BASIC E AND M AVOIDING COMMON ERRORS Start Date: 5/15/18 Duration: 11:00 AM – 12:00 PM - Pacific Daylight Time Type: Web-based Workshop Register Now: https://attendee.gotowebinar.com/register/7977003427311130113 Abstract: This presentation is designed to provide basic information on the billing and...

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The PSAVE Pilot Program: Should You Self-Audit Your Medicare Claims?

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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....

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CMS Compliance Guidelines Focused Trainings

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Since the publication of the Compliance Program Guidelines in 2012, the Medicare Part C & D Oversight and Enforcement Group, Division of Compliance Enforcement, has presented a series of focused trainings for the industry on the application of the seven elements of an effective compliance program. These trainings are designed ...

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Medicare Telemedicine Changes for 2018

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Find-A-Code presented a webinar on “Coding and Auditing Telemedicine Services,” on March 29, 2018, which did not include the new and updated CMS information published in the MNL Matters Number: MM10393 on January 2, 2018. New and exciting changes were introduced in this article, which is addressed below.  Originating Site Fee Each ...

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Home Oxygen Therapy -- A Face-to-Face Encounter

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What is required for a Home Oxygen Therapy, Face-to-Face Encounter.

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Medicare Beneficiary Identifier (MBI) Beginning April 1, 2018 (This is Not a Joke)

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The law requires the Centers for Medicare & Medicaid Services (CMS) to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019. A new unique Medicare number will replace the current Health Insurance Claim Number (HICN) on the new Medicare cards. The new cards will be mailed in...

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Q/A: Billing for GI Anesthesia

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Medicare’s policy requires the use of a different code when a screening colonoscopy becomes a diagnostic procedure requiring you to bill with CPT code 00811 when treating a Medicare Beneficiary.

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Documentation for Ordering Oxygen Supplies and Equipment

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The Medicare Learning Network provides guidance on required documentation for Ordering Oxygen Supplies and Equipment.

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Documentation for Negative Pressure Wound Therapy

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The Medicare Learning Network provides guidance on required documentation for negative pressure wound therapy.

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Documentation for Surgical Dressings

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The Medicare Learning Network provides guidance on required documentation for surgical dressings.

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Documentation for Home Blood Glucose Monitors (BGM)

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The Medicare Learning Network provides guidance on how to Prevent Denials for Home Blood Glucose Monitors (BGM)...

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Documentation for Therapeutic CGMs and Related Supplies

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The Medicare Learning Network, provides coverage guidance on therapeutic CGMs and Related Supplies

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Documentation for Manual Wheelchairs

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The Medicare Learning network provides guidance on how to prevent denials for Manual Wheelchair Bases....

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Documentation for Lower Limb Prosthesis

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The Medicare Learning Network provides guidance on denials for lower leg prostheses and how to prevent them: For the 2017 report period, most of the improper payments for lower leg prostheses were due to insufficient documentation. For Medicare to cover a lower limb prosthesis claim, the medical record must support the beneficiary’s ...

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Documentation for Bacterial Culture Lab Tests

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The Medicare Learning Network provides guidance on how to prevent denials of Bacterial Culture Laboratory Tests

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Documentation for Bacterial Culture Lab Orders

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The Medicare Learning Network provides guidance on delivering orders for bacterial culture laboratory tests...

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Documentation for Power Tilt/Recline Seating Systems for Wheelchairs

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The Medicare Learning Network provides coverage guidance for Power Tilt and/or Recline Seating Systems...

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Documentation for Ostomy Supplies

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The Medicare Learning Network provides guidance on essential documentation elements required to prevent denials for ostomy supplies....

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Documentation for Home Health Services (Part A non DRG)

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The Medical Learning Network provides coverage guidance, which should be documented, for home health services.

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Documentation and Orders for Respiratory Assistive Device

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The Medicare Learning Network provides guidance on required documentation for a respiratory assistive device and ordering guidelines.

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Documentation and Orders for Laboratory Tests

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The Medicare Learning Network provides guidance on required documentation for ordering laboratory tests.

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Documentation for Skilled Nursing Facilities

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The Medicare Learning Network provides guidance on required documentation for Skilled Nursing Facilities (SNF).

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Documentation for Inpatient Rehabilitation Facilities

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The Medicare Learning Network provides guidance on required documentation for Inpatient Rehabilitation Facilities (IRF).

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New Bipartisian Budget Act of 2018 Provisions

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On February 9, 2018, the Bipartisan Budget Act of 2018 was signed into law. There were some changes which will affect Medicare payments. The following is a brief summary, for a more comprehensive summary see the References. Therapy Caps: Some therapy caps (e.g., occupational, physical therapy, speech-language pathology) were discontinued. However, modifier KX will ...

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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?

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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?

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The Comprehensive Error Rate Testing Program

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With nearly a million physicians in this country, how do auditing organizations determine whom to audit?

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Medicare Using Private Payor Prices to Set Payment Rates for Clinical Diagnostic Laboratory Tests Starting January 2018

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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 ...

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MAC Operations Continue During Shutdown

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CMS announced today, during the time that the partial government shutdown is in effect, Medicare Administrative Contractors will continue to perform all functions related to Medicare fee-for-service claims processing and payment. ...

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Influenza, Are You Billing Correctly?

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With this year's Flu season being the most widespread on record, providers are seeing more patients and giving more immunizations for influenza than normal. Here are a few things to keep in mind during this flu season.  Know the rules with your payers to ensure proper reimbursement and correct billing. For example, did you ...

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Psychiatric Partial Hospitalization Programs

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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 ...

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NEW on Find-A-Code...National Coverage Determinations (NCDs)

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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. ...

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Medicare's Integrated Behavioral Healthcare Services and Collaborative Care Program

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Over the last several years, primary care has begun to integrate behavioral health services to better address shortfalls in patient quality of care. Some of the first codes were the Health and Behavior Assessment/Intervention (96152-96155) codes, which were added in 2002. Since then, many different models have been experimented with and have ...

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Preventative Services: Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)

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The following information from the Medicare Learning Network provides guidance on Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)

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New Payment Model launched by CMS- Bundled Payments for Care Improvement Advanced (BPCI Advanced).

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New MIPS Reporting Option for 2017 Data

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On January 2, 2018, CMS announced a new data submission system for eligible clinicians to report quality measures for the Quality Payment Program. Data may be submitted through the new platform on the qpp.cms.gov website. The announcement stated: Data can be submitted and updated any time from January 2, 2018 to March ...

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MIPS - To Participate or Not Participate - That is the Question

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Medicare’s Merit-based Incentive Payment System (MIPS) Final Rule increased the threshold for participation. With this increase, a significant number of providers fall into the exempt category and they are now breathing a sigh of relief. However, there’s one hidden tidbit which you may have missed - the potential damage to ...

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CMS Launches Data Submission System for Clinicians in the Quality Payment Program

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Today, the Centers for Medicare & Medicaid Services (CMS) announced that doctors and other eligible clinicians participating in the Quality Payment Program can begin submitting their 2017 performance data using a new system on the Quality Payment Program website (qpp.cms.gov). The data submission system is an improvement from the former...

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Filing a CMS-1500 Claim form to Medicare PUB-100 40.1.1.1

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An independent clinical laboratory may file a paper claim form shall file Form CMS-1500 for a referred laboratory service (as it would any laboratory service). The line item services must be submitted with a modifier 90. An independent clinical laboratory that submits claims in paper format) may not combine non-referred (i.e., ...

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Physical Therapist can now bill for a substitute Physical Therapist

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As of 6/13/2017 Medicare contractors shall accept claims from Physical Therapists, Provider Specialty 65 – Physical Therapist in Private Practice, for services provided by a substitute physical therapist under a fee-for-time compensation arrangement when submitted with the Q6 modifier. The A/B MAC Part B may pay the patient’s regular physician for physicians' ...

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Quality Payment Program in 2018

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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

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Telehealth Policies for Medicare and Commercial Payers

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What is RBRVS and How Can It Benefit Your Organization

What is RBRVS and How Can It Benefit Your Organization

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Mighty MACRA!

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