Select the title to see a summary and a link to the full article.
May 13th, 2020
Are Diagnoses from Telehealth Services Eligible for Risk Adjustment?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published May 13th, 2020
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 ...
By Wyn Staheli, Director of Research | Published May 4th, 2020
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.
SOME of Us Non-Essentials May be Able to Get Back on the Road!
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 20th, 2020
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 ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 20th, 2020
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, QCC, CMCS, CPC, CMRS | Published April 13th, 2020
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 ...
CMS Announces Final 2021 HCC Risk Adjustment Changes
By Wyn Staheli, Director of Research | Published April 13th, 2020
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.
2020 Medicare Part D Coverage Gap (AKA donut hole)
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 26th, 2020
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 ...
2021 Brings Another Risk Adjustment Calculation Change
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 23rd, 2020
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...
Medicare Announces Coverage of Acupuncture Services
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 30th, 2020
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 ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 7th, 2020
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 ...
Time Is Up! Jan 1 2020 Claims Will be Denied Without MBIs
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 23rd, 2019
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, ...
CMS- Patient Driven Payment Model Effective October 01, 2019
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 19th, 2019
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 ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 9th, 2019
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 ...
Q/A: Can I Order a TENS unit for a Medicare Patient?
By Wyn Staheli, Director of Research | Published December 3rd, 2019 - Last Review/Update December 4th, 2019
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 ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 11th, 2019
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...
By Namas | Published October 11th, 2019 - Last Review/Update October 15th, 2019
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 ...
Are You Aware of Medicare Advantage Plans Timely Filing Rules?
By Aimee Wilcox | Published August 20th, 2019
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 ...
Will Medicare Change Their Rules Regarding Coverage of Services Provided by a Chiropractor?
By Wyn Staheli, Director of Research | Published August 13th, 2019
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.
By Namas | Published August 2nd, 2019 - Last Review/Update August 8th, 2019
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 ...
Anthem is Changing their Timely Filing Requirements for All Plans, Including Medicare Advantage
By Namas | Published July 26th, 2019 - Last Review/Update August 8th, 2019
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 ...
Helping Others Understand How to Apply Incident to Guidelines
By Namas | Published July 5th, 2019 - Last Review/Update July 16th, 2019
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 ...
By Namas | Published June 14th, 2019 - Last Review/Update June 18th, 2019
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 ...
Now is Your Chance to Speak Up! Tell CMS What You Think!
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 13th, 2019
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 ...
By Wyn Staheli, Director of Research | Published April 29th, 2019
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 ...
By Wyn Staheli, Director of Content | Published April 26th, 2019
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.
By By Evan M. Gwilliam, DC MBA BS CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow Clinical Director, PayDC Chiropractic EHR Software President, Gwilliam Consulting LLC drgwil@gmail.com | Published April 22nd, 2019
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.
Q/A: What do I do When a Medicare Patient Refuses to Sign an ABN?
By Wyn Staheli, Director of Research | Published April 8th, 2019
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 ...
Q/A: Can I Tell a Medicare Patient Which Option to Check on the ABN?
By Wyn Staheli, Director of Research | Published April 1st, 2019 - Last Review/Update April 2nd, 2019
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 ...
Clearing Up Some Medicare Participation Misunderstandings
By Wyn Staheli, Director of Research | Published March 25th, 2019 - Last Review/Update April 2nd, 2019
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 ...
By Wyn Staheli, Director of Research | Published March 7th, 2019
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.
Q/A: Can you Help me Understand the New Medicare Insurance Cards?
By Wyn Staheli, Director of Research | Published March 7th, 2019
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.
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 12th, 2019
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 ...
HHS Proposes Significant Changes to Patient Access Rules
By Wyn Staheli, Director of Research | Published February 11th, 2019
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 ...
Charging Missed Appointment Fees for Medicare Patients
By Wyn Staheli, Director of Research | Published February 7th, 2019 - Last Review/Update February 8th, 2019
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 ...
Attestations Teaching Physicians vs Split Shared Visits
By BC Advantage | Published February 1st, 2019 - Last Review/Update February 7th, 2019
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 ...
By Find-A-Code | Published January 28th, 2019 - Last Review/Update January 29th, 2019
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 ...
By Wyn Staheli, Director of Research | Published January 3rd, 2019
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 ...
Medicare Advantage Providers are not Required to be Enrolled in Medicare
By Wyn Staheli, Director of Research | Published December 18th, 2018
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 ...
Errors Billing Outpatient Services When Patient is also Inpatient
By Wyn Staheli, Director of Research | Published November 29th, 2018
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, QCC, CMCS, CPC, CMRS | Published November 26th, 2018
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 ...
CMS: Medicare Diabetes Prevention Program Expanded Model
By Find-A-Code | Published November 1st, 2018
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...
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...
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 ...
By Noridian Medicare | Published August 30th, 2018
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 ...
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 ...
By Terry Ketchersid, MD, MBA | Published July 27th, 2018 - Last Review/Update September 24th, 2018
Today's catchy title may invoke memories of that risqué movie from the 80's starring a young Tom Cruise famously dancing in his "tighty whities." But today's post is not about that type of risk. Instead we are going to spend some time with a risk adjustment model that's quietly become...
CMS Proposes Changes to Evaluation & Management Requirements
By Wyn Staheli, Director of Research | Published July 25th, 2018
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 ...
Provider-Based Facilities and Split Billing: Is Your Facility Being Reimbursed for All Work Performed?
By | Published July 18th, 2018
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 ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 18th, 2018
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 ...
Attention Providers - Please Make Time to Read this Letter
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 17th, 2018
In an effort to show CMS is committed to changing the rules to accommodate their providers CMS released a letter to Doctors of Medicare Beneficiaries. The letter offers encouragement and a promise to reduce the burden of unnecessary rules and requirements. The letter states “President Trump has made it clear that ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 16th, 2018 - Last Review/Update July 17th, 2018
According to CMS changes are coming for E/M codes. A recent proposal from CMS stated: "The E/M visit code set is outdated and needs to be revised and revalued." Since podiatry tends to furnish a lower level of E/M visits, CMS is proposing new G-codes to report E/M office/outpatient visits. The proposed ...
By Wyn Staheli, Director of Research | Published July 12th, 2018
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 ...
ESRD Claims Error: Transitional Drug Adjustment Add-On Payment Adjustment
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 9th, 2018
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 ...
How Does the Physician Compare Website Affect You?
By Wyn Staheli, Director of Research | Published June 25th, 2018
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 ...
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.
Why Is Medicare Denying My Claims for Mammography and Breast Biopsies?
By BC Advantage | Published June 4th, 2018
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...
By Sean M. Weiss & Frank Cohen | Published May 30th, 2018 - Last Review/Update June 4th, 2018
This year (2018), healthcare organizations (Hospitals, Health Systems, and Physician Groups/Practices) must focus on the criticality of creating a culture of compliance to ensure effectiveness and efficiency. Focusing on "compliance"-only approaches leaves healthcare organizations exposed to areas of liability oftentimes far more than what they could ever imagine or even...
By Shannon Cameron, MBA, MHIIM, CPC | Published May 14th, 2018 - Last Review/Update May 24th, 2018
The release of the 2018 Final Rule for the Outpatient Prospective Payment System (OPPS) in November 2017 has created quite a stir across the orthopedic healthcare community. In what has been deemed a questionable decision, the Centers for Medicare and Medicaid Services (CMS) decided to remove Total Knee Arthroplasty...
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...
The PSAVE Pilot Program: Should You Self-Audit Your Medicare Claims?
By Robert Liles, JD, MBA, MS | Published April 20th, 2018 - Last Review/Update April 25th, 2018
As the Medicare program has grown, the Centers for Medicare and Medicaid Services (CMS) has employed a variety of different claims audit mechanisms to better ensure that the Medicare Trust Fund is protected from waste, fraud and abuse....
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 9th, 2018
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 ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 29th, 2018
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 ...
Medicare Beneficiary Identifier (MBI) Beginning April 1, 2018 (This is Not a Joke)
By Brittney Murdock, QCC, CMCS, CPC | Published March 21st, 2018
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...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 21st, 2018 - Last Review/Update March 27th, 2018
Medicare’s policy requires the use of a different code when a screening colonoscopy becomes a diagnostic procedure requiring you to bill with CPT code 00811 when treating a Medicare Beneficiary.
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 15th, 2018
The Medicare Learning Network provides guidance on denials for lower leg prostheses and how to prevent them:
For the 2017 report period, most of the improper payments for lower leg prostheses were due to insufficient documentation.
For Medicare to cover a lower limb prosthesis claim, the medical record must support the beneficiary’s ...
By Wyn Staheli, Director of Research | Published March 1st, 2018
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 ...
Medicare Using Private Payor Prices to Set Payment Rates for Clinical Diagnostic Laboratory Tests Starting January 2018
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 6th, 2018
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 Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 1st, 2018
CMS announced today, during the time that the partial government shutdown is in effect, Medicare Administrative Contractors will continue to perform all functions related to Medicare fee-for-service claims processing and payment.
...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 31st, 2018
With this year's Flu season being the most widespread on record, providers are seeing more patients and giving more immunizations for influenza than normal. Here are a few things to keep in mind during this flu season.
Know the rules with your payers to ensure proper reimbursement and correct billing. For example, did you ...
By Wyn Staheli, Director of Research | Published January 25th, 2018
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 ...
NEW on Find-A-Code...National Coverage Determinations (NCDs)
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 23rd, 2018 - Last Review/Update January 25th, 2018
Medicare limits its coverage of services to those considered to be reasonable and necessary for the diagnosis and treatment of an injury or illness based on coverage guidelines. National Coverage Determinations (NCDs) are created based on research, evidence-based processes, public participation, and other resources, and made available to the public. ...
Medicare's Integrated Behavioral Healthcare Services and Collaborative Care Program
By Wyn Staheli, Director of Research | Published January 18th, 2018
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 Wyn Staheli, Director of Research | Published January 10th, 2018
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 ...
MIPS - To Participate or Not Participate - That is the Question
By Wyn Staheli, Director of Research | Published January 10th, 2018
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 ...
CMS Launches Data Submission System for Clinicians in the Quality Payment Program
By Find-A-Code | Published January 4th, 2018
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...
Filing a CMS-1500 Claim form to Medicare PUB-100 40.1.1.1
By Find-A-Code | Published January 4th, 2018
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., ...
Physical Therapist can now bill for a substitute Physical Therapist
By Find-A-Code | Published January 4th, 2018
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' ...
By Wyn Staheli, Director of Research | Published January 2nd, 2018 - Last Review/Update January 30th, 2019
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
Appropriate Use Criteria for Advanced Diagnostic Imaging Services - 2018 Final Rule
By Jared Staheli | Published December 13th, 2017
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 ...
Medicare Diabetes Prevention Program (MDPP) Expanded Model Information
By Jared Staheli | Published December 12th, 2017
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 ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 11th, 2017
CMS posted new Merit-based Incentive Payment System (MIPS) resources on Quality Payment Program Resource Library webpage:
CMS Web Interface: Excel template for uploading sample beneficiary data with corresponding user guide and instructional video
Extreme and Uncontrollable Circumstances Fact Sheet: Overview of the policy established in the interim final rule with comment period to support clinicians affected by the California wildfires and ...
By Wyn Staheli, Director of Research | Published November 28th, 2017
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 ...
By David Klein CPC, CPMA, CHC | Published October 31st, 2017 - Last Review/Update February 5th, 2019
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.
Avoid Deactivation of your Medicare Billing Privileges
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 18th, 2017
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 CPCO CMCO CPMA QCC | Published October 13th, 2017 - Last Review/Update February 5th, 2019
Chiropractors cannot opt-opt of Medicare. Does that only refer to chiropractors that see Medicare patients? Do all Florida chiropractors have to complete Medicare enrollment/credentialing? Bottom line- do ALL chiropractors, no matter where or who, have to complete Medicare enrollment since they cannot Opt-out?
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 20th, 2017
CMS recently released a new LCD for Jurisdiction F, Bladder/Urothelial Tumor Markers (L36680).
Documentation Requirements
The medical record must clearly identify the number and frequency of bladder marker testing. Medical record documentation must be legible, must be maintained in the patient’s medical record (hard copy or electronic copy), and must meet the ...
American Chiropractic Association Comments on MACRA 2018 Proposed Rule
By ChiroCode | Published September 1st, 2017 - Last Review/Update January 30th, 2019
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 | Published September 1st, 2017 - Last Review/Update February 2nd, 2018
The following information from the Medicare Learning Network provides guidance from the Department of Health and Human Services on Cardiovascular Disease Screening Tests:
80061 -
Lipid panel, this panel must include the following:
82465 - Cholesterol, serum, total
83718 - Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol)
84478 - Triglycerides
Z13.6
All Medicare beneficiaries without apparent signs or symptoms ...
Preventive Services: Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)....
Preventive Services: Lung Cancer Counseling and Annual Screening for Lung Cancer With LDCT
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Lung Cancer Screening Counseling, and Annual Screening for Lung Cancer With Low Dose Computed Tomography (LDCT)....
Preventive Services: Screening for Cervical Cancer with Human Papillomavirus (HPV) Tests
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Screening for Cervical Cancer with Human Papillomavirus (HPV) Tests....
Preventive Services: Screening for STIs and High Intensity Behavioral Counseling (HIBC) to Prevent STIs
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs.....
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Screening Pelvic Examinations (includes a clinical breast examination)....
By Sean Weiss, CHC, CMCO, CEMC, CPMA, CMPE, CPC-P, CPC | Published August 25th, 2017 - Last Review/Update January 31st, 2018
On June 29th, The Centers for Medicare and Medicaid (CMS) issued the Medicare Program: "Changes to the Medicare Claims and Entitlement, Medicare Advantage and Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedures final rule."
By Dr. Mario Fucinari, Author & Member of the Carrier Advisory Committee for Medicare | Published June 28th, 2017 - Last Review/Update February 8th, 2019
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.
By ChiroCode | Published May 12th, 2017 - Last Review/Update January 31st, 2019
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.
By Wyn Staheli, Director of Research | Published February 23rd, 2017
Compliance has a new standard for emergency preparedness plans. On September 8, 2016, CMS issued the final rule titled “Emergency preparedness requirements for Medicare and Medicaid participating providers and suppliers.” This rule creates emergency preparedness Medicare Conditions of Participation (COPs).
There are specific standards for each of the named types of providers ...
CMS Issues Proposed Rule to Increase Patients’ Health Insurance Choices for 2018
By CMS.gov | Published February 15th, 2017
The Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule for 2018, which proposes new reforms that are critical to stabilizing the individual and small group health insurance markets to help protect patients.
By Wyn Staheli, Director of Research | Published February 11th, 2017
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 ...
Code Sets - Health Care Provider Taxonomy Code Set Link
By Raquel Shumway | Published January 24th, 2017
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.
By Wyn Staheli, Director of Research | Published January 23rd, 2017
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 ...
By Brittney Murdock, QCC, CMCS, CPC | Published January 6th, 2017
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) ...
By Brittney Murdock, QCC, CMCS, CPC | Published December 30th, 2016
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.
VACCINE AND VACCINE ADMINISTRATION PAYMENTS UNDER MEDICARE PART D
By Brittney Murdock, QCC, CMCS, CPC | Published December 16th, 2016
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 ...
International Classification of Diseases (ICD)-10 Code Updates and Impact to 4th Quarter 2016 Eligible Professional Medicare Quality Programs
By CMS.gov | Published December 15th, 2016
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...
CMS Announces Additional Opportunities for Clinicians Under the Quality Payment Program
By Brittney Murdock, QCC, CMCS, CPC | Published December 15th, 2016
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 Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 13th, 2016
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 ...
By Wyn Staheli, Director of Research | Published December 12th, 2016
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.
By ChiroCode | Published November 19th, 2016 - Last Review/Update March 5th, 2019
(from page 210 in chapter 3.5 of the 2017 DeskBook) One of the biggest problems providers face when audited is that many services are deemed not medically necessary and are routinely denied. Much of the proof falls back on the medical record.
Here are some specific situations as they may ...
CMS Finalizes the New Medicare Quality Payment Program
By ChiroCode | Published October 17th, 2016 - Last Review/Update March 5th, 2019
On October 14, HHS finalized its policy implementing the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM) incentive payment provisions in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), collectively referred to as the Quality Payment Program.
By Wyn Staheli, Director of Research | Published September 17th, 2016
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 ...
Looking forward to a 9% payment increase for Medicare Part B
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 9th, 2016
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 ...
CMS offering options for MACRA Participation. You Choose - Be prepared!
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 9th, 2016
The most recent Blog Post from CMS has given a new update on The bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). CMS states they will allow providers four options of reporting for the first year of the program stating they can pick their pace of participation for the ...
Continuing the commitment to greater data transparency, the Centers for Medicare & Medicare Services (CMS) today released privacy-protected data on the prescription drugs that were paid for under the Medicare Part D Prescription Drug Program in 2014. This is the second release of the data on an annual basis, which...
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...
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.
The federal government’s readmission penalties on hospitals will reach a new high as Medicare withholds more than half a billion dollars in payments over the next year, records released Tuesday show. The government will punish more than half of the nation’s hospitals — a total of 2,597...
CMS Announces Proposed Payment Changes for Medicare Home Health Agencies for 2017 (CMS-1648-P)
By Brittney Murdock, QCC, CMCS, CPC | Published June 27th, 2016
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 ...
Medicare Will Use Private Payor Prices to Set Payment Rates for Clinical Diagnostic Laboratory Tests Starting in 2018
By Brittney Murdock, QCC, CMCS, CPC | Published June 23rd, 2016
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 ...
Mastering Medicare: When Opting Out is not an Option
By Dr. Ray Foxworth, Certified Medical Compliance Specialist and President of ChiroHealthUSA | Published June 15th, 2016 - Last Review/Update March 5th, 2019
Unlike MDs and DOs, chiropractors may not opt out of Medicare.
When it comes to Medicare, providers and patients alike feel like beating their heads against the wall. Signing up to be a provider or a patient is confusing, understanding what is covered is confusing and just about the time you think you have it figured out, you receive a notice that suggests you don’t.
The hassles of Medicare certainly validate any sane person questioning whether they should see a Medicare patient, but with the rising number of Medicare patients in the US do you really want to limit your patient base?
Mandatory Submission of Staffing Data via PBJ Begins July 1 for Long – Term care facilities
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 9th, 2016
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 ...
CMS Publishes Final Rule on Fire Safety Requirements for Certain Health Care Facilities
By Brittney Murdock, QCC, CMCS, CPC | Published May 3rd, 2016
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; ...
CMS Finalizes its Quality Measure Development Plan
By Kate Goodrich, M.D., M.H.S., Director, Center for Clinical Standards & Quality, CMS | Published May 3rd, 2016
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 ...
CMS Publishes Final Rule on Fire Safety Requirements for Certain Health Care Facilities
By Brittney Murdock, QCC, CMCS, CPC | Published May 3rd, 2016
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 Wyn Staheli, Director of Research | Published April 13th, 2016
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.
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.
By InstaCode Institute | Published February 15th, 2016
CMS is developing a new Unified Program Integrity Contractor (UPIC) program to consolidate Medicare and Medicaid reviews. This consolidation of the Medicaid Integrity Contractors (MICs) and the Medicare Zone Program Integrity Contractors (ZPICs) could relieve some of the overlap and burdens under the current systems.
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 Wyn Staheli, Director of Research | Published January 29th, 2016
The Merit-Based Incentive Payment System (MIPS) combines PQRS, VM, and EHR into a single Medicare pay-for-performance quality payment system scheduled to begin in 2019.
6 ways to stop filing duplicate Medicare claims - Duplicates could expose your practice to fraud investigation
By | Published January 6th, 2016
Whenever a Medicare Administrative Contractor (MAC) releases a list of the top reasons for claims denials, the list almost never fails to include duplicate claims. When the MAC perceives the claim to be a duplicate, based typically on a match of the patient identifying information, furnishing...
Preventive Medicine Services for Medicare Patients
By Codapedia | Published January 6th, 2016
The most widely known fact about Medicare and preventive medicine is that fee-for-service Medicare does not cover an annual physical exam. This is because in its beginning, Medicare was prohibited from paying for routine services. Over the years, Congress has mandated the payment of some screening...
Are the following statements true or false? • The PCP cannot be paid to do a pre-op assessment of a Medicare patient prior to surgery because of the new consult rules. • The surgeon can never be paid to do a pre-op visit if s/he...
CMS Announces: Final Rule on Authorization Process for Certain Durable Medical Equipment
By Brittney Murdock, QCC, CMCS, CPC | Published January 5th, 2016
CMS has established a new prior authorization process for DMEPOS items that are frequently subject to unnecessary utilization. The final rule will create an initial Master list that includes items that meet specific criteria.
Items already on the Master List that are identified by a GAO/OIG, or CERT DME and/or DMEPOS ...
By Aimee Wilcox, MA CST CCS-P | Published December 21st, 2015
If your organization performs incident-to services, be sure to perform a periodic review of the rules that govern incident to and then compare them to the practices of your providers to ensure they would pass an audit. Here are just a few of the guidelines that should be reviewed; however, ...
CMS clarified in 2007 that a physician practice may bill Medicare patients for failing to keep an appointment. The CMS MedLearn matters article is attached as a resource. Check with your state Medicaid to see if you can bill Medicaid patients. If you are billing Medicare...
CMS clarifies the ways physician practices can respond to additional documentation requests
By | Published December 2nd, 2015
It’s one of the inevitabilities of running a physician practices that never happens at a good time and seems to rarely go very smoothly. You see an additional documentation request – known as an ADR – from either your Medicare Administrative Contractor (MAC) or one of...
You do not need to change or rewrite your original orders
By Find-A-Code | Published November 24th, 2015
CMS wants to remind you not to change or rewrite your original orders for any service or product due to the change of code sets from ICD-9-CM to ICD-10-CM.
For any type of product or service prior to October 1, 2015, do not change the order, even if it will be ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 24th, 2015
Prescription (order) Requirements face-to-face examination is required each time a new prescription for one of the specified items is ordered. A new prescription is required by Medicare:
• For all claims for purchases or initial rentals
• When there is a change in the prescription for the accessory, supply, drug, etc.
• If ...
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 ...
Fee For Service Advance Beneficiary Notice of Noncoverage - Free
By Find-A-Code | Published November 9th, 2015
Fee For Service Advance Beneficiary Notice of Noncoverage
The Advanced Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is issued by providers (including independent laboratories, home health agencies, and hospices), physicians, practitioners, and suppliers to Original Medicare (fee for service) beneficiaries in situations where Medicare payment is expected to be denied. Guidelines ...
National Supplier Clearinghouse - SUGGESTED TEMPLATES FOR COMPLIANCE WITH CERTAIN SUPPLIER STANDARDS - FREE
By Find-A-Code | Published November 9th, 2015
The attached model forms were created in an effort to educate suppliers regarding certain supplier standards listed in 42 CFR.424.57(c). Please note that these forms are simply templates and suppliers should feel free to create their own forms. Suppliers using their own forms must ensure the forms are capturing and documenting information ...
DME MAC Jurisdiction A ASCA Waiver Request Form - Free
By Find-A-Code | Published November 9th, 2015
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.
...
Medicare Redetermination Request Form - The Redetermination Request Form is for all DMEPOS suppliers to use when submitting a redetermination request. The form is designed so that users can easily include all of the basic information needed to submit a redetermination request and is valid in all four DME MAC Jurisdictions. A ...
Medicare Reopening Request Form - The Reopening Request Form is for all DMEPOS suppliers to use when submitting a Reopening request. The form is designed so that users can easily include all of the basic information needed to submit a Reopening request and is valid in all four DME MAC Jurisdictions. A ...
PMD Prior Authorization Demonstration Coversheet - This coversheet is used for items associated with the PMD Prior Authorization Demonstration. More information concerning the PMD Prior Authorization Demonstration can be found on the CMS Web site.
...
By Christine Taxin | Published September 25th, 2015
Coordination of benefits, (COB) is a clause in most group policies, which is in place to minimize the over-payment or duplicate payment of claims. COB applies to patients covered by more than one insurance plan and limits the amount paid by each plan.
With the COB clause the payments made by ...
Medicare Makes Moderate Sedation Payable
Christine Taxin
Should your primary care physicians ever find cause to perform moderate sedation, you’ll be interested in a new Medicare policy that may make it payable as of Oct. 1. Medicare Pub. 100-04 Transmittal 1324 finally makes Medicare policy consistent with the fee schedule pricing for ...
Dental practices that do not work with medical are truly confused when it comes to Medicare. I decided to put together a simple outline of what we should be doing to be compliant with Medicare.
Summary of Adjustments to Fee Schedule Computations (Rev.1931, Issued:03-12-10)
By | Published August 19th, 2015
For services prior to January 1, 1994, B/MACs computed the fee schedule amount for every service. Through 1995, the fee schedule amount is the transition fee schedule amount. For services after 1995, CMS computes and provides the fee schedule amount for every service discussed below. Certain adjustments are made in ...
Chiropractic Listed as Focal Point in 2015 OIG Work Plan
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published August 19th, 2015 - Last Review/Update January 30th, 2017
With the recent release of the 2015 OIG Work Plan, many providers and facilities are reviewing the content to learn which areas of interest pertaining to their specialty will be points of interest for federal auditing programs for the 2015 Fiscal Year. The information contained in this Work Plan addresses the ...
First Physician Fee Schedule Proposed Rule Since SGR Repeal
By Wyn Staheli, Director of Research | Published August 19th, 2015
Even though the SGR has been repealed, providers still need to be aware of annual fee revisions by CMS. On July 8, 2015, CMS announced their first proposed Medicare Physician Fee Schedule (MFPS) since the SGR repeal. As in years past, there will continue to be reviews of the Relative Value ...
G-Codes for Functional Reporting and Severity/Complexity Modifiers
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 19th, 2015
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 ...
Opting out of Medicare Electing to Order/Certify Items and Services to Medicare Beneficiaries
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 10th, 2015
Physicians and practitioners who do not wish to enroll in the Medicare program may “opt-out” of Medicare. This means that neither the physician, nor the beneficiary submits the bill to Medicare for services rendered. Instead, the beneficiary pays the physician out-of-pocket and neither party is reimbursed by Medicare. A private ...
Notice of Election (NOE) - Form CMS - 1450 (Rev. 3118)
By Find-A-Code | Published August 3rd, 2015
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 ...
Levels of Care Data Required on the Institutional Claim to Medicare Contractor
By | Published August 3rd, 2015
With the exception of payment for physician services, Medicare payment for hospice care is made at one of four predetermined rates for each day that a Medicare beneficiary is under the care of the hospice. The four rates are prospective rates; there are no retroactive adjustments other than the application ...
Method for Computing Fee Schedule Amount (Rev. 1, 10-01-03)
By | Published August 3rd, 2015
B3-15006
The CMS continually updates, refines, and alters the methods used in computing the fee schedule amount. For example, input from the American Academy of Ophthalmology has led to alterations in the supplies and equipment used in the computation of the fee schedule for selected procedures. Likewise, new research has changed ...
Carriers pay for physicians’ services furnished on or after January 1, 1992, on the basis of a fee schedule. The Medicare allowed charge for such physicians’ services is the lower of the actual charge or the fee schedule amount. The Medicare payment is 80 percent of the allowed charge after ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 3rd, 2015
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 ...
Hospice Pre - Election Evaluation and Counseling Services (Rev. 2258)
By Find-A-Code | Published July 20th, 2015
Effective January 1, 2005, Medicare allows payment to a hospice for specified hospice pre-election evaluation and counseling services when furnished by a physician who is either the medical director of or employee of the hospice.
Medicare covers a one-time only payment on behalf of a beneficiary who is terminally ill, (defined ...
Formats for Submitting Claims to Medicare - Electronic Submission Requirements
By Find-A-Code | Published July 20th, 2015
(Rev. 3086, Issued: 10-03-14, Effective: ICD-10: Upon Implementation of ICD-10, ASC X12: January 1, 2012, Implementation ICD-10: Upon Implementation of ICD- 10; ASC X12: November 4, 2014)
The Administrative Simplification Compliance Act (ASCA) requires that claims be submitted to Medicare electronically unless certain exceptions are met. In addition, the Health Insurance ...
(Rev. 3086, Issued: 10-03-14, Effective: ICD-10: Upon Implementation of ICD-10, ASC X12: January 1, 2012, Implementation ICD-10: Upon Implementation of ICD- 10; ASC X12: November 4, 2014)
The standards adopted under HIPAA include both a transaction standard and an implementation guide.
Claims sent electronically to Medicare must abide by the HIPAA standards ...
Payment Jurisdiction Among A/B MACs (B) for Services Paid Under the Physician Fee Schedule and Anesthesia Services (Rev. 3086)
By Find-A-Code | Published July 20th, 2015
(Rev. 3086, Issued: 10-03-14, Effective: ICD-10: Upon Implementation of ICD-10, ASC X12: January 1, 2012, Implementation ICD-10: Upon Implementation of ICD- 10; ASC X12: November 4, 2014) The jurisdiction for processing a request for payment for services paid under the Medicare Physician Fee Schedule (MPFS) and for anesthesia services is ...
Payment Jurisdiction for Services Subject to the Anti-Markup Payment Limitation
By Find-A-Code | Published July 20th, 2015
(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)
Diagnostic tests and their interpretations are paid on the MPFS. Therefore, they are subject ...
Claims Processing Requirements for Deported Beneficiaries (Rev. 943, Issued: 05-05-06)
By Find-A-Code | Published July 17th, 2015
Section 202(n) of the Social Security Act (the Act), requires the termination of Title II benefits upon deportation. Moreover, Sections 226 and 226(A) of the Act provide that no payments may be made for benefits under Part A of Title XVIII of the Act if there is no monthly benefit ...
Implementation of Payment Policy for Deported Medicare Beneficiaries (Rev. 943, Issued: 05-05-06)
By Find-A-Code | Published July 17th, 2015
A. CWF Editing of Claims
1. An auxiliary file shall be established in the Common Working File to contain deportation status.
2. This auxiliary file will be the basis for an edit that rejects claims submitted by Medicare contractors.
3. The edit will reject a claim where the beneficiary HIC number on ...
Provider Assignment to FIs and MACs (Rev. 1707; Issued: 03-27-09)
By Find-A-Code | Published July 17th, 2015
A. The Process of Moving Providers from FIs to MACs
1. The General Case
An existing Medicare provider with a claims history will remain in its current workload assignment. As each MAC contract is awarded, the new MAC will take over workload from the carriers and FIs that serviced the state(s) in ...
FI Service to HHAs and Hospices (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
Under 42 CFR 421.117, CMS is authorized to designate RHHIs to service HHAs and hospices. This provision was implemented through the designation of regional FIs to service all HHAs and hospices. See http://www.cms.hhs.gov/contacts/incardir.asp for RHHI jurisdictions.
An HHA or hospice chain may request to be served under an arrangement involving a ...
Provider Change of Ownership (CHOW) (Rev. 861, Issued: 02-17-06)
By Find-A-Code | Published July 17th, 2015
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 ...
CMS No Longer Accepts Provider Requests to Change Their FI (Rev. 2876, Issued: 02-07-14)
By Find-A-Code | Published July 17th, 2015
Medicare providers will no longer be able to request a change of FI, they must remain with the FI to which they have been assigned.
Pub 100-04 Medicare Claims Processing Manual
...
The RO uses the provider tie-in notice, Form CMS-2007 (see the CMS forms page at http://www.cms.hhs.gov/forms/), as an official notification to the FI of a change in its list of providers. The RO completes and transmits a Form CMS-2007 to the home office of the FI in each of the ...
Content and Terms of Provider Participation Agreements (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
In the agreement/attestation statement signed by a provider serviced by an FI, the provider agrees to maintain its compliance with all of the conditions for certification in 42 CFR 491. If a provider fails to maintain compliance with one or more of the conditions, it must promptly report this (usually ...
Provider Charges to Beneficiaries (Rev. 2921, Issued: 04-04-14)
By Find-A-Code | Published July 17th, 2015
In the agreement/attestation statement signed by a provider, it agrees not to charge Medicare beneficiaries (or any other person acting on a beneficiary’s behalf) for any service for which Medicare beneficiaries are entitled to have payment made on their behalf by the Medicare program. This includes items or services for ...
Charges to Hold a Bed During SNF Absence (Rev. 1522, Issued: 05-30-08)
By Find-A-Code | Published July 17th, 2015
Charges to the beneficiary for admission or readmission are not allowable. However, when temporarily leaving a SNF, a resident can choose to make bed-hold payments to the SNF.
Bed-hold payments are readily distinguishable from payments made prior to initial admission, in that the absent individual has already been admitted to the ...
Provider Refunds to Beneficiaries (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
In the agreement between CMS and a provider, the provider agrees to refund as promptly as possible any money incorrectly collected from Medicare beneficiaries or from someone on their behalf.
Money incorrectly collected means any amount for covered services that is greater than the amount for which the beneficiary is liable ...
Provider Treatment of Beneficiaries (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
In the agreement between CMS and a provider, the provider agrees to accept Medicare beneficiaries for care and treatment. The provider cannot impose any limitations with respect to care and treatment of Medicare beneficiaries that it does not also impose on all other persons seeking care and treatment. If the ...
Assignment of Provider’s Right to Payment (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
Except as provided in §30.2.1, FIs pay benefits due a provider only to the provider.
Carriers may pay assigned benefits only to the physician, practitioner, or supplier who furnished the service. They do not pay the benefits to any other person or organization under an assignment or reassignment, power of attorney, ...
Exceptions to Assignment of Provider’s Right to Payment – Claims Submitted to A/B MACs (Rev. 1931, Issued: 03-12-10)
By Find-A-Code | Published July 17th, 2015
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 ...
Background and Purpose of Reassignment Rules - Claims Submitted to B/MACs (Rev. 1931, Issued: 03-12-10)
By Find-A-Code | Published July 17th, 2015
In 1972, Congress acted to stop a practice under which some physicians and other suppliers providing covered services reassigned their Medicare and Medicaid receivables to other organizations and groups, which then claimed and received payment. Often the organizations acquired the claims at a percentage of face value. It had become ...
Reassignments by Nonphysician Suppliers - Claims Submitted to FIs (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
Definition of Participating From MIM 3005
Nonphysician suppliers may reassign benefits under conditions similar to those under which physicians reassign benefits. Note, however, that when a supplier furnishes services to patients of a participating provider (e.g., a participating hospital or SNF) under arrangement (within the meaning of §1861(w) of the ...
Effect of Payment to Ineligible Recipient (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
An otherwise correct Medicare payment made to an ineligible recipient under an assignment or other authorization by the provider does not constitute a program overpayment. Sanctions may be invoked against a provider (see §30.2.15) to prevent it from executing or continuing in effect such an authorization in the future. Neither ...
Payment to Agent - Claims Submitted to Carriers (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
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 ...
Medicare payments due a provider or supplier of services may be sent to a bank (or similar financial institution) for deposit in the provider/supplier’s account so long as the following requirements are met:
• The bank may provide financing to the provider/supplier, as long as the bank states in writing, in ...
Payment to Employer of Physician - Carrier Claims Only (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
The carrier may pay Part B benefits for covered physician services under an assignment or for enrollees that did not execute assignment before death to the physician’s employer, provided that under the terms of the physician’s employment, only the employer and not the physician has the right to charge or ...
Payment for Services Provided Under a Contractual Arrangement - Carrier Claims Only (Rev. 472, Issued: 02-11-05)
By Find-A-Code | Published July 17th, 2015
A carrier may make payment to an entity (i.e., a person, group, or facility) enrolled in the Medicare program that submits a claim for services provided by a physician or other person under a contractual arrangement with that entity, regardless of where the service is furnished. Thus, the service may ...
University-Affiliated Medical Faculty Practice Plans - Claims Submitted to Carriers (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
A carrier may make Part B payment to a university-affiliated medical faculty practice plan that has the following attributes:
• There is a written agreement between the Governing Board of the University and the Governing Board of the Medical Faculty Practice Plan describing the relationship between both parties.
• The Medical Faculty ...
Indirect Payment Procedure (IPP) - Payment to Entities that Provide Coverage Complementary to Medicare Part B (Rev. 2896, Issued: 03-07-14)
By Find-A-Code | Published July 17th, 2015
Medicare Part B payment otherwise payable to a beneficiary for the services of a physician or supplier who charges on a fee-for-service basis may be paid to an entity using the indirect payment procedure (IPP). Any entity registered in accordance with the instructions in Pub. 100-08, chapter 15, sections 15.7.9 ...
Payment to Physician or Other Supplier for Diagnostic Tests Subject to the Anti-Markup Payment Limitation - Claims Submitted to A/B MACs (B) (Rev. 3089, Issued: 10-21-14)
By Find-A-Code | Published July 17th, 2015
(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 ...
Payment Under Reciprocal Billing Arrangements - Claims Submitted to Carriers (Rev. 1486, Issued: 04-04-08)
By Find-A-Code | Published July 17th, 2015
The patient’s regular physician may submit the claim, and (if assignment is accepted) receive the Part B payment, for covered visit services (including emergency visits and related services) which the regular physician arranges to be provided by a substitute physician on an occasional reciprocal basis, if:
• The regular physician is ...
Physician Payment Under Locum Tenens Arrangements - Claims Submitted to Carriers (Rev. 1486, Issued: 04-04-08)
By Find-A-Code | Published July 17th, 2015
A. Background
It is a longstanding and widespread practice for physicians to retain substitute physicians to take over their professional practices when the regular physicians are absent for reasons such as illness, pregnancy, vacation, or continuing medical education, and for the regular physician to bill and receive payment for the ...
Establishing That a Person or Entity Qualifies to Receive Payment on Basis of Reassignment - for Carrier Processed Claims (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
Any person or entity wishing to receive Part B payment as a reassignee of one or more physicians (or other practitioner or supplier), or as the supplier of the services, must furnish to the carrier sufficient information to establish clearly that it qualifies to receive payment for those services. Where ...
Billing Procedures for Entities Qualified to Receive Payment on Basis of Reassignment - for A/B MAC (B) Processed Claims (Rev. 3086, Issued: 10-03-14)
By Find-A-Code | Published July 17th, 2015
Except where otherwise noted, the following procedures apply to both assigned and unassigned claims submitted by medical groups and other entities entitled to bill and receive payment for physician services under §§30.2-30.2.8. They are used whether the charges are compensation related or non-compensation related.
A General
Chapter 26 contains general claims ...
A. Disseminating Information
From time to time, A/B MACs must disseminate through professional relations media information regarding the prohibition in §30.2.
A/MACs
The following language may be used by A/MACs or adapted for this purpose: The Medicare law prohibits us from paying benefits due a provider to another person or organization ...
A. Developing Questionable Payment Arrangements
Contractors (both FIs and Carriers) should assume that an arrangement in which Medicare payment is being sent or is to be sent to an address other than the physical location of the provider/supplier is consistent with the requirements of §30.2 in the absence of evidence ...
Sanctions for Prohibited Payment Arrangement (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
A. Advice to Provider
If the contractor finds that a provider (for Part B, physician or other supplier, or party eligible to receive the payment under §30.2 as an employer, facility or organization) has entered into, or is considering entering into, a payment arrangement prohibited by §30.2, the contractor must ...
A. Basic Prohibition
Except as provided in subsection B, carriers pay only the beneficiary (or beneficiary legal representative or representative payee) benefits payable directly to the beneficiary FIs do not send money directly to beneficiaries, they must require providers they pay to refund monies to beneficiaries when circumstances so warrant ...
Institutional providers (those that bill Fiscal Intermediaries (FIs)) are paid direct by the FI. In contrast, physicians, practitioners, and suppliers that bill the carrier may choose to enter into a participation agreement.
Carrier “Participating Providers” are paid at 100 percent of the physician fee schedule and must accept assignment (must accept ...
Mandatory Assignment on Carrier Claims (Rev. 2487, Issued: 06-08-12)
By Find-A-Code | Published July 17th, 2015
The following practitioners who provide services under the Medicare program are required to accept assignment for all Medicare claims for their services. This means that they must accept the Medicare allowed amount as payment in full for their practitioner services. The beneficiary’s liability is limited to any applicable deductible plus ...
Processing Claims for Services of Participating Physicians or Suppliers by Carriers (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
The participating physician or supplier submits any claims for services furnished by the physician or supplier, except in the limited circumstances specified in §30.2.8.3 or §30.2.16. (The exception concerns situations where the physician or supplier accepts, as full payment, payment by certain organizations.) When an unassigned claim is received from ...
Nature and Effect of Assignment on Carrier Claims (Rev. 643, Issued: 08-12-05)
By Find-A-Code | Published July 17th, 2015
Assignment is a written agreement between beneficiaries, their physicians or other suppliers, and Medicare. The beneficiary agrees to let the physician or other supplier request direct payment from Medicare for covered Part B services, equipment, and supplies by assigning the claim to the physician or supplier. The physician/supplier in return ...
Dentists: Prescriptions and Referring to other providers with Medicare
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 13th, 2015
Are you aware you must be participating with Medicare Part D to be eligible to prescribe medication's to patients that have Medicare? If you are not participating, your patients will not be able to fill their prescriptions.
You may also enroll to become an ordering and referring Medicare provider. You will not be recognized ...
Transfer of Claims Material Between Carrier and Intermediary (FI) (Rev. 2474, Issued: 05-18-12)
By Find-A-Code | Published July 13th, 2015
If a beneficiary erroneously submits a Form CMS-1490 (beneficiary-filed claim form) to a carrier with an itemized bill for services that must be paid by the FI, the carrier forwards such claims to the FI for the necessary action. The FI will inform the provider to submit a claim once ...
A DME MAC receives a Paper Claim with Items or Services that are in Another DME MAC's Payment Jurisdiction (Rev. 2474, Issued: 05-18-12)
By Find-A-Code | Published July 13th, 2015
When a DME MAC receives a claim submitted on the Form CMS-1500 for Medicare payment that should be processed by a DME MAC but was sent to the wrong DME MAC, the claim shall be returned as unprocessable.
Use the following messages:
CARC 109 – Claim not covered by this payer/contractor. You ...
FI Jurisdiction of Requests for Payment (Rev. 1, 10-01-03)
By Find-A-Code | Published July 13th, 2015
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 ...
FI Payment for Emergency and Foreign Hospital Services (Rev. 1, 10-01-03)
By Find-A-Code | Published July 13th, 2015
A. Beneficiary Services Outside United States - Emergency Hospital Admissions
See chapter 3, for detailed information concerning beneficiary services outside the United States. Generally, payment is made for emergency inpatient hospital services in qualified Canadian or Mexican hospitals in the following circumstances:
• A Medicare beneficiary is in the United States ...
Payments Under Part B for Services Furnished by Suppliers of Services to Patients of a Provider (Rev. 1, 10-01-03)
By Find-A-Code | Published July 13th, 2015
Section 1861(w)(1) of the Act permits a hospital, critical access hospital, skilled nursing facility, home health agency, or hospice to obtain under arrangement, services for which an individual is entitled to under Medicare. Doing so discharges the liability of such individual or any other person to pay for the services. ...
Claims Submitted for Items or Services Furnished to Medicare Beneficiaries in State or Local Custody Under a Penal Authority (Rev. 1944, Issued: 04-09-10)
By Find-A-Code | Published July 13th, 2015
Under Section 1862(a)(2) of the Social Security Act (“the Act”), the Medicare program does not pay for services if the beneficiary has no legal obligation to pay for the services and no other person or organization has a legal obligation to provide or pay for that service. Also, under Section ...
Medicare Carrier or RRB-Named Carrier to Welfare Carrier (Rev. 2474, Issued: 05-18-12)
By Find-A-Code | Published July 10th, 2015
When a Medicare carrier or RRB-named carrier receives a query reply from CMS that includes a disposition code 46 and a welfare administration carrier number, it transfers the claim to the welfare carrier and notifies the beneficiary. Any pertinent information received or developed is transferred with the claim.
This occurs only ...
Protests Concerning Transfer of Requests for Payment to Carrier (Rev. 2474, Issued: 05-18-12)
By Find-A-Code | Published July 10th, 2015
If Palmetto GBA receives a protest concerning the transfer of a request for Medicare payment to the carrier, the protest, including pertinent name and claim number(s) information, is forwarded to:
Railroad Retirement Board Medicare Section
844 Rush Street
Chicago, IL 60611
Pub 100-04 Medicare Claims Processing Manual
...
HCPCS Subject To and Excluded From CLIA Edits (Rev. 865, 07-03-06)
By Jared Staheli | Published July 10th, 2015
At this time, all claims submitted for laboratory tests subject to CLIA are edited at the CLIA certificate level. However, the HCPCS codes that are considered a laboratory test under CLIA change each year. The CMS identifies the new HCPCS (non-waived, nonprovider-performed procedure) codes, including any modifiers that are subject ...
Payment Jurisdiction for Reassigned Services (Rev. 1987)
By Find-A-Code | Published July 9th, 2015
Though a supplier or provider may reassign payment for his services to another entity, suppliers are still required to bill the correct B/MAC for reassigned services when they are paid under the MPFS. The billing entity must submit claims to the B/MAC that has jurisdiction over the geographic area where ...
Exceptions to Jurisdictional Payment (Rev. 1, 10-01-03)
By Find-A-Code | Published July 9th, 2015
Exceptions to billing the area carrier are:
• A claim for covered services performed in the United States by a legally authorized Canadian or Mexican physician is within the jurisdiction of the carrier servicing the location where the services were rendered.
• Because coverage of Part B services furnished in Canada or ...
Suppliers of Durable Medical Equipment, Prosthetics, Orthotics, Supplies, Parental and Enteral Nutrition (PEN) (Rev. 2487)
By Find-A-Code | Published July 9th, 2015
(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 ...
Supplier of Portable X-Ray, EKG, or Similar Portable Services (Rev. 1, 10-01-03)
By Find-A-Code | Published July 9th, 2015
If a supplier operates mobile units in geographic areas served by more than one carrier, the carrier serving the area where the service was performed must process the claims.
Pub 100-04 Medicare Claims Processing Manual
...
Ambulance Services Submitted to Carriers (Rev. 1, 10-01-03)
By Find-A-Code | Published July 9th, 2015
Jurisdiction of the claim is based on whether only one ambulance vehicle or multiple vehicles were used.
A. One Ambulance Vehicle Used
If only one vehicle is used to transport the patient from the point of initial pickup to the final destination, jurisdiction is with the carrier serving the point of ...
Jurisdiction of claims for laboratory services furnished by an independent laboratory normally lies with the carrier serving the area in which the laboratory test is performed. However, there are some situations where a regional or national lab chain jurisdiction is with a single carrier.
Pub 100-04 Medicare Claims Processing Manual
...
If the specimen is drawn or received by an independent laboratory approved under the Medicare program that performs a covered test, but the lab refers the specimen to another laboratory in a different carrier jurisdiction for additional tests, the carrier servicing the referring laboratory retains jurisdiction for services performed by ...
Carrier jurisdiction claims for individuals who are QRRBs, including those who are entitled to both social security and railroad retirement benefits, are handled by the Palmetto Government Benefits Administrators (GBA) LLC, a subsidiary of Blue Cross and Blue Shield of South Carolina, with the following exceptions:
• The services are furnished ...
Section 1843(f) of Title XVIII permits a State agency that administers a plan under Titles I, XVI, or XIX to become the carrier for individuals enrolled in the State’s Buy In agreement. Currently there are no State agencies that are serving as carriers.
Pub 100-04 Medicare Claims Processing Manual
...
Disposition of Misdirected Claims to the B/MAC/Carrier/DME MAC (Rev. 2474, Issued: 05-18-12)
By Find-A-Code | Published July 9th, 2015
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 ...
A Local B/MAC/Carrier Receives a Claim for Services that are in Another Local B/MAC/Carrier’s Payment Jurisdiction (Rev. 2474, Issued: 05-18-12)
By Find-A-Code | Published July 9th, 2015
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, ...
A Local B/MAC/Carrier Receives a Claim for Services that are in A DME MAC’s Payment Jurisdiction (Rev. 2474, Issued: 05-18-12)
By Find-A-Code | Published July 9th, 2015
When a local contractor (Part B MAC or carrier) receives a CMS-1500 or electronic claim for Medicare payment for items/services that are in a DME MAC’s payment jurisdiction, the claim shall be returned as unprocessable.
Use the following messages for claims indicated above except for claims that are identified as UMWA ...
A DME MAC Receives a Claim for Services that are in A Local B/MAC/Carrier’s Payment Jurisdiction (Rev. 2474, Issued: 05-18-12)
By Find-A-Code | Published July 9th, 2015
When a local DME MAC receives a CMS-1500 or electronic claim for Medicare payment for items/services that are in a Part B MAC or carrier’s payment jurisdiction, the claim shall be returned as unprocessable.
Use the following messages for claims indicated above except for claims that are identified as UMWA claims:
CARC ...
A Local B/MAC/Carrier Receives a Claim for an RRB Beneficiary (Rev. 2474, Issued: 05-18-12)
By Find-A-Code | Published July 9th, 2015
When a local contractor (Part B MAC or carrier) receives a Form CMS-1500 or electronic claim that is identified as a RRB claim for Medicare payment that should be processed by the RRB contractor, the claim shall be returned as unprocessable. Use the following messages:
CARC 109 – Claim not covered ...
A Local B/MAC/Carrier/DME MAC Receives a Claim for a UMWA Beneficiary (Rev. 2474, Issued: 05-18-12)
By Find-A-Code | Published July 9th, 2015
When a local contractor (Part B MAC or carrier/DME MAC) receives a Form CMS-1500 or electronic claim that is identified as a UMWA claim for Medicare payment that should be processed by the UMWA, the claim shall be returned as unprocessable.
Use the following messages:
CARC 109 - Claim not covered by ...
Payment Jurisdiction for Services Subject to the Anti-Markup Payment Limitation
By Find-A-Code | Published June 30th, 2015
(Rev. 3089, Issued: 10-21-14, Effective Date: January 1, 2015 - For Analysis, Design, and Programming April 1, 2015 - For Testing and Implementation; Implementation January 5, 2015, April 6, 2015 – For MAC testing of PECOS changes only)
Diagnostic tests and their interpretations are paid on the MPFS. Therefore, they are ...
(Rev. 3086, Issued: 10-03-14, Effective: ICD-10: Upon Implementation of ICD-10, ASC X12: January 1, 2012, Implementation ICD-10: Upon Implementation of ICD- 10; ASC X12: November 4, 2014) The standards adopted under HIPAA include both a transaction standard and an implementation guide. The following are the claims transactions and the implementation ...
Claims Processing Instructions for Payment Jurisdiction
By Find-A-Code | Published June 29th, 2015
(Rev. 3086, Issued: 10-03-14, Effective: ICD-10: Upon Implementation of ICD-10, ASC X12: January 1, 2012, Implementation ICD-10: Upon Implementation of ICD- 10; ASC X12: November 4, 2014)
A. Instructions for the 4010/4010A1 Version of the ASC X12 837 Professional Electronic Claim (for Claims Processed Before Implementation of Version 5010)
Note that ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 22nd, 2015 - Last Review/Update August 7th, 2017
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 ...
HO-400, HO-400.G, HO-403, HO-412
The hospital may bill only for services provided. If the provider billing system initiates billing based on services ordered, the provider must confirm that the service has been provided before billing either the carrier or intermediary (FI).
The provider agreement to participate in the program requires the provider ...
Carrier Jurisdiction of Requests for Payment (Rev. 2487)
By Find-A-Code | Published June 15th, 2015
Carriers have jurisdiction for all claims from the following:
• Physicians;
• Other individual practitioners;
• Groups of physicians or practitioners;
• Labs not part of a hospital;
• Ambulance claims submitted by ambulance companies under their own Medicare number (hospitals may operate ambulances as part of the hospital and bill the intermediary (FI));
• Ambulatory ...
Proposed FY 2016 Medicare Payment And Policy Changes For Inpatient Psychiatric Facilities
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 28th, 2015 - Last Review/Update January 25th, 2017
FACT SHEET
April 24, 2015
Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries
Proposed FY 2016 Medicare Payment And Policy Changes For Inpatient Psychiatric Facilities
OVERVIEW: On April 24, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule outlining proposed fiscal year (FY) 2016 Medicare payment policies and ...
By Dr. Chris Andersn | Published April 24th, 2015 - Last Review/Update June 9th, 2016
Compliance is an issue that you should look at as an expedition rather than an endpoint. Board complaints can be a terrifying ordeal, especially if you don’t keep up on compliance in your clinic. Board complaints are something that you have to expect to happen but you can turn that ...
Medicare Updates Preventive Exam and Wellness Visit Information
By Wyn Staheli, Director of Research | Published April 15th, 2015 - Last Review/Update June 9th, 2016
Medicare has updated their provider educational tools for the Initial Preventive Physical Examination (IPPE) and the Annual Wellness Visit (AWV). These tools were designed to help providers gain a greater understanding of these services. Learn what the required elements for these services as well as important coverage and coding information.
CLICK ...
By Wyn Staheli, Director of Research | Published April 15th, 2015 - Last Review/Update February 3rd, 2017
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 Wyn Staheli, Director of Research | Published March 27th, 2015 - Last Review/Update June 9th, 2016
It appears that the repeal of the Sustainable Growth Rate formula (SGR) could finally be a real possibility. On Thursday, March 26, The U.S. House of Representatives overwhelmingly passed H.R 2, The Medicare Access and CHIP Reauthorization Act which includes both repeal and replace the flawed SGR formula that has ...
Billing Imminuzation for Pneumococcal, Influenza, and Hepatitis B with Medicare
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 9th, 2015 - Last Review/Update August 9th, 2017
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 ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 26th, 2015 - Last Review/Update March 2nd, 2016
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 ...
Billing Requirements for G0466, G0467, G0468, G0469 or G0470 - MLN
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 21st, 2015 - Last Review/Update February 18th, 2016
Basic Billing Requirements
When reporting an encounter/visit for payment, the claim (77X TOB) must contain a FQHC specific payment code (G0466, G0467, G0468, G0469 or G0470) that corresponds to the type of visit.
FQHC specific payment specific codes G0466, G0467 and G0468 must be reported under revenue code 052X or under ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 15th, 2015 - Last Review/Update March 1st, 2016
40-Effect of Beneficiary Agreements Not to Use Medicare Coverage
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)
(Rev. 194, 09-03-14)
Normally physicians and practitioners are required to submit claims on behalf of beneficiaries for all items and services they provide for which Medicare payment may be made under Part B. Also, they are ...
By | Published February 10th, 2015 - Last Review/Update February 18th, 2016
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 | Published February 3rd, 2015 - Last Review/Update June 9th, 2016
The following information (emphasis added) is from: http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs15.html
Provider Non-Discrimination PHS Act section 2706(a), as added by the Affordable Care Act, states that a “group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against ...
Medicare Parts C & D Fraud, Waste, and Abuse Training and General Compliance Training
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 19th, 2014 - Last Review/Update March 1st, 2016
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 ...
Compliance Program - What are the Requirements to Implement an Effective Program
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 19th, 2014 - Last Review/Update March 1st, 2016
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 ...
Coding for ICD-10-CM: More of the Basics MLN Connectsâ„¢ Video
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 18th, 2014 - Last Review/Update March 1st, 2016
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, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
What are NCDs and LCDs?
NCD — NATIONAL COVERAGE DETERMINATIONS
Medicare specific coverage on the national level. All Medicare carriers are required to follow the NCDs. The NCDs are developed by CMS to describe the circumstances for Medicare coverage nationwide for an item or service. NCDs generally outline the conditions for which an ...
OASIS Data to be Submitted via Assessment Submission and Processing (ASAP) System Effective Jan 1, 2015
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
Effective January 1, 2015, OASIS assessment data will be submitted to CMS via the national OASIS Assessment Submission and Processing (ASAP) system. With the implementation of the OASIS ASAP system, Home Health Agencies will no longer submit OASIS assessment data to CMS via their state databases. To access the ...
CMS - Final Rule to Deny or Revoke the Enrollment of Entities that Pose an Integrity Risk to Medicare
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
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 ...
Durable Medical Equipment - Documenting Continued Use
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
Treating physicians’ records often omit documentation of a beneficiary’s continuing use of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). By Medicare statute, lack of physician documentation regarding a beneficiary’s continued need and use of an item of DMEPOS will result in claim denials. Many “model charts” from various clinical ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
Vacuum pumps coded L7900 must demonstrate a capability to generate a negative pressure in the range of greater than 3.9 and less than 17 inches of mercury (100 and 432 mmHg, respectively). All devices coded L7900 for reimbursement by Medicare must include a vacuum limiter such that a maximum vacuum ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update March 1st, 2016
The outcome of care measures and the utilization measures are risk adjusted. The process of care measures aren't risk adjusted. Risk adjustment of the outcome of care and utilization measures is a multi-step process. These are the major steps in this process displayed in temporal order:
OASIS-C assessment data collection and ...
Aligning the Way Providers are Paid to Reward Value Rather than Volume (Value Based Modifiers)
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update March 1st, 2016
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 ...
CMS Will Begin Applying the Value Modifier in Calendar Year (CY) 2017 to All Physicians
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update March 1st, 2016
CMS will begin applying the Value Modifier in calendar year (CY) 2017 to all physicians; including those in groups with two or more eligible professionals (EPs), and to physicians who are solo practitioners. This policy completes the phase-in of the Value Modifier to all physicians and groups of physicians as ...
CMS Announces a Getting Started with Quality Measures Virtual Office Hours Session for 2014 Physician Quality Reporting System (PQRS)
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update March 1st, 2016
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 ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update March 1st, 2016
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) ...
By | Published November 19th, 2014 - Last Review/Update January 30th, 2017
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 contains information about each zone as well as activity and updates in those regions.Â
ZPIC
Zone
States in Zone
Safeguard Services (SGS)
1
California, Hawaii, Nevada, American Samoa, Guam, Mariana Islands
Health Integrity
(subcontractor ...
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published November 19th, 2014 - Last Review/Update January 30th, 2017
Recovery Audit Contractors, also known as RAC, is a program that seeks to identify and correct improper payments for services provided to Medicare Parts A & B beneficiaries. This includes both recoupment of overpayments and corrected distribution of underpayments made by CMS.  RAC began in 2005 as a three-year demonstration project consisting ...
Medicare's Screening, Brief Intervention, and Referral to Treatment (SBIRT) Services
By Wyn Staheli, Director of Research | Published November 17th, 2014 - Last Review/Update January 6th, 2017
Medicare understands that there are individuals who may not meet the diagnostic criteria for substance abuse, but who are still at risk. To help identify these individuals and take steps to keep them from reaching the level of abuse, Medicare has established a program called the Screening, Brief Intervention, and ...
CMS Announces 2013 eRx Incentive Program Payments are Now Available
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 20th, 2014 - Last Review/Update March 2nd, 2016
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 ...
Medicare Billing Information for Rural Providers and Suppliers Booklet - Revised
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 17th, 2014 - Last Review/Update January 30th, 2017
The “Medicare Billing Information for Rural Providers and Suppliers” Booklet (ICN 006762) was revised and is now available in downloadable format. To assist rural providers who have limited internet access, see the “Medicare Billing Information for Rural Providers and Suppliers Text-Only”
Booklet is available in text-only format. This booklet is designed ...
Billing Requirements for Medicare Secondary Payer (MSP) Provisions
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 17th, 2014 - Last Review/Update January 30th, 2017
MSP provisions apply to situations when Medicare is not the beneficiary’s primary health insurance coverage. Before you submit a claim, you must determine whether Medicare is the primary or secondary payer for all inpatient admissions and outpatient encounters, thereby assisting in ensuring the appropriate use of Medicare funds. If another ...
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published October 16th, 2014 - Last Review/Update January 23rd, 2017
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 ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 16th, 2014 - Last Review/Update January 30th, 2017
Visit this site to view the top rejection messages and avoid costly mistakes. Using the top denial reason codes, NGS will show you how to avoid this and the steps needed to correct this error. Take a look at the National Government Services web site: NGS
For example:
CO-16 Claim/service lacks information which is ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 16th, 2014 - Last Review/Update January 30th, 2017
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 ...
Chiropractic is Listed as a Priority in the 2014 OIG Work Plan...Find Out Why
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published October 16th, 2014 - Last Review/Update January 30th, 2017
Each year the Office of Inspector General (OIG) issues an updated work plan which outlines the objectives and enforcement priorities for each new year. For Medical providers, including Chiropractic, this information is necessary to review and be familiar with so we may evaluate our own practice systems to ensure compliance ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 16th, 2014 - Last Review/Update January 30th, 2017
For a list of HACs and Codes
Medicare learning network ICN 901045 October 2012
(This list was current with Medicare when published October 2012)
Affected Hospitals
The Hospital-Acquired Conditions payment provision applies only to IPPS hospitals. At this time, the following hospitals are EXEMPT from the HAC payment provision:
Critical Access Hospitals (CAHs)
Long-Term Care Hospitals ...
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published October 16th, 2014 - Last Review/Update November 29th, 2017
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 ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 9th, 2014 - Last Review/Update January 23rd, 2017
Medicare has set annual therapy caps at $1920 and they start over Jan. 1 of each year. Medicare combined the therapy limits SLP (Speech-Language Pathology) and PT (Physical Therapy) for a combined total of $1920.00 in 2014. There is also a therapy cap limit for OT (Occupational Therapy) Services of $1920. ...
By | Published October 9th, 2014 - Last Review/Update January 30th, 2017
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 ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 9th, 2014 - Last Review/Update January 30th, 2017
After a claim has been submitted and a reimbursement decision has been made, you or your billing agent receive a Remittance Advice (RA). The RA is a notice of payments and adjustments that the MAC produces as a companion to claim payments or an explanation when there is no payment. ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 3rd, 2014 - Last Review/Update January 30th, 2017
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 ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 26th, 2014 - Last Review/Update January 30th, 2017
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 ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 25th, 2014 - Last Review/Update January 30th, 2017
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 ...
CMS - How to Understand Medicare's ID Numbers (HIC or HICN)
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 23rd, 2014 - Last Review/Update January 30th, 2017
A HIC number (HICN) is a Medicare beneficiary’s identification number. Also, remember when billing, ALWAYS use the name as it appears on the patient's Medicare card.
Both CMS and the Railroad Retirement Board (RRB) issue Medicare HIC numbers. The format of a HIC number issued by CMS is a Social Security ...
By Wyn Staheli, Director of Research | Published September 15th, 2014 - Last Review/Update July 12th, 2016
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.
Face-to-Face Encounter Compliance Requirement for Certain Durable Medical Equipment
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 9th, 2014 - Last Review/Update January 30th, 2017
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 | Published August 27th, 2014 - Last Review/Update January 30th, 2017
PQRS FAQs: How do I report for the 2014 PQRS? What is the MAV and when does it apply? What happens if we report less than 9 measures across 3 domains? How does CMS apply the MAV Clinical Relation/Domain test for PQRS?
Q & A: Does an individual need to have the job title of medical assistant in order to use the CPOE function of Certified EHR Technology?
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 26th, 2014 - Last Review/Update August 9th, 2017
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, QCC, CMCS, CPC, CMRS | Published August 12th, 2014 - Last Review/Update January 23rd, 2017
Information related to Medicare's E-Health programs can be viewed here. (Click Here) E-Health includes: E-Prescribing Electronic Health Records Personal Health Records EHR Incentive Programs  eRx Electronic Prescribing Incentive Program (Click Here) The eRx Incentive Program Ended in 2013, but Electronic Prescribing Continues with Meaningful Use. ...
How do I find a HCPCS code for a laxative given to a patient in our office?
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 12th, 2014 - Last Review/Update August 9th, 2017
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 ...
Durable Medical Equipment, Prosthetics, Orthotics and Supplies
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 7th, 2014 - Last Review/Update January 25th, 2017
Reimbursement for most Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) is established by fee schedules. Payment is limited to the lower of the actual charge or the fee schedule amount.  We have given you some basic information to get you started including modifiers and how CMS views DMEPOS, please ...
Medicare Requiring Prior Authorization for Power Mobility Devices
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 31st, 2014 - Last Review/Update January 25th, 2017
Due to the fact that Power Mobility Devices have a climbing high rate of fraud and improper payments the Centers for Medicare & Medicaid announced in May it has extended the pre authorization process to 12 more states for power mobility devices. These states include Arizona, Georgia, Indiana, Kentucky, Louisiana, Maryland, ...
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published July 31st, 2014 - Last Review/Update January 25th, 2017
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 ...
By | Published July 24th, 2014 - Last Review/Update January 29th, 2016
Are Medicare fees going up? Or down? Results for the following:
Sequestration
Chiropractic Demonstration Project
Electronic Health Record/Meaningful Use
Physician Quality Reporting System - PQRS
Value-Based Modifier
By | Published April 17th, 2014 - Last Review/Update January 25th, 2017
January 1, 2014 was the required date for adoption of standards for both Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA). The Centers for Medicare & Medicaid Services (CMS) recently announced that the implementation of these new standards has resulted in benefits for both providers and CMS. Not surprisingly, ...
Inappropriate Medicare Payments for Chiropractic Services
By | Published August 30th, 2012 - Last Review/Update January 27th, 2017
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.
View articles for the current subject by subtopic:
Access to this feature is available in the following products:
HCC Coder
Find-A-Code Professional
Find-A-Code Facility Base
Select the webinar title to view a summary and link to the webinar video.
November 5th, 2019
Proving Medical Necessity and Functional Improvement
Medicare is required by law to pay for care that is medically necessary. Medicare considers functional improvement to be the primary indicator of medical necessity for chiropractic care. It is up to you, the doctor, to prove functional improvement and medical necessity with your documentation. Dr. Short will show you how to use common practice tools to document functional improvement, medical necessity and maximum medical improvement.
Currently Medicare only pays for the adjustment and then only when it is used to correct a subluxation. This injustice within the Social Security Act needs corrected. Dr. Ron Short will discuss the Medicare laws as they relate to chiropractic and what changes need to be made and why.
...
Chiropractic Manipulative Treatment and Medicare - Part 2
In this CE webinar, Dr. Gwilliam will continue his discussion from the webinar delivered Dec. 18 about chiropractic manipulative treatment. But this time, it is all about Medicare. If you don't treat Medicare beneficiaries, you should probably listen anyway. Usually whatever Medicare wants is the same thing as all the other payers. Find out the difference between acute, chronic, and maintenance, as well as when to use certain modifiers.
Medicare continues to increase their efforts to review doctors and recover “overpayments”. This increases the likelihood that your notes will be reviewed and that you will be required to pay money back to Medicare. In this webinar Dr. Short will show you:
Why you should appeal every adverse decision.
How to appeal adverse decisions.
What information you need in your documentation for an effective appeal.
How to structure your appeals to be most effective.
In this webinar, Dr. Marty Kotlar (certified coding and compliance expert) will discuss how to create an OIG/Medicare compliance plan. He will explain how to create policies, how to perform a "self-test" on your SOAP notes, search the Medicare exclusions list, Stark, anti-kickback and how to handle compliance concerns.
Medicare reviews claims for a variety of reasons. Some are routine and are not a problem for the doctor or the practice. Some are investigatory in nature and indicate a serious potential threat for both the doctor and the practice. Dr. Ron Short will go over the types of reviews and which are routine and which should cause you to lose sleep.
In this webinar you will learn:
-What routine reviews are and why they are conducted
-What reviews are a potential risk
-What triggers reviews
-When to get help and what kind of help to get
This presentation will review how risk management is no longer limited to just malpractice claims. It also includes your financial policy. There is now a greater risk of financial loss due to improper discounting and faulty financial and collection policies than ever before. It is widely known that the Office of Inspector General (OIG) and Medicare are cracking down on healthcare fraud and abuse, but what most chiropractors are unaware of, is how widely successful these efforts have been. In this presentation, we will identify the five most dangerous things we face in chiropractic and how to avoid them. All attendees will receive a free sample 1-page financial policy that can be customized for their practice and a link to receive a free risk assessment score for their practice.
The Future of Reimbursement: Medicare's Quality Payment Program
You may have heard rumblings about MACRA, MIPS, MU, PQRS, VBM, and some other acronyms from CMS (Medicare.) Don't get overwhelmed, Dr. Gwilliam will take you through the basics and let you know what you need to do in 2017 to avoid a payment adjustment (penalty), and maybe even qualify for incentives (up to 5%! woohoo!) Even if you don't treat Medicare beneficiaries, this model could be the future of payment for healthcare. This is a webinar that you won't want to miss.
Find-A-Code's 2020 specialty specific Reimbursement Guides give you the coding, billing, and documentation support you need to get paid properly and keep it.
Medicare
Procedure & Supply codes
Documentation
Compliance
HCC information
ICD-10-CM codes
suggest a resource
If you know of a resource that should be included here (links, data, etc.) please contact us.
Quick, Current, Complete - www.findacode.com