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Compliance Billing: Power Mobility Devices

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

In May of 2022, the OIG conducted a nationwide audit of Power Mobility Device (PMD) repairs for Medicare beneficiaries. The findings were not favorable; the audit revealed CMS paid 20% of durable medical suppliers incorrectly during the audit period of October 01, 2018- September 30, 2019. This was a total of $8 million in device repairs out of $40 million paid by CMS. We gathered information in this article to assist providers and suppliers in keeping the payments received, protecting beneficiaries, and assisting you in ensuring compliance.

2023 Evaluation & Management Updates Free Webinar

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Congratulations on a successful 2021 implementation of the Evaluation and Management (E/M) changes! That was a big change, but now an even bigger change is headed your way for inpatient and all other E/M categories. How great is it that almost all of the E/M categories will now be scored based on medical decision making (MDM) or total provider time? Standardized scoring and one set of E/M guidelines has the potential of bringing about a change or improvement of provider fatigue due to over regulation and documentation burden.

End-Stage Renal Disease Risk Model Updates for 2023

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

For the first time, ESRD Medicare beneficiaries were permitted to enroll in Medicare Advantage plans beginning in 2021. Since that time, CMS has been working to revise the program to reduce costs, improve quality, and drive benefits. Effective January 1, 2025, one such change will include a definition change for "oral-only drugs." Why is Medicare changing the definition of these drugs and how will that be a driving force in advancing care models for ESRD in the future?

Seven Major Changes Proposed by CMS in the 2023 Proposed Rule

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

As the COVID-19-related public health emergency (PHE) seems to be dying down, CMS publishes the 2023 Medicare Proposed Rule that outlines more than a dozen major changes to existing programs, including some that relate to telemedicine after the PHE is declared officially over. Of the many changes, seven (7) really stand out and make us think about how the end of the PHE may affect services such as telemedicine or new E/M encounter types.

Are You Prepared to Avoid Repayments

by  Raquel Shumway

Watchful care is needed when submitting claims. The Office of the Inspector General (OIG), after completing an audit on a Medicare Advantage Plan in August 2022, is now demanding repayment of claims to the tune of $3,518,465. Although the payer is contesting that amount, it is possible that they may begin demanding repayments from the providers to cover their costs of repayment.

CMS Publishes Over 1,000 New ICD-10-CM Codes Effective on October 1, 2022

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Each October 1st, the newest updates to ICD-10-CM take effect. This year with more than a thousand new codes added there is a lot of information to dig into and prepare our providers for. Many of the deleted and changed code descriptions, including the endeavor to capture social determinants of health, were made to enable expansion of specific coding categories so additional details could be reported, when captured in the documentation.

Billing and Coding: Bone Mass Measurement

by  Amanda Ballif

Guidance for billing, coding, and other guidelines in relation to local coverage policy L36460-Bone Mass Measurement.

Calendar Year 2023 Medicare Physician Fee Schedule Proposed Rule

by  Amanda Ballif

The Centers for Medicare and Medicaid Services (CMS) is soliciting public comments on proposed changes for Medicare payments under the Physician Fee Schedule (PFS) and other Medicare Part B issues effective on January 1, 2023 and thereafter. The Calendar Year (CY) 2023 PFS proposed rule is one of several proposed rules aimed at increasing equity in health care.

More Audits and More Problems

by  Ronald Hirsch, MD FACP CHCQM CHRI

More audits are coming, how do we stay compliant? We have been saying it but now it is happening. More audits are coming your way. One of the two CMS Recovery Audit Contractors seems to have taken on a business expansion plan. It appears they are contacting payers...

Making the Case for Clean Claims

by  Knicole C. Emanuel, Esq.

Medicare providers are your claims clean? Federal regulations mandate that 90 percent of “clean claims” must be paid to healthcare providers within 30 days. But what if the payor doesn’t pay within 30 days? What if your claims are unclean? The problem is – who determines what a...

$636 Million in Overpayments Made by Medicare to Providers for Neurostimulators

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

According to the OIG "MEDICARE OVERPAID MORE THAN $636 MILLION FOR NEUROSTIMULATOR IMPLANTATION SURGERIES." So often we think if we get paid, we must be doing it right, well this is not always the case. You may get paid and then have to return the funds if billed incorrectly or a step ...

Split/Shared Visits No Longer Specific to Medicare Plans in 2022

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Medicare is making changes to the reporting guidelines for split or shared services. Some important changes have already gone into effect as of January 1, 2022 and others are scheduled to go into effect in 2023. If your organization reports split or shared services, it’s time to look more closely at how the new rules will affect your compliance policies and reimbursement.

How Soon Will the United States Adopt ICD-11?

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

The ICD-11 diagnostic codeset went into effect worldwide on January 1, 2022 and has been adopted by some countries while others are still considering implementation, including the United States. The changes from ICD-9 to ICD-10 were significant but the change to ICD-11 will include the addition of new chapters, concepts, and symbols like the ampersand (&). Take a minute to familiarize yourself with this diagnostic coding  set. The goal is to  adopt a single version that has the flexibility to  accommodate future code revisions and additions. 

Understanding ASCs and APCs: Indicators and Place of Service

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

The decision regarding the most appropriate care setting for a given surgical procedure is determined by the physician based on the patient's individual clinical needs and preferences. Of course, there is a difference in reimbursement, and the billing depends on where the procedure took place, such as an office setting, inpatient ...

Is Your Organization Ready to Deal with Provider Relief Fund (PRF) Audit Contractors?

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Audits are currently underway to verify the monies distributed through the CARES Act were warranted and properly used by those organizations that received them. The federal government has contracted with financial institutions such as KPMG and PricewaterhouseCoopers, among others, to perform these audits referred to as Provider Relief Fund (PRF) audit contractors, funded with monies from the very same program. There were four phases of funding disbursements with phase 1 audits beginning in September. How ready are you to be audited?

Injection Services

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Injection Service Codes Injection service codes, are reported under administration of vaccines/toxoids, using 96372, 90460, 90461, 90471, 90472, 0001A, 0002A, 0003A, 0011A, 0012A, 0021A, 0022A, 0031A, 0041A, and 0042A. Other injections services include: Non-antineoplastic hormonal therapy injections – 96372 Anti-neoplastic nonhormonal injection therapy 96401 Anti-neoplastic hormonal injection therapy- 96402 Allergen immunotherapy - 95115-95117 According to CMS, do ...

Understanding How Place of Service Codes Work

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

The Place of service (POS) codes are used by CMS, Medicaid, and other private insurance to indicate where medically related items and services are sold or dispensed for a patient. POS codes are used for professional billing and are required to be reported on each claim submitted on a CMS-1500 ...

Compliance in the Dental Office or Small Practice

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

If your practice does not already have a compliance program in place, you will want to get started after reading this article. We have uncovered some important findings with the Office of Inspector General (OIG) in dental practices you need to be aware of. A compliance program offers standard procedures to follow, ...

Since When did Dental Claims Require Diagnosis Codes?

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

The objective of the Accountable Care organization is to integrate and consolidate patient care management to improve patient outcomes. Changes and coordination of dental and medical care are already becoming more apparent when dental offices are being required to bill a patient's medical plan for dental visits due to an ...

Cross-A-Code Instructions in Find-A-Code 

by  Raquel Shumway

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.
Subscribers will see related documentation, coding and billing tips. Access to this feature is available in the following products:
  • HCC Plus
  • Find-A-Code Professional
  • Find-A-Code Facility Base

Select the title to see a summary and a link to the full webinar information.  some webinars require a subscription to view.

What Claim Forms are Revealing 

by  Find-A-Code™

What Claim Forms are Revealing

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