Compliance Articles and Resources

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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.

CMS Updates COVID Vaccine Requirements for Staff

by  Wyn Staheli, Director of Content - innoviHealth

CMS is revising its guidance and survey procedures for all provider types related to assessing and maintaining compliance with the staff vaccination regulatory requirements. This new memorandum replaces memoranda QSO 22-07-ALL Revised, QSO 22-09-ALL Revised, and QSO 22-11-ALL Revised.

Four Ways Your Organization Can Benefit from Gathering and Reporting Social Determinants of Health Data

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

Providers who actively engage in collecting and reporting social determinants of health (SDoH) open avenues of identifying and treating their patients' population health trends. Pairing chronic conditions that are difficult to control with identified SDoH circumstances such as transportation or electricity insecurity, can help identify those patients who may wish to be healthier, but who are dealing with circumstances that prevent compliance, such as transportation or access to electricity, for instance.

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 Encourages Medicaid MCOs and CHIP to Employ Section Waivers to Improve SDoH and Reduce Healthcare Costs

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

Over the past few years, at least 15 states have consistently pursued the goal of using social determinants of health (SDOH) in their overall healthcare analysis and treatment programs for patients, and CMS has taken notice. Data and outcomes obtained from these state programs have essentially provided an outline of how the government intends to pursue health equity through managed care contracts (MCOs) and Children's Health Insurance Program (CHIP). What is CMS seeing that they like so much and how might that affect future MCO contracts?

How CMS Determines Which Telehealth Services are Risk Adjustable

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

Medicare Advantage Organizations (MAOs) have gone back and forth on whether or not to use data collected from telehealth, virtual Care, and telephone (audio-only) encounters with Medicare beneficiaries for risk adjustment reporting, but the following published documents from CMS cleared that up once and for all by providing an answer to a question specifically related to this question.

Before Requesting a Review on Modifiers, Read This!

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Generally, there is uniformity in the use of modifiers between payers. However, this is not always the case; you may see a difference in payer policies and how modifiers are handled. One way to know if a modifier can be used according to CMS rules can be found when using ...

CMS Started to Enforce Applicable Price Transparency Requirements

by  Amanda Ballif

Beginning July 1, 2022, CMS started to enforce applicable price transparency requirements because of the Trump Administration's historic price transparency requirement in 2019 to increase competition and lower healthcare costs for all Americans.

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.

Medicare Advantage and Part D Advance Notice Addresses Health Equity Initiatives Slated for 2023

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

The current Administration constantly talks about health equity initiatives but what exactly does that mean for our providers and medical practices? Centers for Medicare and Medicaid Services (CMS) has published the 2023 Medicare Advantage and Part D Advance Noticed with significant focus on their definition of health equity and what is means to promote it within our individual practices and among health payer plans.

The Beginning of the End of COVID-19-Related Emergency Blanket Waivers

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

It appears that the end of the 1135 waivers related to the COVID-19 public health emergency (PHE) has begun. According to CMS, the residents of skilled nursing facilities, long-term care facilities, and inpatient hospice centers have struggled due to the effects of some of the 1135 waivers. CMS is focusing primarily on removing the 1135 blanket waivers that pertain to certain aspects of care, training, and maintenance of these facilities to ensure the weakest of our citizens are guaranteed adequate care.

New Audio-Only Telehealth Guidance to Meet HIPAA Rules

by  U.S. Department of Health & Human Services

Covered entities (healthcare providers and health plans) can use remote communications, called telehealth, to provide services to patients as long as they follow certain guidelines. Because certain populations may have difficulty using audio-video telehealth, HHS is now issuing this guidance on audio-only telehealth. This guidance will help ensure that individuals can continue to benefit from audio-only telehealth by clarifying how covered entities can provide telehealth services and improve public confidence that covered entities are protecting the privacy and security of patients' health information.

Sometimes it's the Little Coding Conundrums That Keep Us Concerned

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

We all experience coding situations that make us stop and rethink our coding path. Do we have the most current information on this situation? Does the payer contract change the way we must report the service? Are we missing something? Each of us experience simple to complex coding issues in our work and sometimes it is just nice to collaborate and discuss them openly to see how they may be resolved. Have you ever questioned the proper use of major depressive disorder codes versus the newly added (2021) depression, unspecified code? Take a look at what the OIG said about these codes and how the payer responded.

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...

2022-06-16-MLNC - ICD-10-CM Diagnosis Codes: Fiscal Year 2023

by  CMS - MLNConnects

News - Comprehensive Error Rate Testing Program Report: Sample Reduced for Reporting Year 2023 - Men’s Health: Talk to Your Patients About Preventive Services - Compliance - Implanted Spinal Neurostimulators: Document Medical Records - Claims, Pricers, & Codes - ICD-10-CM Diagnosis Codes: Fiscal...

2022-05-26-MLNC - Biosimilars: Interchangeable Products May Increase Patient Access

by  CMS - MLNConnects

News - COVID-19: New Administration Code for Pfizer Pediatric Vaccine Booster Dose - - Biosimilars: Interchangeable Products May Increase Patient Access - - Critical Care Evaluation & Management Services: Comparative Billing Report in May - -...

Using Health IT to Support Safer Use and Management of Controlled Substance Prescriptions

by  Chelsea Richwine  and  Christian Johnson

New ONC data show that, as of 2021, nearly all non-federal acute care hospitals were enabled to electronically prescribe controlled substances (EPCS). According to the American Hospital Association (AHA) Information Technology (IT) Supplement Survey, the proportion of non-federal acute care hospitals enabled for EPCS increased from 67% in...

Medicare Improper Payment Report (2021)

by  Raquel Shumway

The Medicare Improper Payment Report does not measure fraud, but 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 July 1, 2019 through June 30, 2020, was 93.74%, which is up slightly from last year. The estimated improper payment rate (claims paid incorrectly) was . . .

Preventive Services

by  Shannon O. DeConda, CPC CPC-I CEMC CEMA CPMA CRTT

In Today’s Take, let’s discuss the difference between preventive care. You might be thinking this is “101”. But it really isn’t. Oftentimes, when conducting chart audits, we not only we see issues with a lack of documentation criteria, especially with Medicare preventive services, but we also see confusion regarding...
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Exclusions: What They Mean to You 

by  Ron Short, DC MCS-P CPC

Do Minor Procedures Feel like Major Work? 

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

What do Chiropractors Need to do to Comply with the No Surprises Act? 

by  Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow

Does a Self-Care Rx Effect Medical Reimbursement and How? 

by  Tom Grant DC, Med-Legal Consultant, Pragma Intel Director of Education

This is the easiest of therapies to initiate and it adds great medical value. Most DC's do not prescribe/proscribe self-care instructions. Self-care Rx's have defined timelines for implementation and updates. Done incorrectly, self-care Rx's damage medical value and decrease reimbursements.

HIPAA Has New Requirements (New as of 2013-11-07) 

by  Wyn Staheli, Director of Content - innoviHealth

HIPAA Has New Requirements ...

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