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Medicare Articles & Resources

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And Then There Were Fees...

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Find-A-Code offers fees and pricing for just about everything, this article will address two of some of the most common payment systems with CMS. (OPPS) -Outpatient Medicare Outpatient Prospective Payment System. (MPFS)- Medicare Physician Fee Schedule The Fees section on each code page is determined on the type of services...

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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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CMS and HHS Tighten Enrollment Rules and Increase Penalties

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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 ...

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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 OIG Work Plan: What Is It and Why Should I Care?

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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 ...

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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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Q/A: What do I Need to Document for Periodic Adjustments on a Medicare Patient?

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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 ...

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Act Now on CMS Proposal to Cover Acupuncture for Chronic Low Back Pain

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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.

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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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What is Medical Necessity and How Does Documentation Support It?

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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 ...

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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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The Impact of Medical Necessity on High Level E/M Services

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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. ...

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Revised ABN Requirements Still Fuzzy

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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 ...

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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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Understanding NCCI Edits

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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 ...

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Medicare Supplemental Policies (MediGap) and Extremity Adjustments

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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 ...

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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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How to Report Co-Surgeons Using Modifier 62

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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 ...

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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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Reciprocal Billing and Locum Tenens Arrangements Changes

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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.

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Are you Ready for CMS' 2019 Medicare Physician Fee Schedule Final Rule?

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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 ...

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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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PSAVE Pilot Program - What Does it Mean to You?

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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?

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Medicare Timed Codes Guidelines

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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 ...

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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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Q/A: Is it Legal to Shred Archived Patient Records After a Certain Amount of Time?

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Shredding patient records. When is it appropriate? Read more to find out.

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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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Medicare Claim Submission Exceptions

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There are several exceptions to the Medicare "Mandatory Claim Submission Rule." What are they?

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Q/A: Can a PT Assistant Perform Physical Therapy Modalities?

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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.

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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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Will Medicare's Proposed Reformations Affect Your Practice?

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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 ...

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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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Q/A: Am I Supposed to List the Frequency and Duration on the ABN?

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How to fill out Box D (Services) on the ABN form. What information is required?

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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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Documenting DMEs

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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 ...

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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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Indications for Serotypes A and B Botulinum Toxins

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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 ...

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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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OIG Reviews Medicare Advantage Claims

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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; ...

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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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Medicare Requiring Specific Modifiers on Therapy Services

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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 ...

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Billing with a GP Modifier

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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?

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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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Select the webinar title to view a summary and link to the webinar video.

November 5, 2019: Proving Medical Necessity and Functional Improvement

Topic and description coming soon!

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September 10, 2019 — Inappropriate Payments Made to Chiropractors – An OIG Review

In this webinar, Dr. Gwilliam will take you on a fun filled journey through all of the reports created by the Office of the Inspector General based on their reviews of chiropractors. If you can understand what they see, and what advice they give Medicare when dealing with chiropractors, then you will be better prepared to not become their next target. This webinar may feel a little frightening with hundreds of thousands of dollars paid back to CMS, but, by the end, you will know exactly what to do and what not to do.

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July 9th, 2019: Expanding Chiropractic Coverage in Medicare

Presented by Ron Short DC, MCS-P, CPC July 9th, 2019 Tuesday @ 10:15 AM PT, 11:15 AM MT, 12:15 PM CT, 1:15 PM ET Register here: https://register.gotowebinar.com/register/2199887868052877059 ...

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Telehealth Policies for Medicare and Commercial Payers

Telehealth Policies for Medicare and Commercial Payers

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Chiropractic Manipulative Treatment and Medicare - Part 2

In this CE webinar, Dr. Gwilliam will continue his discussion from the webinar delivered Dec. 18 about chiropractic manipulative treatment. But this time, it is all about Medicare. If you don't treat Medicare beneficiaries, you should probably listen anyway. Usually whatever Medicare wants is the same thing as all the other payers. Find out the difference between acute, chronic, and maintenance, as well as when to use certain modifiers.

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Medicare Reviews

Medicare continues to increase their efforts to review doctors and recover “overpayments”. This increases the likelihood that your notes will be reviewed and that you will be required to pay money back to Medicare. In this webinar Dr. Short will show you:  Why you should appeal every adverse decision.  How to appeal adverse decisions.  What information you need in your documentation for an effective appeal.  How to structure your appeals to be most effective.

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How to Create a Medicare Compliance Plan

In this webinar, Dr. Marty Kotlar (certified coding and compliance expert) will discuss how to create an OIG/Medicare compliance plan. He will explain how to create policies, how to perform a "self-test" on your SOAP notes, search the Medicare exclusions list, Stark, anti-kickback and how to handle compliance concerns.

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Medicare Reviews

Medicare reviews claims for a variety of reasons. Some are routine and are not a problem for the doctor or the practice. Some are investigatory in nature and indicate a serious potential threat for both the doctor and the practice. Dr. Ron Short will go over the types of reviews and which are routine and which should cause you to lose sleep. In this webinar you will learn: -What routine reviews are and why they are conducted -What reviews are a potential risk -What triggers reviews -When to get help and what kind of help to get

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Coding and Auditing Wound Care

In this webinar, Aimee will review wound care coding and auditing information for wound care services, including proper modifier use, NCCI edits, Medicare coverage guidelines, and documentation requirements.

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Risky Business

This presentation will review how risk management is no longer limited to just malpractice claims. It also includes your financial policy. There is now a greater risk of financial loss due to improper discounting and faulty financial and collection policies than ever before. It is widely known that the Office of Inspector General (OIG) and Medicare are cracking down on healthcare fraud and abuse, but what most chiropractors are unaware of, is how widely successful these efforts have been. In this presentation, we will identify the five most dangerous things we face in chiropractic and how to avoid them. All attendees will receive a free sample 1-page financial policy that can be customized for their practice and a link to receive a free risk assessment score for their practice.

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The ABN 2018

The Advanced Beneficiary Notice of Non-coverage is one of the most important Medicare forms that you can use in your office because it protects your right to be paid. Dr. Ron Short will show you how, when and why to use the ABN and how to properly complete the form.

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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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1995 E/M Guidelines1997 E/M GuidelinesAccountable Care Organizations (ACO) - by CMSAdvanced Beneficiary Notice of Noncoverage (ABN) Form Instructions ToolCare Plan Oversight (CPO) services information by CGS MedicareCMS Complying with Medicare Signature Requirements Fact SheetCMS Physician Fee Schedule Look-UpCMS Recovery Audit Program - Center for Medicare & Medicaid ServicesCMS Report: "CMS Should Use Targted Tactics to Curb Questionable and Inappropriate Payments for Chiropractic ServicesCMS/Medicare Podiatry ServicesCMS: Value Based Modifier (VBM)Details about EHR Incentive ProgramDurable Medical Equipment (DME) Medicare Administrative Contractor (MAC) JurisdictionsDurable Medical Equipment Center (DME) - by CMSeHealth Initiative websiteElectronic Prescribing (eRx) Incentive Program - by CMSExclusion ListFAQ on the use of the AT and GA modifiers togetherFeedback Report Requests PortalFurther Details on the Revalidation of Provider Enrollment Information by CMSHCC Risk Calculator by Find-A-CodeHIPAA: Health Insurance Portability and Accountability Act by AMAHow to use the Medicare National Correct Coding Initiative (NCCI) Tools by MLNIs your Office Listed on the PECOS Listing?kidneyfund.org Anemia In Chronic Kidney Disease InformationLink to CMS Form - Request For Medicare Hearing by an Administrative Law JudgeLink to CMS Form - Third Level of Appeal: Hearing by an Administrative Law Judge FormsLink to CMS Form - Transfer of Appeal RightsMaintenance of Certification Program (MOC)Medicare Advantage Plans: Cost Sharing LimitsMedicare and Medicaid Programs; Modifications to the Medicare and Medicaid Electronic Health Record (EHR) Incentive Program for 2014 and Other Changes to the EHR Incentive Program; and Health InformatMedicare Appeals - by CMSMedicare as Secondary PayerMedicare Benefit Policy Manual, Chapter 15 (also known as Medicare Carriers Manual)Medicare Claims Processing Manual - Chapter 25Medicare Claims Processing Manual, Chapter 12Medicare Claims Processing Manual, Chapter 29 - Appeals of Claims DecisionsMedicare Claims Processing Manual, Chapter 9 - Rural Health Clinics/Federally Qualified Health CentersMedicare Compliance Manual 2018Medicare Coverage for Skilled NursingMedicare Medical Savings Account (MSA) Plans - by CMSMedicare Part A for Skilled NursingMedicare Provider Enrollment Application InformationMedicare Provider-Supplier Enrollment - by CMSMedicare Reconsideration RequestMedicare Redetermination RequestMedicare Removes SSN from Medicare Cards - Press ReleaseMedicare Secondary Payer fact sheet by CMSMedicare Shared Savings Program (MSSP) Requiremenst for ACOs - by ACAMedicare Topics PageMedicare Topics Page - ChiropracticMedicare, Overpayments, FraudMedicare: To Participate or Not to Participate?Misinformation about Chiropractic Services - by Medicare Learning NetworkMLN ConnectsNCCI Instructions for Modifier 59NPI RegistryOpting out of Medicare and/or Electing to Order and Refer Services - MedLearn articleParticipating vs. Non-Participating (Medicare Part B Claims)Press release: New CMS rule allows flexibility in certified EHR technology for 2014Q&A on Skilled Nursing Facility Consolidated BillingQuality Payment ProgramReminder to Stop Billing Duplicate Claims by Medicare Learning NetworkSkilled Nursing Facility Best Practice GuidelinesSkilled Nursing Facility Consolidated BillingSkilled Nursing Facility Education and TrainingSpecial Advisory Bulletin, Offering Gifts and Other Inducements (2002) - by the Office of the Inspector General (OIG)Special Advisory Opinion 12-21 , Offering Gifts and Other Inducements (2013)- by the Office of the Inspector General (OIG)Summary of 2015 Physician Value-based Payment Modifier PoliciesThe CMS eHealth InitiativeThe Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.1 BYour Guide to Who Pays First - by CMS


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