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

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Ch. 1 Medicare Claims Processing Manual

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Noridian: Quick Reference Billing Guide

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Revised version is available, learn how to complete the forms and collect pmt.

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National Coverage Determinations

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2021 Medicare Physician Fee Schedule Updates - Do You Really Need to Worry?

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Delving Into the 360 Assessment Fraud Complaint

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The Department of Justice is pursuing claims of healthcare fraud against Cigna Health-Spring Medicare Advantage plan based on how they used data from their 360 Program in 2012. A review of the allegations may help other payers avoid similar accusations.

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CMS Expands Telehealth Again

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On October 14, 2020, CMS announced further changes to expand telehealth coverage. Eleven (11) new codes have been added to their list of covered services bringing the current total to 144 services. The new services include some neurostimulator analysis and programming services as well as some cardiac and pulmonary rehabilitation services.

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Stay out of Trouble — Understand the Qualified Medicare Beneficiary (QMB) Program

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To assist low-income Medicare beneficiaries, CMS created the Qualified Medicare Beneficiary (QMB) program; a Medicaid benefit which pays for Medicare deductibles, coinsurance, or copays for any Medicare-covered items and services for Medicare Part A, Part B, and Medicare Advantage (Part C). Providers/suppliers are prohibited from billing premiums and cost sharing to Medicare beneficiaries who are enrolled in QMB.

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New Value-Based Payment Models for Primary Care (Primary Care First and Direct Contracting)

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This article summarizes the new Medicare value-based payment models: Primary Care First and Direct Contracting.

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2021 Brings Another Risk Adjustment Calculation Change

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In 2021, a big change in Risk Adjustment score calculations will take place, which will affect payments to Medicare Advantage (MA) plans for the coming year and take us closer to quality and value-based programs instead of fee-for-service (FFS) or risk-adjusted (RA). Currently, CMS pays a per-enrollee capitated...

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Office of Inspector General Says Medicare Advantage Organizations are Denying Services Inappropriately

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We attended the recent virtual RISE National Conference and had the opportunity to listen to presenters share their knowledge about risk adjustment and HCC reporting and data validation. Among the presenters were representatives from the Office of Inspector General (OIG), who presented findings from encounter data from 2012-2016. They began ...

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Payment Adjustment Rules for Multiple Procedures and CCI Edits

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Surgical and medical services often include work that is required to be done prior to a procedure and post-procedure. When there are multiple procedures done by the same physician, group, or another qualified healthcare professional on the same day, the pre and post work is only required once. Therefore, CMS ...

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Are Diagnoses from Telehealth Services Eligible for Risk Adjustment?

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On April 10th, CMS released a memo with the subject line, “Applicability of diagnoses from telehealth services for risk adjustment,” suggesting there may be some telehealth services that might not qualify for risk adjustment. However, in the memo CMS states: “Diagnoses resulting from telehealth services can meet the risk adjustment face-to-face ...

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Additional Telehealth Changes Announced by CMS

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On April 30, 2020, CMS announced additional sweeping changes to meet the challenges of providing adequate healthcare during this pandemic. These changes expand the March 31st changes. The article covers some of the key changes. See the official announcement in the references below.

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SOME of Us Non-Essentials May be Able to Get Back on the Road!

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The day is coming when the freeways will have 5:00 pm stop-and-go traffic again, no doubt. However, when it comes to re-opening our world, CMS has Recommendations! Changes are finally here; we are starting to see a decline in COVID-19 cases in some states and certain locations. It may be time ...

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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 Important Information on COVID-19 Released

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CMS has recently released some important information on their last MLN, the highlights are below. COVID-19: Dear Clinician Letter CMS posted a letter to clinicians that outlines a summary of actions CMS has taken to ensure clinicians have maximum flexibility to reduce unnecessary barriers to providing patient care during the unprecedented outbreak ...

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CMS Announces Final 2021 HCC Risk Adjustment Changes

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On April 6, 2020, the Centers for Medicare & Medicaid Services (CMS) published their final Medicare Advantage (MA) and Part D payment methodologies for CY 2021. Read more to be prepared for these upcoming changes.

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2020 Medicare Part D Coverage Gap (AKA donut hole)

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Not every Medicare drug plan has complete coverage for prescription drugs - most have some sort of coverage gap, known as the “Donut Hole”. The coverage gap is a temporary limit on coverage under the drug plan. This coverage gap will not affect everyone and begins after you have used ...

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Medicare Part D Coverage Gap (Donut Hole) Closes in 2020

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Overview of the Part D coverage gap, how it got closed, what the picture looks like for 2020, and long-term outlook.

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Medicare Begins Covering Acupuncture Services

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Medicare is changing their policy regarding coverage of acupuncture, but in order to provide these services, you must follow their rules.

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Medicare Announces Coverage of Acupuncture Services

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On January 21, 2020, a CMS Newsroom press-release read, This new announcement is both exciting and refreshing. Acupuncture, a key component of traditional Chinese medicine and most commonly used to treat pain, is now being officially recognized by Medicare and several other large payers as a covered, alternative treatment option for ...

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Denials due to MUE Usage - This May be Why!

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CMS assigns Medically Unlikely Edits (MUE's) for HCPCS/CPT codes, although not every code has an MUE. MUE edits are used to limit tests and treatments provided to a Medicare patient for a single date of service or for a single line item on a claim form. It is important to understand MUE's are ...

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CMS Report on QPP Shows Increasing Involvement

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MIPS 2018 participation increased according to the final report issued by CMS on January 6, 2020.

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Proving Medical Necessity and Functional Improvement

Medicare is required by law to pay for care that is medically necessary. Medicare considers functional improvement to be the primary indicator of medical necessity for chiropractic care. It is up to you, the doctor, to prove functional improvement and medical necessity with your documentation. Dr. Short will show you how to use common practice tools to document functional improvement, medical necessity and maximum medical improvement.

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Expanding Chiropractic Coverage in Medicare

Currently Medicare only pays for the adjustment and then only when it is used to correct a subluxation. This injustice within the Social Security Act needs corrected. Dr. Ron Short will discuss the Medicare laws as they relate to chiropractic and what changes need to be made and why. ...

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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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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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1995 E/M Guidelines1997 E/M GuidelinesABN- Medicare Advance Written Notices of Noncoverage (October 2018)Accountable Care Organizations (ACO) - by CMSAdvance Beneficiary Notice of Noncoverage (ABN) by MedLearnAdvanced Beneficiary Notice of Noncoverage (ABN) Form Instructions ToolAllergy Testing and Allergy Immunotherapy LCDL30471Annual Wellness Visit (AWV) by CMSASC Payment RulesAvoiding Medicare and Medicaid Fraud and Abuse; A Roadmap for PhysiciansBehavioral Health Provider TypesBilateral Surgeries: Claim SubmissionCare Plan Oversight (CPO) services information by CGS MedicareCenters for Medicare & Medicaid Services Patient-Driven Groupings ModelCLFSClinical Review Judgment Change Request 6954 by CMSCMS Complying with Medicare Signature Requirements Fact SheetCMS Implementation Guide for Quality Reporting Document Architecture Category I and Category IIICMS Meaningful Use Registration and Attestation WebsiteCMS Medicare Fee for Service Recovery Audit ProgramCMS Noridian - Active LCDsCMS Physician Fee Schedule Look-UpCMS Preventive Services Educational ToolCMS Recovery Audit Program - Center for Medicare & Medicaid ServicesCMS Report: "CMS Should Use Targted Tactics to Curb Questionable and Inappropriate Payments for Chiropractic ServicesCMS-Novitas Solutions: E/M Documentation Auditor's InstructionsCMS-Novitas Solutions: Specialty Exam: CardiovascularCMS-Novitas Solutions: Specialty Exam: DermatologyCMS-Novitas Solutions: Specialty Exam: Ears, Nose and ThroatCMS-Novitas Solutions: Specialty Exam: EyesCMS-Novitas Solutions: Specialty Exam: Genitourinary (Female)CMS-Novitas Solutions: Specialty Exam: Genitourinary (Male)CMS-Novitas Solutions: Specialty Exam: MusculoskeletalCMS-Novitas Solutions: Specialty Exam: NeurologyCMS-Novitas Solutions: Specialty Exam: RespiratoryCMS/Medicare Podiatry ServicesCMS: Telehealth Services MLN BookletCMS: Value Based Modifier (VBM)Continued Use of Modifier 59 after Jan 1, 2015Details about EHR Incentive ProgramDurable Medical Equipment (DME) Medicare Administrative Contractor (MAC) JurisdictionsDurable Medical Equipment Center (DME) - by CMSeHealth Initiative websiteEHR Program Timeline by CMSElectronic Prescribing (eRx) Incentive Program - by CMSElectronic Prescribing (eRx) Incentive Program: Payment AdjustmentExclusion 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 AMAHospice Medicare Billing Codes Sheet by CGS MedicareHospital - Acquired Conditions (HACs)How to use the Medicare National Correct Coding Initiative (NCCI) Tools by MLNInitial Preventive Physical Examination (IPPE)Is your Office Listed on the PECOS Listing?kidneyfund.org Anemia In Chronic Kidney Disease InformationLimiting Charge Information by CMSLink 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 RightsLocal Coverage Determination (LCD): Chiropractic Services (L34009)Local Coverage Determinations (LCDs) by Contractor IndexMaintenance of Certification Program (MOC)Measure-Applicability Validation (MAV) CourseMedicare 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 7 - SNF Part B BillingMedicare 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 and Payment of Virtual ServicesMedicare Coverage for Skilled NursingMedicare Documentation Job Aid for Doctors of Chiropractic — MLNMedicare Enrollment and Claim Submission GuidelinesMediCare Enrollment Appication CMS-855BMEDICARE ENROLLMENT APPLICATION Institutional Providers CMS-855AMedicare Learning Network - Chiropractic ServicesMedicare Manual - Chapter 5 – Items and Services Having Special DME Review ConsiderationsMedicare Medical Savings Account (MSA) Plans - by CMSMedicare Mental Health Services booklet by CMSMedicare OverpaymentsMedicare Part A for Skilled NursingMedicare Provider Enrollment Application InformationMedicare Provider-Supplier Enrollment - by CMSMedicare Reconsideration RequestMedicare Recovery Audit by HHS Office of the Inspector GeneralMedicare 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?Medicare’s Vision Services Fact SheetMisinformation about Chiropractic Services - by Medicare Learning NetworkMLN ConnectsMLN Matters Number: MM3927MLN Matters: Cataract Removal with Medicare Part BMLN Matters: MPPR on the TC of Diagnostic Cardiovascular and Ophthalmology ProceduresMLN Matters: Presbyopia-Correcting Intraocular LensesMLN: Medicare Vision Services Fact SheetModifier 50 UsageNational Medicaid Audit Program fact sheet - by CMSNCCI Instructions for Modifier 59Noridian Documentation ChecklistsNoridian: Ambulance ResourcesNovitas - Specialty Exam Score SheetsNPI RegistryOffice of Inspector General: Questionable Billing for Medicare Ophthalmology Services 2012Online Research ToolsOpting out of Medicare and/or Electing to Order and Refer Services - MedLearn articleOverview of Mandatory Complinace ProgramPalmetto GBAParticipating vs. Non-Participating (Medicare Part B Claims)PECOSPhysician Payment WebsitePQRS Analysis and Payment by CMSPress release: New CMS rule allows flexibility in certified EHR technology for 2014Q&A on Skilled Nursing Facility Consolidated BillingQuality Care ManagementQuality Measures for MIPS by CMSQuality Payment ProgramQuality Payment Program Fact Sheet by CMSReminder to Stop Billing Duplicate Claims by Medicare Learning NetworkScreening Pap Tests and Pelvic Examinations by CMSSkilled 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 BTimely Claims Filing: Additional Instructions - MedLearn Article by CMSUseful Medicare siteWPS Medicare how do they price Non-ASP New drugs and NOC Drugs?Your Guide to Who Pays First - by CMS


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Risk Factor Scoring using the Encounter Data Processing System (EDPS)

Risk Adjustment Coding and the New Blended RAPS with Encounter Data changes for 2020 and 2021. CMS has made it clear they wish to change from the long-standing Fee-For-Service (FFS) reimbursement model to one that can motivate providers to carefully assess the health of each individual Medicare beneficiary and by accessing ...

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Medicare now covers acupuncture. Wha?!

Did you know acupuncture services are now payable by Medicare?  In the face of the current opioid crisis, acupuncture, an age-old Chinese Medicine tool has recently been approved by Medicare as a covered benefit to address chronic low back pain (cLBP). But who does Medicare consider able to perform acupuncture ...

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