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Medicare Articles & Resources
News and Important Information
Medicare Revises Their Appeals Process
Clearing Up Some Medicare Participation Misunderstandings
Additional Guidelines & Resources:
- Medicare Jurisdiction Links by State
- Internet-Only Manuals (IOMs)
- Clinical Laboratory Improvement Amendments (CLIA)
- Advance Beneficiary Notice of Non-Coverage (ABN)
Related Topics:
- Medicare as Secondary Payer (MSP)
- Medicare Appeals
- Quality Payment Program (MIPS)
Resources
General Links and Resources
CMS Noridian - Active LCDsHospital Outpatient Regulations and NoticesMedicare Enrollment - PECOS- Medicare Provider Enrollment, Chain, and Ownership SystemMedicare Provider/Supplier to Healthcare Provider TaxonomyThe Medicare Learning Network® - Free educational materials for health care professionals on CMS programs, policies, and initiatives.General Billing Requirements - Ch. 1 Medicare Claims Processing ManualNoridian: Quick Reference Billing Guideedicare Advance Written Notices of Noncoverage - Revised version is available, learn how to complete the forms and collect pmt.Standard Written Order (SWO) - Dates of Service on or After January 1, 2020
Find-A-Code Tools and Resources
Select the title to see a summary and a link to the full article. some articles require a subscription to view.
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Updated Article - REMINDER! This is important news for durable medical suppliers! Effective January 1, 2023, CMS is discontinuing the use of Certificates of Medical Necessity (CMNs) and DME information forms (DIFs). We knew this was coming as the MLN sent out an article on May 23, 2022, but it is time to make sure your staff knows about these changes.
Oct 31st, 2022
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.
Aug 18th, 2022
CMS says Less Paperwork for DME Suppliers after Jan 2023!
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
This is important news for durable medical suppliers! Effective January 1, 2023, CMS is discontinuing the use of Certificates of Medical Necessity (CMNs) and DME information forms (DIFs). We knew this was coming as the MLN sent out an article on May 23, 2022, but it is time to make sure your staff knows about these changes.
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?
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Have you had a chance to review the new ICD-10-CM codes for FY 2022? Did you know that many payers do not want to see unspecified codes when there is a possibility for better data? How adept are you at assigning and sequencing COVID-19 codes? Take a minute to review 5 of the major changes to the FY2022 ICD-10-CM code updates and claim your chance to watch our most recent webinar where we review the newest code updates.
Sep 29th, 2021
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 ...
Jul 29th, 2021
Medicare's ABN Booklet Revised
by Wyn Staheli, Director of Content - innoviHealth
The “Medicare Advance Written Notices of Non-coverage” booklet, published by CMS’s Medicare Learning Network, was updated. This article discusses the changes to this booklet regarding the use of the ABN.
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
As the OIG has published their intent to further investigate the 9.5% of improper payments based on incorrect ICD-10-CM code assignation, they implore Managed Care Organizations (MCOs) to begin employing some of the CMS tools and data analytic programs used to help identify outliers.
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Between June 2019 and June 2020, the United States saw a total of 107,750 deaths from COVID-19. The spread of this virus was so extraordinary that it led President Trump to declare a public health emergency, and we watched as individual states began implementing laws and regulations to limit social interaction ...
by Jared Staheli, MPP
When Congress passed the expansive American Rescue Plan Act last month, most Americans were focused on the direct payment provision of the bill. However healthcare administrators and policymakers had their attention on another aspect: cuts to Medicare payments. Why would Congress be cutting Medicare payments during the COVID-19 Public Health ...
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Question: I am in an ENT office as part of a large clinic with separate practices including audiology, CT, and allergy, all billing under the same TAX ID. Sometimes tests are ordered which are done in other departments that my office does not bill for, would those be considered an outside source?
Answer: This is a great question and one that has been asked by many coders and auditors.
Mar 18th, 2021
How Reporting E/M Based on Time May Lose Money
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Just like math teachers who require students to show their work so they can see how the student reached their answer, providers are also required to "show their work" through the documentation process in the medical record. By the time a provider has reviewed the patient's subjective complaints (i.e., patient's ...
by Jared Staheli, MPP
The Office of Inspector General for the United States Department of Health and Human Services (HHS-OIG) is responsible for ensuring the integrity of programs operated by HHS, including the Medicare and Medicaid programs. One of the ways this is accomplished is through the identification of fraudulent activities, one of which ...
Oct 20th, 2020
CMS Expands Telehealth Again
by Wyn Staheli, Director of Content - innoviHealth
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.
by Wyn Staheli, Director of Content - innoviHealth
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.
by Jared Staheli, MPP
This article summarizes the new Medicare value-based payment models: Primary Care First and Direct Contracting.
Aug 24th, 2020
2021 Brings Another Risk Adjustment Calculation Change
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
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...
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
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 ...
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
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 ...
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
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 ...
May 4th, 2020
Additional Telehealth Changes Announced by CMS
by Wyn Staheli, Director of Content - innoviHealth
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.
Apr 20th, 2020
Dismal OIG Report on Telemedicine
by Wyn Staheli, Director of Content - innoviHealth
Providers need to understand the rules for reporting telemedicine services. A recent OIG report shows that this is not the case. What problems are being found in documentation claims? As providers are expanding their telehealth offerings, now is the time to understand the potential pitfalls since disallowed amounts will be taken back.
Apr 20th, 2020
Now That is Fraud! Genetic Testing "Public alert"
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
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 ...
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
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 ...
Apr 15th, 2020
CMS Temporarily Suspends Contract-Level RADV Audits
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
The Centers for Medicare and Medicaid Services (CMS) is suspending contract-level RADV audits, related to the payment year 2015 and will not initiate any new ones until after the public health emergency has ended. Any documentation already submitted will be reviewed as usual.
Apr 15th, 2020
New CPT® Codes Approved for COVID-19 Antibody Identification
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
On April 10, 2020, the American Medical Association approved and published a revision of code 86318 and added two new codes 86328 and 86769 for reporting Coronavirus [COVID-19] antibody testing.
Apr 13th, 2020
CMS Announces Final 2021 HCC Risk Adjustment Changes
by Wyn Staheli, Director of Content - innoviHealth
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.
Apr 13th, 2020
CMS Important Information on COVID-19 Released
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
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 ...
Mar 26th, 2020
2020 Medicare Part D Coverage Gap (AKA donut hole)
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
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 ...
Mar 26th, 2020
Medicare Part D Coverage Gap (Donut Hole) Closes in 2020
by Jared Staheli, MPP
Overview of the Part D coverage gap, how it got closed, what the picture looks like for 2020, and long-term outlook.
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Do you still find yourself searching the internet for an ICD10 code? Medical coders often type into their search engine, what is the ICD10 code for ... and a specific diagnosis code, to avoid repeatedly dragging out the incredibly large ICD10 codebook. Ironically, some of the most commonly searched ICD10 diagnoses include: ...
by Aubrie Rowley
The current coronavirus pandemic refers to COVID-19, a novel or new type of coronavirus known as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The first victim of the virus was identified in Wuhan, Hubei, China at the end of 2019. There is no immunization available to prevent it from spreading and ...
Feb 19th, 2020
Medicare Begins Covering Acupuncture Services
by Wyn Staheli, Director of Content - innoviHealth
Medicare is changing their policy regarding coverage of acupuncture, but in order to provide these services, you must follow their rules.
Feb 10th, 2020
A 2020 Radiology Coding Change You Need To Know
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
The radiology section of the 2020 CPT© has 1 new, 18 revised, and 14 deleted codes. Interestingly, six of the 14 deleted codes were specific to reporting single-photon computerized tomographic (SPECT) imaging services of the brain, heart, liver, bladder, and others. If your organization reports radiology services, it is...
Jan 30th, 2020
Medicare Announces Coverage of Acupuncture Services
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
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 ...
Jan 7th, 2020
Denials due to MUE Usage - This May be Why!
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
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 ...
Jan 6th, 2020
CMS Report on QPP Shows Increasing Involvement
by Wyn Staheli, Director of Content - innoviHealth
MIPS 2018 participation increased according to the final report issued by CMS on January 6, 2020.
Dec 23rd, 2019
Time Is Up! Jan 1 2020 Claims Will be Denied Without MBIs
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
New Medicare Card Transition Ends Next Week: Claim Reject Codes Beginning January 1
If you want to get paid you should be reporting MBIs on all of your Medicare claims. The deadline is here: if you are not using Medicare Beneficiary Identifiers (MBIs) on claims (with a few exceptions) after January 1, ...
Dec 19th, 2019
CMS- Patient Driven Payment Model Effective October 01, 2019
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
According to CMS, In July 2018, CMS finalized a new case-mix classification model, the Patient-Driven Payment Model (PDPM), that, effective beginning October 1, 2019, will be used under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) for classifying SNF patients in a covered Part A stay.
Using the new Patient-Driven ...
Dec 9th, 2019
CMS says Codes are on the Move!
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
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 ...
Dec 3rd, 2019
Q/A: Can I Order a TENS unit for a Medicare Patient?
by Wyn Staheli, Director of Content - innoviHealth
Question
Can a chiropractor order a TENS unit for a Medicare patient? We cannot order X-rays for a Medicare patient so I assume we cannot order a TENS unit either.
Answer
It’s not that you can’t order the TENS unit, it’s just that when it comes to doctors of chiropractic, Medicare only covers ...
Nov 11th, 2019
And Then There Were Fees...
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
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...
Oct 21st, 2019
VA- Reasonable Charges Rules, Notices, & Federal Register
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Oct 11th, 2019
Why is HIPAA So Important?
by NAMAS
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 ...
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Atrial fibrillation (AF) is the most common type of abnormal heart rhythm (arrhythmia). It is caused by a disorder in the heart’s electrical system. AF is the result of abnormal contractions of the atria (upper two chambers of the heart) causing them to quiver and beat out of sync with ...
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
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 ...
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Have you ever had a patient take more time with the provider than they were scheduled for? Do you understand which codes to report and the rules that govern them to allow for better reimbursement?
Prolonged Service codes were created just for that reason but you must carefully follow the documentation ...
by Wyn Staheli, Director of Content - innoviHealth
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.
Aug 2nd, 2019
The Slippery Slope For CDI Specialists
by NAMAS
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 ...
by NAMAS
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 ...
by NAMAS
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 ...
Jun 17th, 2019
Extrapolation Policies Apply to RAD-V Audits
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Risk Adjustment is a program that was implemented to identify and support Medicare beneficiaries with health conditions, illnesses, or injuries that put them at risk of death or organ system/bodily function failure. Through Risk Adjustment (RA), Medicare ensures their beneficiaries are being followed at least annually for any healthcare conditions ...
Jun 14th, 2019
A United Approach
by NAMAS
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 ...
Jun 13th, 2019
Now is Your Chance to Speak Up! Tell CMS What You Think!
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
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 ...
Jun 13th, 2019
What Medical Necessity Tools Does Find-A-Code Offer?
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Find-A-Code is a great resource for individuals working in all aspects of healthcare, from providers and ancillary staff to the attorneys and payers who assess and critique the documentation supporting the services performed. When recently asked what tools Find-A-Code has to help support medical necessity, our response was, "We provide many resources ...
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Is "noncontributory" really an unacceptable word to describe a patient whose family history doesn't have any bearing on the condition being evaluated and treated today?
Apr 29th, 2019
Medicare Revises Their Appeals Process
by Wyn Staheli, Director of Content - innoviHealth
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 ...
Apr 26th, 2019
Medicare Revises Their Appeals Process
by Wyn Staheli, Director of Content - innoviHealth
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.
Apr 23rd, 2019
Let's Talk High Risk E/M Services
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Have you ever assigned a high-complexity E/M code (e.g., 99205, 99215, 99223, 99233, 99245, etc.) and wondered if it would stand up to further scrutiny? Well, let’s take a closer look at the requirements for reporting high-level E/M services.
Both the American Medical Association and Medicare-published E/M Guidelines agree that a ...
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
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 ...
Apr 22nd, 2019
Auditing Chiropractic Services
by Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow
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.
by Wyn Staheli, Director of Content - innoviHealth
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 ...
by Wyn Staheli, Director of Content - innoviHealth
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 ...
Mar 25th, 2019
Clearing Up Some Medicare Participation Misunderstandings
by Wyn Staheli, Director of Content - innoviHealth
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 ...
Mar 21st, 2019
The Impact of Medical Necessity on High Level E/M Services
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
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. ...
Mar 18th, 2019
How to Report Imaging (X-Rays) of the Thumb
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
If you've ever taken piano lessons, you know that the thumb is considered the first finger of the hand. Anatomically, it is also referred to as the first phalanx (finger). However, when you are coding an x-ray of the thumb, images are captured of the thumb, hand, wrist, and all ...
Mar 7th, 2019
Date of Service Reporting for Radiology Services
by Wyn Staheli, Director of Content - innoviHealth
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.
by Wyn Staheli, Director of Content - innoviHealth
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.
Mar 1st, 2019
Understanding NCCI Edits
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
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 ...
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Telemedicine continues its rise, with new technologies allowing for better communication and access to more aspects of healthcare than ever before. Each year Medicare has made strides, albeit small strides, in their telemedicine coverage while commercial payers continue to make great strides, constantly improving and expanding telemedicine service offerings to ...
Feb 12th, 2019
Coding Medicare Initial Preventive Physical Exams (IPPE)
by Aubrie Rowley
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 ...
Feb 11th, 2019
HHS Proposes Significant Changes to Patient Access Rules
by Wyn Staheli, Director of Content - innoviHealth
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 ...
Feb 7th, 2019
Charging Missed Appointment Fees for Medicare Patients
by Wyn Staheli, Director of Content - innoviHealth
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 ...
Feb 1st, 2019
Attestations Teaching Physicians vs Split Shared Visits
by BC Advantage
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 ...
Jan 28th, 2019
Empowering Medicare Beneficiaries
by Find-A-Code™
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 ...
Jan 23rd, 2019
How to Report Co-Surgeons Using Modifier 62
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
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 ...
Jan 22nd, 2019
Home Oxygen Therapy
Jan 4th, 2019
Nine New Codes for Fine Needle Aspirations (FNA) in 2019
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
If your practice performs a lot of fine needle aspirations (FNA), you probably have the code options memorized (10021 without image guidance and 10022 with image guidance). However, the 2019 CPT codes now include nine (9) new FNA codes (10004-10012), one deleted FNA code (10022) and one revised FNA code ...
Jan 3rd, 2019
CMS Finalizes Major Changes to ACO Program
by Wyn Staheli, Director of Content - innoviHealth
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 ...
by Wyn Staheli, Director of Content - innoviHealth
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 ...
by Wyn Staheli, Director of Content - innoviHealth
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 ...
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
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 ...
Nov 1st, 2018
CMS: Medicare Diabetes Prevention Program Expanded Model
by Find-A-Code™
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...
Oct 17th, 2018
Wolters Kluwer Drug Pricing
by Find-A-Code™
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...
Oct 11th, 2018
Type of Bill Codes
by Find-A-Code™
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 ...
Aug 30th, 2018
Keys to Successful Claims Filing
by Noridian Medicare
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 ...
Aug 15th, 2018
BREAKING NEWS: CMS Proposes to Change E&M Coding
by Nicole Olsen, QCC
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 ...
Jul 25th, 2018
CMS Proposes Changes to Evaluation & Management Requirements
by Wyn Staheli, Director of Content - innoviHealth
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 ...
Jul 18th, 2018
Patients Over Paperwork?! We have Great News!
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
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 ...
by Brandon Herman, QMC QMCC QMBHC QMPM QMPoC
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 ...
Jul 12th, 2018
Dual Medicare-Medicaid Billing Problems
by Wyn Staheli, Director of Content - innoviHealth
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 ...
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
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 ...
Jun 25th, 2018
How Does the Physician Compare Website Affect You?
by Wyn Staheli, Director of Content - innoviHealth
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 ...
by Wyn Staheli, Director of Content - innoviHealth
Do we need an ABN if the patient has Part C and we are out-of-network? Read More.
Jun 14th, 2018
Home Oxygen Therapy -- CMN for Oxygen
by Raquel Shumway
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.
by BC Advantage
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...
May 1st, 2018
Webinar: Basic E&M Avoiding Common Errors
by Find-A-Code™
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...
Apr 9th, 2018
CMS Compliance Guidelines Focused Trainings
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
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 ...
Mar 29th, 2018
Medicare Telemedicine Changes for 2018
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
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 ...
Mar 27th, 2018
Home Oxygen Therapy -- A Face-to-Face Encounter
by Raquel Shumway
What is required for a Home Oxygen Therapy, Face-to-Face Encounter.
by Brittney Murdock, QCC CMCS CPC
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...
Mar 8th, 2018
Documentation and Orders for Laboratory Tests
by Medicare Learning Network
The Medicare Learning Network provides guidance on required documentation for ordering laboratory tests.
Mar 8th, 2018
Documentation for Home Blood Glucose Monitors (BGM)
by Medicare Learning Network
The Medicare Learning Network provides guidance on how to Prevent Denials for Home Blood Glucose Monitors (BGM)...
Mar 8th, 2018
Documentation for Home Health Services (Part A non DRG)
by Medicare Learning Network
The Medical Learning Network provides coverage guidance, which should be documented, for home health services.
Mar 1st, 2018
New Bipartisian Budget Act of 2018 Provisions
by Wyn Staheli, Director of Content - innoviHealth
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 ...
by Wyn Staheli, Director of Content - innoviHealth
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?
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
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 ...
by Wyn Staheli, Director of Content - innoviHealth
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 (emphasis added):
Services furnished under the Outpatient ...
Jan 25th, 2018
Psychiatric Partial Hospitalization Programs
by Wyn Staheli, Director of Content - innoviHealth
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 ...
by Wyn Staheli, Director of Content - innoviHealth
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 ...
by Find-A-Code™
The following information from the Medicare Learning Network provides guidance on Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)
by Wyn Staheli, Director of Content - innoviHealth
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 ...
Jan 10th, 2018
New MIPS Reporting Option for 2017 Data
by Wyn Staheli, Director of Content - innoviHealth
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 ...
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
by Find-A-Code™
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...
by Find-A-Code™
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., ...
by Find-A-Code™
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' ...
Jan 2nd, 2018
Quality Payment Program in 2018
by Wyn Staheli, Director of Content - innoviHealth
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
by Jared Staheli, MPP
What is the AUC program? From the CMS website:
Section 218(b) of the Protecting Access to Medicare Act of 2014 amended Title XVIII of the Social Security Act to add section 1834(q) directing CMS to establish a program to promote the use of appropriate use criteria (AUC) for advanced diagnostic imaging ...
Dec 13th, 2017
Specialty Exceptions — 2018 PE RVU Changes
by Raquel Shumway
Some specialties are not included in the new PPIS PE/HR RVU changes
by Jared Staheli, MPP
Diabetes treatment places an ever-increasing strain on the resources of the U.S. healthcare system. CMS estimated that in 2016 alone, Medicare incurred an additional $42 billion in costs due to the number of beneficiaries with diabetes. The best way to keep these costs down in the future is by preventing ...
Dec 4th, 2017
Revised ABN and Non-Participating Providers
by Wyn Staheli, Director of Content - innoviHealth
Non-participating providers have the option to strikeout part of the ABN form.
Nov 28th, 2017
Medicare Expands Value Based Plans
by Wyn Staheli, Director of Content - innoviHealth
In 2015, the CMS Innovation Center announced plans for new value-based Medicare Advantage plans in an effort to reduce healthcare costs while improving quality of care. This five year pilot program began in 2017 with seven states and is expanding to ten states for 2018. Results must have been positive because they ...
Oct 31st, 2017
Correct Coding for Group Therapy
by David Klein, CPC CPMA CHC
Recent events regarding delegation of services to ancillary personnel have given rise to concerns regarding the delivery of outpatient physical medicine by Chiropractors, specifically regarding the appropriate use of one-on-one codes as opposed to group therapy code CPT 97150 - Therapeutic procedure(s), group (2 or more individuals). This advisory provides guidance on how to properly use one-on-one and group therapy codes, both independently and together.
Oct 18th, 2017
Avoid Deactivation of your Medicare Billing Privileges
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
According to the Affordable Care Act all Medicare providers are required to re-validate their enrollment information every three or five years. To determine if you are due for re-validation the list below will display a re-validation due date. If you have a due date of “TBD”, this means there has not ...
by Brandy Brimhall, CPC CMCO CPCO CCCPC CPMA QCC
Do we need to charge for non-covered services performed under a maintenance visit if we use the S8990 code when billing Medicare?
Sep 30th, 2017
Annual Wellness Visit & Health Risk Assessment
by Find-A-Code™
Coding tips regarding Annual Wellness Visit and Health Risk Assessments
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
There are many rules and guidelines a coder must be aware of when it comes to appropriately selecting an Evaluation and Management (EM) code and avoiding doubling dipping is one of them. Double dipping occurs when the same information is used in more than one of the subcomponents of history.
The subcomponents of history include:
Chief Complaint ...
by ChiroCode™
Arlington, Va. - The American Chiropractic Association (ACA) recently submitted comments to the Centers for Medicare and Medicaid Services (CMS) in response to the federal agency's proposed rule changes to the Quality Payment Program (QPP) for 2018.
QPP is a new payment model for physicians, including chiropractors, created by the Medicare Access and CHIP ...
by Find-A-Code™
The following information from the Medicare Learning Network provides guidance on Diabetes Self-Management Training....
Sep 1st, 2017
Preventive Services: Hepatitis C Virus (HCV) Screening
by Find-A-Code™
The following information from the Medicare Learning Network provides guidance on Hepatitis C Virus (HCV) Screening....
Jun 28th, 2017
Medicare Announces New Cards to Be Issued
by Mario Fucinari, DC CCSP CPCO MCS-P MCS-I
Identity theft has become a major problem in the United States. As a prevention measure, the Centers for Medicare& Medicaid Services (CMS) is readying a fraud prevention initiative that removes Social Security numbers from Medicare cards to help combat identity theft, and safeguard taxpayer dollars.
May 12th, 2017
NGS E/M Code Changes for 2017
by ChiroCode™
The Medicare contractor, NGS, made changes to its E/M coding guidelines for level 3 exams. Even if you don't bill NGS, this change could be a sign of things to come for other payers. Watch here.
Feb 11th, 2017
Podiatry Class Findings
by Wyn Staheli, Director of Content - innoviHealth
The following modifiers are required when reporting medically necessary routine foot care services per Medicare guidelines:
Q7: One Class A finding
Q8: Two Class B findings
Q9: One Class B and two Class C findings
Appropriate: With foot care (podiatry) codes to indicate covered foot care
Inapproriate:
With any code not related to foot care
When the foot ...
by Brandy Brimhall, CPC CMCO CPCO CCCPC CPMA QCC
We have been leaving box 14 on the 1500 claim form blank for Medicare claims and are getting denials. Could this be why?
Jan 24th, 2017
Code Sets - Health Care Provider Taxonomy Code Set Link
by Raquel Shumway
Every Provider needs to know their Health Care Provider Taxonomy Codes. The Taxonomy Codes define the provider type, classification, and area of specialization. We have provided a link and instructions to help you locate your code.
Jan 23rd, 2017
Virtual Groups and MIPS
by Wyn Staheli, Director of Content - innoviHealth
During the comment period of the MIPS Proposed Rule (Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models), there were some concerns about NPI and TIN usage for MIPS reporting for smaller organizations.
The following statements are from the MIPS Final ...
Jan 6th, 2017
Assistant-At-Surgery Services
by Brittney Murdock, QCC CMCS CPC
An "assistant at surgery" is a physician who actively assists the physician in charge of a case in performing a surgical procedure. The "assistant at surgery" provides more than just ancillary services.
Codes eligible for reimbursement for an assistant surgeon are designated by the Centers for Medicare and Medicaid Services (CMS) ...
Dec 30th, 2016
How APC Payment Rates Are Set
by Brittney Murdock, QCC CMCS CPC
The payment rates for most separately payable medical and surgical services are determined by multiplying the prospectively established scaled relative weight for the service’s clinical APC by a conversion factor (CF) to arrive at a national unadjusted payment rate for the APC.
Dec 20th, 2016
ABN FAQs
by Wyn Staheli, Director of Content - innoviHealth
This handy FAQ addresses the uses and mis-uses of the ABN form.
by Brittney Murdock, QCC CMCS CPC
Please note: The information in this publication applies only to Medicare Part D; the Prescription Drug Benefit.
Except for vaccines covered under Medicare Part B, Medicare Part D plans cover all commercially available vaccines as long as the vaccine is reasonable and necessary to prevent illness.
Health care professionals (sometimes known as ...
by Brittney Murdock, QCC CMCS CPC
Today, the Centers for Medicare & Medicaid Services (CMS) announced more new opportunities for clinicians to join Advanced Alternative Payment Models (APMs) to improve care and earn additional incentive payments under the Quality Payment Program, which implements the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Beginning in January...
by CMS.gov
On October 1, 2016, new International Classification of Diseases (ICD)-10-CM and ICD-10-PCS code sets went into effect. Updating of these codes traditionally occurs on an annual basis, however, during the immediate years leading up to the ICD-9 to ICD-10 transition there was an extended freeze to code updates to support...
Dec 13th, 2016
Health Risk Assessment
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Risk Adjustment models are used to calculate risk scores used in predicting average beneficiaries healthcare expenditures. Currently Medicare Advantage and Prescription Drug programs include a risk adjustment as a component of the bidding and payment process to standardize bids, compare bids, and adjust plan payments. If you are not familiar ...
Dec 12th, 2016
60 Day Final Rule
by Wyn Staheli, Director of Content - innoviHealth
Effective March 14, 2016, the CMS Final Rule clarifying the standards for handling
overpayments for both Medicare and Medicaid takes effect. Failure to report and
subsequently return an overpayment within 60 days after the overpayment was
“identified” is a violation of the False Claims Act.
Sep 17th, 2016
Government Healthcare Programs
by Wyn Staheli, Director of Content - innoviHealth
The Department of Health and Human Services (HHS) oversees all government health care programs. They are administered by various agencies such as the Centers for Medicare & Medicaid Services (CMS), the Veterans Administration (VA) and even at the state level. Here are the basic government programs:
Medicare
Federal Workers’ Compensation
Military and Veterans
Medicaid
Federal ...
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
What in the world is MACRA, MIPS and APM? More acronyms, rules and payment changes are headed our way. If you are a Medicare Part B provider, you will want to pay special attention.
MACRA- Medicare Access and CHIP Reauthorization Act of 2015
MIPS- Merit-Based Incentive Payment System
APM – Alternative Payment Model ...
Aug 16th, 2016
2017 ICD-10- CM Gynecology Updates
by Bonnie G. Schreck, CCS CPC COC CCS-P COBGC
The final list of the new ICD-10- CM codes that become effective October 1, 2016 has been released. There are approximately 1600 changes to the code set, making up for the four years the ICD-10- CM codes have not had a complete update. For fiscal year (FY) 2017, updates to...
Aug 16th, 2016
2017 ICD-10-CM and ICD-10-PCS Code Updates
by Brittney Murdock, QCC CMCS CPC
The 2017 ICD-10-CM and ICD-10-PCS code updates, including a complete list of code titles, are available on the 2017 ICD-10-CM and GEMs and 2017 ICD-10-PCS and GEMs webpages.
by Brittney Murdock, QCC CMCS CPC
Today, the Centers for Medicare & Medicaid Services (CMS) announced proposed changes to the Medicare home health prospective payment system (HH PPS) for calendar year (CY) 2017 that would foster greater efficiency, flexibility, payment accuracy, and improved quality. Approximately 3.4 million beneficiaries received home health services from approximately 11,400 home ...
by Brittney Murdock, QCC CMCS CPC
Today, the Centers for Medicare & Medicaid Services (CMS) released a final rule implementing Section 216(a) of the Protecting Access to Medicare Act of 2014 (PAMA), requiring laboratories performing clinical diagnostic laboratory tests to report the amounts paid by private insurers for laboratory tests. Medicare will use these private insurer ...
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Electronic submission of staffing data through the Payroll-Based Journal (PBJ) is required of all long-term care facilities starting July 1. The last day to submit data for fiscal quarter four (July 1 through September 30) is November 14, 2016. Nursing homes can register now in the PBJ system to prepare:
Obtain ...
May 3rd, 2016
CMS Finalizes its Quality Measure Development Plan
by Kate Goodrich, MD MHS Director - Center for Clinical Standards & Quality - CMS
On December 18, 2015, we posted our draft Quality Measure Development Plan, a strategic framework for clinician quality measurement development to support the new Merit-based Incentive Payment System (MIPS) and advanced alternative payment models (APMs). Through March 1, 2016, we asked for stakeholder feedback and received responses from 60 individuals ...
by Brittney Murdock, QCC CMCS CPC
Today, the Centers for Medicare & Medicaid Services (CMS) announced a final rule (https://www.federalregister.gov/public-inspection) to update health care facilities’ fire protection guidelines to improve protections for all Medicare beneficiaries in facilities from fire.
The new guidelines apply to hospitals; long term care (LTC) facilities; critical access hospitals (CAHs); inpatient hospice facilities; ...
by Brittney Murdock, QCC CMCS CPC
Today, the Centers for Medicare & Medicaid Services (CMS) announced a final rule (https://www.federalregister.gov/public-inspection) to update health care facilities’ fire protection guidelines to improve protections for all Medicare beneficiaries in facilities from fire.
The new guidelines apply to hospitals; long term care (LTC) facilities; critical access hospitals (CAHs); inpatient hospice facilities; ...
Apr 13th, 2016
Telehealth Basics
by Wyn Staheli, Director of Content - innoviHealth
Telehealth and telemedicine are covered for many payers for services such as consultation, office visits, individual psychotherapy, and pharmacologic management delivered via a telecommunications system.
Apr 5th, 2016
Voluntary Disclosure - Look Before You Leap
by Melissa Hall
Occasionally providers are faced with the need to assess the option of making a voluntary disclosure to the government. Here are steps that every provider should consider before disclosing information to the government.
Feb 1st, 2016
Definitive Diagnoses - To Code or Not To Code
by Bonnie G. Schreck, CCS CPC COC CCS-P COBGC
For inpatient coding, there are times when the diagnosis(es) cannot be established at the time of admit or throughout the course of the admission. In these cases, they are documented in the medical record as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “rule out” conditions. This guideline is true for certain...
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Practices that bill incident to services need to periodically audit compliance with Medicare and private payor guidelines to avoid potential denials or third-party audits.
Nov 20th, 2015
Charging Medicare Patients for Missed Appointments
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Nov 19th, 2015
Not Documented, Not Done: Medicare Myth or Rule?
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
After years of unchallenged recitation, the coding community has virtually canonized the phrase “not documented—not done” into coding scripture. But there are good reasons to question whether the now-famous epigram reflects an actual rule or whether it has simply taken on a life of its own like ...
by Find-A-Code™
CERTIFICATE OF MEDICAL NECESSITY CMS-848 — TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR (TENS) - DME 06.03B
...
Nov 9th, 2015
DME MAC Jurisdiction A ASCA Waiver Request Form - Free
by Find-A-Code™
Submit this form, along with your supporting documentation, when requesting an Administration Simplification Compliance Act (ASCA) waiver which grants the ability to submit paper claims for suppliers in specific circumstances.
...
by Find-A-Code™
Electronic Funds Transfer (EFT) Authorization Agreement - CMS 588
...
Nov 9th, 2015
VPIQ/CSI Enrollment Form - Free
by Find-A-Code™
Use this form for adding new users, reactivating users, terminating users or adding/deleting PTANs from active IDs in the CSI/VPIQ System.
...
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Beginning January 1, 2013, Functional Reporting requires therapy practitioners and providers to report non-payable G-codes and modifiers to convey information about the beneficiary’s functional status including projected goal status throughout the episode of care.
For the severity modifiers, providers should include a description of how the modifiers were determined.
Functional ...
Aug 3rd, 2015
Medicare Secondary Payer
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Medicare Secondary Payer (MSP) is the term generally used when the Medicare program does not have primary payment responsibility - that is, when another entity has the responsibility for paying before Medicare.
Primary payers are those that have the primary responsibility for paying a claim. Medicare remains the primary payer for ...
Aug 3rd, 2015
Notice of Election (NOE) - Form CMS - 1450 (Rev. 3118)
by Find-A-Code™
When a Medicare beneficiary elects hospice services, hospices must complete form locators identified in section 20.1.2 for the Uniform (Institutional Provider) Bill (Form CMS-1450), which is an election notice.
In addition, the hospice must complete the Form CMS-1450 when the election is for a patient who has changed an election from one ...
by Find-A-Code™
A. Payment to Government Agency
Medicare payment for the services of a provider is not made to a governmental agency or entity except when payment to the governmental agency or entity is permissible under the other listed reassignment exceptions, e.g., where the agency is the employer of the physician.
B. Payment ...
by Find-A-Code™
A. Conditions
The FI or carrier makes payment in the name of the provider (Carriers additionally may pay in the name of supplier or employer, facility, or organized health care delivery system.) to an agent who furnishes billing or collection services if:
• The agent receives the payment under an agreement ...
by Find-A-Code™
(Rev. 3089, Issued: 10-21-14, Effective Date: January 1, 2015 - For Analysis, Design, and Programming April 1, 2015 - For Testing and Implementation; ImplementationJanuary 5, 2015, April 6, 2015 – For MAC testing of PECOS changes only)
A physician or other supplier may bill for the technical component (TC) and/or professional ...
by Find-A-Code™
Providers (as defined in 1861(u) of the Act, and institutional suppliers such as RHCs) that undergo a change in their ownership structure are required to notify CMS concerning the identity of the old and new owners. They are also required to inform CMS on how they will organize the new ...
Jul 13th, 2015
FI Jurisdiction of Requests for Payment (Rev. 1, 10-01-03)
by Find-A-Code™
The FIs have jurisdiction for the following:
• All Part A services (hospital, SNF, HHA, and hospice);
• Most Part B services from providers that furnish Part A services; and
• Part B facility services from CORFs, Renal; Dialysis Facilities, Rural Health Clinics, Religious Nonmedical Institutions, Outpatient Physical Therapy Centers, Federally Qualified Health ...
by Find-A-Code™
When a local contractor (Part B MAC or carrier) receives a CMS-1500 or electronic claim for Medicare payment for items/services furnished outside of its payment jurisdiction, the claim shall be returned as unprocessable.
NOTE: This instruction also applies to claims for DMEPOS items/services that are appropriately billed to the B MAC/carrier, ...
by Find-A-Code™
A “misdirected claim” is a claim that has been submitted to the wrong place. This section summarizes the disposition of misdirected claims by B MACs, carriers, and DME MACs.
Each fee-for-service claims administration contractor is assigned a specific geographic and subject matter jurisdiction for claims processing. Physicians and other suppliers are ...
by Find-A-Code™
(Issued: 06-08-12, Effective: 01-01-11, Implementation: 06-19-12) B3-3116, B-3102
Claims for DMEPOS submitted by suppliers for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) are handled by Durable Medical Equipment Medicare Administrative Contractors (DME MACs).
To determine which services are processed by DME MACs vs. local carriers, CMS maintains and updates a table ...
Jun 22nd, 2015
Chiropractic Policy Addendum: Maintenance Therapy CR2717
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
The Centers for Medicare & Medicaid Services (CMS) has further defined Chiropractic Maintenance Therapy. Section 2251.3 of the Medicare Carriers Manual (MCM) has been amended to clarify Medicare requirements for treatment of chiropractic therapy.
"MCM 2251.3 Necessity for Treatment.--
A. The patient must have a significant health problem in the form of a neuromusculoskeletal ...
Apr 15th, 2015
SGR Repeal Passes
by Wyn Staheli, Director of Content - innoviHealth
On April 14, 2015, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) passed the Senate by an overwhelming vote of 92-8. Although President Obama has not officially signed the bill into law, weeks ago he indicated his full support when H.R. 2 passed the House of Representatives.
For over a decade, ...
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
The current diagnosis pointer for, Influenza, Pneumococcal or Hepatitis B vaccines is ICD-10-CM code Z23. Listed are tips for coding, and also the diagnosis pointers used for claims previous to 10/01/15:
Influenza: G0008
Procedure codes:
90630
90653-90662
90672-90674
90685-90688
Medicare codes:
Q2034-Q2039
Expired diagnosis code:
V04.81
Pneumococcal: G0009
Procedure codes:
90670
90732
Expired diagnosis code:
V03.82
Hepatitis B: G0010
Procedure codes
90739-90747
Expired diagnosis code
V05.3
Both Influenza and Pneumococcal Vaccines received in same visit: G0008 with G0009
Procedure codes:
(See previous)
Expired diagnosis code:
V06.6 (effective 10/01/06 - 09/30/15)
Extra Tips:
Be sure ...
Feb 26th, 2015
Levels of Supervision Required by Medicare
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Be sure you know and understand the levels of supervision required so as not to result in non-compliance audits, possible fines and take-backs. Supervision requirements may also affect your documentation requirements; be sure to document the presence during the procedure or performance if it requires personal supervision.
Find-A-Code has levels of supervision ...
Feb 10th, 2015
MAC Jurisdictions Resources
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
The Centers for Medicare & Medicaid Services (CMS) uses a network of contractors called Medicare Administrative Contractors (MAC) to process Medicare claims, enroll health care providers in the Medicare program and educate providers on Medicare billing requirements. MACs also handle claims appeals and answer beneficiary and provider inquiries. Even though ...
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
All sponsors are required to adopt and implement an effective compliance program,which must include measures to prevent, detect and correct Part C or D program noncompliance as well as FWA.
The compliance program must, at a minimum, include the following core requirements:
1. Written Policies, Procedures and Standards of Conduct;
2. Compliance ...
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
All persons who provide health or administrative services to Medicare enrollees must satisfy general compliance and FWA training requirements. This module may be used to satisfy both requirements.
This training module consists of two parts:
(1) Medicare Parts C & D Fraud, Waste, and Abuse (FWA) Training and Compliance
Objectives:
Meet the regulatory requirement ...
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
In this MLN Connects™ video on Coding for ICD-10-CM: More of the Basics, Sue Bowman from the American Health Information Management Association (AHIMA) and Nelly Leon-Chisen from the American Hospital Association (AHA) provide a basic introduction to ICD-10-CM coding. The objective of this video is to enhance viewers’ understanding of ...
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
On December 3, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that will improve CMS’ ability to deny or revoke the enrollment of entities and individuals that pose a program integrity risk to Medicare.
This fact sheet summarizes CMS’ regulatory additions and changes.
SUMMARY OF THE PROVIDER ...
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
CMS is aligning the way providers are paid to reward value rather than volume.
Paying providers for quality, not quantity of care. In 2015, Medicare is continuing to phase in the Value-based Payment Modifier, which adjusts traditional Medicare payments to physicians and other eligible professionals based on the quality and ...
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
The Centers for Medicare & Medicaid Services (CMS) is pleased to announce that a Virtual Office Hours session regarding Getting Started with Quality Measures has been scheduled for Monday, November 17, 2014 from 3:00–4:00 PM ET
This session will allow stakeholders an opportunity to ask a CMS representative questions about getting ...
Nov 21st, 2014
What is an LMRP and Where Can I Find Them?
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Local Medical Review Policies (LMRPs) were converted to LCDs. This was done as a result of the Benefits Improvement and Protection Act of 2000 (BIPA 2000). The difference between LCDs and previously written LMRPs is that LCDs contain only reasonable and necessary conditions of coverage as allowed under section 1862(a)(1)(A) ...
Nov 19th, 2014
Understanding ZPIC
by Jared Staheli, MPP
The following chart identifies each of the 7 zones for ZPIC and the states/regions within each zone. Links are provided for each zone which contain information about each zone as well as activity and updates in those regions.
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
CMS is pleased to announce that the 2013 Electronic Prescribing (eRx) Incentive Program incentive payments are now available for eligible professionals and group practices who submitted data for Medicare Physician Fee Schedule Part B services provided January 1, 2013 through December 31, 2013.
As required by law, President Obama issued a ...
Oct 16th, 2014
ABN FAQ for Chiropractic Care
by Jared Staheli, MPP
What is the ABN form used for?
The Advanced Beneficiary Notice of Non-Coverage (ABN) is the Notice of Liability that is required to be provided to Medicare patients in the event that the service(s) rendered to them are expected to not be covered. For chiropractic, reason for non-coverage is generally due ...
Oct 16th, 2014
Incarcerated Beneficiary Update - CMS
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
In 2013, CMS initiated recoveries from providers and suppliers based on data that indicated a beneficiary was incarcerated on the date of service. CMS subsequently discovered that some of the data used was incomplete. Since some of these recoveries might have been erroneous, CMS initiated refunds. Most of the incarcerated beneficiary erroneous ...
Oct 16th, 2014
Is Compliance a Dirty Word?
by Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow
In October of 2000 in the Federal Register the Office of the Inspector General (who investigates fraud against the federal government on behalf of the Department of Health and Human Services) offered general guidelines for health care facilities to set up a “Compliance Program”. This advice has long been pushed ...
Oct 3rd, 2014
Effective Billing Dates for new CMS Providers
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
As of May 14, 2012, the billing effective date can be made retroactive as far back as 30 calendar days from the date the application was received in Medicare's office.
Provider offices must submit the CMS 855 form as soon as the provider begins seeing Medicare patients to ensure their services will be ...
Sep 26th, 2014
Patient Electronic Access Tipsheet - Measure Compliance
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
MEASURE COMPLIANCE - Meeting the Patient Electronic Access Objective
Starting in 2014, CMS requires that providers participating in both Stage 1 and Stage 2 of the EHR Incentive Programs must meet the Patient Electronic Access objective, which gives patients access to their health information in a timely manner. Providers participating in ...
Sep 25th, 2014
PQRS: Questions and Answers for Psychologists
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Questions and Answers for Psychologists and PQRS. In 2007, Psychologists had very limited opportunity to participate in PQRS. As of 2014, there are 11 measures available for claims-based reporting and two for registry reporting.
For the entire article read more here: PracticeCentral.org
Below are the 11 new measures for 2014
Major depressive disorder: diagnostic evaluation (#106)
Major ...
Sep 15th, 2014
Medicare Definition of Timed Codes
by Wyn Staheli, Director of Content - innoviHealth
Many procedure codes are considered "timed codes," that is, the number of units are determined by the amount of time spent performing the service. Medicare Claims Processing Manual, Chapter 5 clarification included here.
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
On September 9, 2013, the Centers for Medicare & Medicaid Services (CMS) announced that it would begin actively enforcing and would expect full compliance with new DME face-to-face requirements on a date to be announced in Calendar Year 2014. We are publishing this announcement to make clear that the delay ...
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Q: When meeting the meaningful use measure for computerized provider order entry (CPOE) in the Electronic Health Records (EHR) Incentive Programs, does an individual need to have the job title of medical assistant in order to use the CPOE function of Certified EHR Technology (CEHRT) for the entry to count toward ...
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
A Laxative is considered a “Self Administered Drug” (SAD). Insurance will usually pay for the care you provide but will only cover certain drugs in the outpatient setting such as drugs administered through an IV. Therefore it would not be appropriate to report this under the Outpatient Prospective Payment System ...
Jul 31st, 2014
GP Modifier for Physio Therapy Services
by Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow
The -GP modifier needs to be appended to physio-therapy codes when submitting Medicare claims. However, be aware of differing policies for different types of payers. Chiropractors typically use the following Physical Medicine codes from the CPT book: 97010 thru 97799 (except for 97597-97610 for active wound care management). The current ...
Aug 30th, 2012
Inappropriate Medicare Payments for Chiropractic Services
by Karalyn
OIG released two reports critical of the way chiropractic handled documentation and coding. Their findings are included in this article. Read further to see what documentation is needed for proper payment.
As required by the Social Security Act, Medicare pays only for reasonable and necessary chiropractic services, which are limited to active/corrective manual manipulations of the spine to correct subluxations. A chiropractic service must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function.
Nov 30th, -0001
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Subscribers will see related documentation, coding and billing tips. Access to this feature is available in the following products:
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Nov 5th, 2019
Proving Medical Necessity and Functional Improvement
by Ron Short, DC MCS-P CPC
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.Jun 17th, 2019
Telehealth Policies for Medicare and Commercial Payers
Telehealth Policies for Medicare and Commercial Payers
by Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow
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.Dec 21st, 2017
What is RBRVS and How Can It Benefit Your Organization
by Find-A-Code™
What is RBRVS and How Can It Benefit Your OrganizationFeb 2nd, 2017
How to Check NCCI Edits Using FindACode
by Find-A-Code™
How to Check NCCI Edits Using FindACodeFeb 2nd, 2017
Mighty MACRA!
by Find-A-Code™
Mighty MACRA!Links and resources by topic.
ABN - Advanced Beneficiary Notice
Auditing
CMS 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 InstructionsMedicare Recovery Audit by HHS Office of the Inspector GeneralNational Medicaid Audit Program fact sheet - by CMS
Billing
Avoiding Medicare and Medicaid Fraud and Abuse; A Roadmap for PhysiciansCGS - Medicare Advanced Beneficiary Notice of Noncoverage (ABN) Form Instructions ToolCGS Medicare - Bilateral Surgeries: Claim SubmissionCMS Physician Fee Schedule Look-UpContinued Use of Modifier 59 after Jan 1, 2015FAQ on the use of the AT and GA modifiers togetherHospital - Acquired Conditions (HACs)How to use the Medicare National Correct Coding Initiative (NCCI) Tools by MLNLink to CMS Form - Request For Medicare Hearing by an Administrative Law JudgeMedicare Advantage Plans: Cost Sharing LimitsMedicare Benefit Policy Manual, Chapter 15 (also known as Medicare Carriers Manual)Medicare Claims Processing Manual - Chapter 25Medicare Claims Processing Manual, Chapter 9 - Rural Health Clinics/Federally Qualified Health CentersMedicare Coverage and Payment of Virtual ServicesMedicare Removes SSN from Medicare Cards - Press ReleaseMedicare Secondary Payer fact sheet by CMSMedicare’s Vision Services Fact SheetMisinformation about Chiropractic Services - by Medicare Learning NetworkMLN Matters: Cataract Removal with Medicare Part BOffice of Inspector General: Questionable Billing for Medicare Ophthalmology Services 2012Q&A on Skilled Nursing Facility Consolidated BillingSkilled Nursing Facility Consolidated BillingTimely Claims Filing: Additional Instructions - MedLearn Article by CMSYour Guide to Who Pays First - by CMS
CMS1500
CPT Coding
Claims Processing
Medicare Claims Processing Manual - Chapter 25Medicare Claims Processing Manual, Chapter 12Medicare Claims Processing Manual, Chapter 9 - Rural Health Clinics/Federally Qualified Health CentersParticipating vs. Non-Participating (Medicare Part B Claims)Reminder to Stop Billing Duplicate Claims by Medicare Learning NetworkTimely Claims Filing: Additional Instructions - MedLearn Article by CMS
Coding
Annual Wellness Visit (AWV) by CMSASC Payment RulesAvoiding Medicare and Medicaid Fraud and Abuse; A Roadmap for PhysiciansCare Plan Oversight (CPO) services information by CGS MedicareCGS Medicare - Bilateral Surgeries: Claim SubmissionContinued Use of Modifier 59 after Jan 1, 2015FAQ on the use of the AT and GA modifiers togetherHow to use the Medicare National Correct Coding Initiative (NCCI) Tools by MLNInitial Preventive Physical Examination (IPPE)Local Coverage Determinations (LCDs) by Contractor IndexMedicare Claims Processing Manual, Chapter 12Medicare Coverage and Payment of Virtual ServicesMedicare Learning Network - Chiropractic ServicesMisinformation about Chiropractic Services - by Medicare Learning NetworkNCCI Instructions for Modifier 59Summary of 2015 Physician Value-based Payment Modifier Policies
Collections
Compliance
ASC Payment RulesAvoiding Medicare and Medicaid Fraud and Abuse; A Roadmap for PhysiciansCMS Complying with Medicare Signature Requirements Fact SheetCMS Medicare Fee for Service Recovery Audit ProgramHIPAA: Health Insurance Portability and Accountability Act by AMAMedicare Recovery Audit by HHS Office of the Inspector GeneralNational Medicaid Audit Program fact sheet - by CMSOverview of Mandatory Complinace ProgramPhysician Payment WebsiteSpecial 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)The Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.1 B
DME
Denial Management
Clinical Review Judgment Change Request 6954 by CMSCMS Recovery Audit Program - Center for Medicare & Medicaid ServicesLink 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 RightsMedicare Appeals - by CMSMedicare Claims Processing Manual, Chapter 29 - Appeals of Claims DecisionsMedicare Reconsideration RequestMedicare Redetermination RequestNCCI Instructions for Modifier 59Reminder to Stop Billing Duplicate Claims by Medicare Learning Network
Documentation
CMS Meaningful Use Registration and Attestation WebsiteCMS-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: RespiratoryDetails about EHR Incentive ProgramMedicare Advantage Plans: Cost Sharing LimitsMedicare Documentation Job Aid for Doctors of Chiropractic — MLNNoridian Documentation ChecklistsQuality Payment ProgramScreening Pap Tests and Pelvic Examinations by CMSThe Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.1 B
E+M Documentation and Coding
EHR
CMS Complying with Medicare Signature Requirements Fact SheetCMS Implementation Guide for Quality Reporting Document Architecture Category I and Category IIICMS Meaningful Use Registration and Attestation WebsiteDetails about EHR Incentive ProgrameHealth Initiative websiteEHR Program Timeline by CMSElectronic Prescribing (eRx) Incentive Program - by CMSMedicare 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 InformatPress release: New CMS rule allows flexibility in certified EHR technology for 2014The CMS eHealth InitiativeThe Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.1 B
Fees
Forms
CMS-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: RespiratoryLink to CMS Form - Request For Medicare Hearing by an Administrative Law JudgeLink to CMS Form - Transfer of Appeal RightsMedicare Reconsideration RequestMedicare Redetermination RequestSkilled Nursing Facility Best Practice Guidelines
Fraud
Avoiding Medicare and Medicaid Fraud and Abuse; A Roadmap for PhysiciansMedicare Recovery Audit by HHS Office of the Inspector GeneralSpecial 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)
HCPCS Coding
HIPAA
Health Care Reform
Hospital
Insurance
Medicaid
Medicare
1995 E/M Guidelines1997 E/M GuidelinesABN- Medicare Advance Written Notices of Noncoverage (October 2018)Accountable Care Organizations (ACO) - by CMSCare Plan Oversight (CPO) services information by CGS MedicareCGS - Medicare Advanced Beneficiary Notice of Noncoverage (ABN) Form Instructions ToolCMS 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-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: Value Based Modifier (VBM)CMS/Medicare Podiatry ServicesContinued 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 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)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 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 Documentation Job Aid for Doctors of Chiropractic — MLNMedicare Medical Savings Account (MSA) Plans - 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?Misinformation about Chiropractic Services - by Medicare Learning NetworkMLN ConnectsMLN 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 SheetNCCI Instructions for Modifier 59NPI RegistryOffice of Inspector General: Questionable Billing for Medicare Ophthalmology Services 2012Opting 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 BWPS Medicare how do they price Non-ASP New drugs and NOC Drugs?Your Guide to Who Pays First - by CMS
Medicare Secondary Payer
Modifier Coding
PQRS
CMS: Value Based Modifier (VBM)eHealth Initiative websiteFeedback Report Requests PortalMaintenance of Certification Program (MOC)Measure-Applicability Validation (MAV) CourseMedicare Topics PageMedicare Topics Page - ChiropracticPQRS Analysis and Payment by CMSSummary of 2015 Physician Value-based Payment Modifier PoliciesThe CMS eHealth Initiative
Payer Guidelines
Practice Management
ABN- Medicare Advance Written Notices of Noncoverage (October 2018)Behavioral Health Provider TypesCMS Complying with Medicare Signature Requirements Fact SheetCMS Medicare Fee for Service Recovery Audit ProgramCMS Physician Fee Schedule Look-UpDetails about EHR Incentive ProgramDurable Medical Equipment (DME) Medicare Administrative Contractor (MAC) JurisdictionsFurther Details on the Revalidation of Provider Enrollment Information by CMSHIPAA: Health Insurance Portability and Accountability Act by AMAIs your Office Listed on the PECOS Listing?Link to CMS Form - Transfer of Appeal RightsMedicare Advantage Plans: Cost Sharing LimitsMEDICARE ENROLLMENT APPLICATION Institutional Providers CMS-855AMedicare Medical Savings Account (MSA) Plans - by CMSMedicare OverpaymentsMedicare Provider-Supplier Enrollment - by CMSMedicare Reconsideration RequestMedicare Secondary Payer fact sheet by CMSMedicare: To Participate or Not to Participate?Misinformation about Chiropractic Services - by Medicare Learning NetworkMLN: Medicare Vision Services Fact SheetNPI RegistryOpting out of Medicare and/or Electing to Order and Refer Services - MedLearn articleSkilled Nursing Facility Best Practice GuidelinesSpecial 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)Your Guide to Who Pays First - by CMS
Procedure Coding
Quality Payment Program
Reimbursement
CMS Recovery Audit Program - Center for Medicare & Medicaid ServicesCMS: Value Based Modifier (VBM)Electronic Prescribing (eRx) Incentive Program: Payment AdjustmentFeedback Report Requests PortalLink 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 FormsMaintenance of Certification Program (MOC)Measure-Applicability Validation (MAV) CourseMedicare Appeals - by CMSMedicare Claims Processing Manual, Chapter 29 - Appeals of Claims DecisionsMedicare Reconsideration RequestMedicare Recovery Audit by HHS Office of the Inspector GeneralMedicare Redetermination RequestPhysician Payment WebsitePQRS Analysis and Payment by CMSReminder to Stop Billing Duplicate Claims by Medicare Learning NetworkSummary of 2015 Physician Value-based Payment Modifier Policies
Risk Adjustment
Supply Coding
Technology
HIPAA: Health Insurance Portability and Accountability Act by AMAMedicare 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 InformatPress release: New CMS rule allows flexibility in certified EHR technology for 2014
UB04 Form and Coding
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