Stay current with the latest industry news along with coding, billing and reimbursement case studies and analyses. http://www.shopingenix.com/CodingCircleArticles/ Hospital outpatient departments could see a Medicare payment increase of 2.4 percent in calendar year 2011 if proposed rates become final.... http://www.shopingenix.com/CodingCircleArticles/?id=252 For calendar year 2011, the Centers for Medicare and Medicaid Services (CMS) is proposing somewhat of a compromise in the supervision policy for therapeutic services that will apply to all hospitals, including critical access hospitals (CAHs).... http://www.shopingenix.com/CodingCircleArticles/?id=260 For calendar year 2011, the Centers for Medicare and Medicaid Services is proposing to set different payment rates for partial hospitalization programs (PHPs) in community mental health centers and hospital outpatient departments.... http://www.shopingenix.com/CodingCircleArticles/?id=261 The Centers for Medicare and Medicaid Services (CMS) has released its proposed changes to the Physician Quality Reporting Initiative for 2011.... http://www.shopingenix.com/CodingCircleArticles/?id=253 Congress finally passed legislation signed into law by President Obama that not only prevents physicians from receiving a 21.3 percent payment reduction but actually establishes a 2.2 percent payment increase.... http://www.shopingenix.com/CodingCircleArticles/?id=254 It’s that time of year once again—providers are gearing up to make the necessary changes to codes submitted on medical claims. Up first are changes to the ICD-9-CM coding system. The ICD-9-CM Coordination and Maintenance Committee has approved revisions to the ICD-9-CM code set that are effective October 1, 2010. These codes were published in the Federal Register dated May 4, 2010, and CMS-1498-P, tables 6A-6F, and the official ICD-9-CM addenda effective October 1, 2010.... http://www.shopingenix.com/CodingCircleArticles/?id=248 Payers and providers could save hundreds of billions of dollars by centralizing and standardizing cumbersome and time-consuming administrative and medical tasks. It is with these enormous savings in mind that the Blue Cross and Blue Shield Association (BCBSA), in conjunction with America’s Health Insurance Plans (AHIP), has launched an initiative involving regional and statewide plans. The insurers will evaluate options enabling physicians to access multiple insurers through one universal information channel (i.e., web portal) in a specific area of the country.... http://www.shopingenix.com/CodingCircleArticles/?id=250 The Centers for Medicare and Medicaid Services (CMS) has determined that pulmonary rehabilitation programs are covered and payable as of January 1, 2010, when certain beneficiary and program requirements are met.... http://www.shopingenix.com/CodingCircleArticles/?id=251 This is proving to be a challenging year for physicians due to delays in implementing concrete legislative revisions to the Medicare physician fee schedule that would prevent payment cuts and alleviate uncertainty as to future reimbursement.... http://www.shopingenix.com/CodingCircleArticles/?id=243 The American Medical Association (AMA), in conjunction with the American Osteopathic Association (AOA) and the Medical Society of the District of Columbia, has filed a suit in federal court seeking to block the Federal Trade Commission (FTC) from imposing the “red flag” rule on physicians.... http://www.shopingenix.com/CodingCircleArticles/?id=244 The Centers for Medicare and Medicaid Services (CMS) released the latest revision to the HCPCS Level II coding system on May 21.... http://www.shopingenix.com/CodingCircleArticles/?id=245 On May 10, 2010, the Centers for Medicare and Medicaid Services released a revised conversion factor of $36.0791 (as opposed to the existing factor of $36.0846).... http://www.shopingenix.com/CodingCircleArticles/?id=234 Payment for the technical component (TC) for certain radiologic procedures will be reduced as a result of a provision in the Patient Protection and Affordable Care Act of 2009 (PPACA).... http://www.shopingenix.com/CodingCircleArticles/?id=232 Both the U.S. House of Representatives and the U.S. Senate have drafted proposed laws that would provide statutory updates to physician Medicare payment of 2.2 percent for the remainder of 2010 and an additional 1 percent increase in 2011.... http://www.shopingenix.com/CodingCircleArticles/?id=235 The <em>Patient Protection and Affordable Care Act</em> (PPACA), signed into law on March 23, 2010, shortened the time period allowed for filing Medicare fee-for-service (FFS) claims. The aim is to curb fraud, waste, and abuse in the Medicare program.... http://www.shopingenix.com/CodingCircleArticles/?id=229 Providers are reporting a great deal of confusion now that recovery audit contractors (RAC) are soliciting refunds by sending demand letters and recouping overpayment amounts through remittance advice offsets.... http://www.shopingenix.com/CodingCircleArticles/?id=227 Four more states and Puerto Rico have received federal money to implement electronic health records (EHR).... http://www.shopingenix.com/CodingCircleArticles/?id=228 The Medicare physician fee schedule will not receive an April update, according to a spokesperson for the Centers for Medicare and Medicaid Services (CMS). The next update is scheduled to become effective July 2010.... http://www.shopingenix.com/CodingCircleArticles/?id=219 On April 19, 2010, the Centers for Medicare & Medicaid Services (CMS) proposed the fiscal 2011 Medicare policies and payment rates for inpatient services provided by both acute care and long-term care hospitals. The proposed rule does not address provisions contained in the Patient Protection and Affordable Care Act or the Health Care and Education Affordability Reconciliation Act. The agency will address these provisions separately.... http://www.shopingenix.com/CodingCircleArticles/?id=225 The Centers for Medicare and Medicaid Services (CMS) has added code V12.53 (Personal history of sudden cardiac arrest) to the list of seven other codes not requiring modifier Q0 for coverage.... http://www.shopingenix.com/CodingCircleArticles/?id=224 The Centers for Medicare and Medicaid Services (CMS) has added code V12.53 (Personal history of sudden cardiac arrest) to the list of seven other codes not requiring modifier Q0 for coverage.... http://www.shopingenix.com/CodingCircleArticles/?id=226 As of April 1, 2010, hospitals are required to submit to Medicare separate claims for noncovered and covered services provided during the same inpatient stay.... http://www.shopingenix.com/CodingCircleArticles/?id=220 As part of the Patient Protection and Affordable Care Act that President Obama signed into law on March 23, the exceptions process for outpatient therapy caps was extended for another year (see section 3103).... http://www.shopingenix.com/CodingCircleArticles/?id=221 On March 16, the Centers for Medicare and Medicaid Services released new instructions for medical reviewers to follow regarding medical record authentication.... http://www.shopingenix.com/CodingCircleArticles/?id=214 The most recently published Comprehensive Error Rate Testing (CERT) report dated November 2009 indicates a paid claims error rate of 7.8 percent; the error rate for the previous year was 3.6 percent. The increase may be the result of significant revisions in the methods the Centers for Medicare and Medicaid Services (CMS) uses to identify and calculate paid claim error rates. It should be noted that due to these revisions, results from previous-year CERT reports cannot be directly compared with the 2009 report.... http://www.shopingenix.com/CodingCircleArticles/?id=217 In a recent transmittal, the Centers for Medicare and Medicaid Services indicated that there is no evidence supporting the conclusion that outpatient intravenous insulin treatment (OIVIT) improves health outcomes in Medicare patients. For this reason, CMS has determined that OIVIT is not reasonable and necessary and is a noncovered service.... http://www.shopingenix.com/CodingCircleArticles/?id=218 Hospitals treating patients with insulin-dependent diabetes mellitus are preparing for billing and coding changes for intravenous insulin therapy.... http://www.shopingenix.com/CodingCircleArticles/?id=215 With incentives for providers who implement an electronic health record (EHR) come increasing guidelines regarding the EHR. The Health Information Technology for Economic and Clinical Health Act (HITECH Act) includes guidelines for “meaningful use” requirements of the EHR. The meaningful use has been defined and includes creation of certification programs for health information technology.... http://www.shopingenix.com/CodingCircleArticles/?id=216 The Centers for Medicare and Medicaid Services (CMS) has indicated that due to a software snag, claims that Medicare contractors should have automatically sent to supplemental payers have not been sent, even though the remittance advice indicates otherwise. The problem began January 5, 2010, and has affected both Part A and Part B claims with the exception of those processed by durable medical equipment Medicare administrative contractors (DME MACs).... http://www.shopingenix.com/CodingCircleArticles/?id=211 Renal dialysis facilities will be required to report new quality data for dialysis adequacy, infection, and vascular access on all end-stage renal disease (ESRD) and hemodialysis claims on or after July 1, 2010. The new data reported will enable the Centers for Medicare & Medicaid Services (CMS) to implement a specific quality incentive payment for dialysis providers.... http://www.shopingenix.com/CodingCircleArticles/?id=212 The interim final rule, titled Breach Notification for Unsecured Protected Health Information, published in the Federal Register on August 24, 2009, requires that providers take extraordinary measures when patients’ medical information is released to unauthorized persons.... http://www.shopingenix.com/CodingCircleArticles/?id=213 The discontinuation of Medicare coverage for consultation services as of January 1, 2010, seems on the surface like a straightforward change to make. However, the drop in coverage also affects the reporting of evaluation and management (E/M) services in other, less obvious ways.... http://www.shopingenix.com/CodingCircleArticles/?id=206 On January 4, the Centers for Medicare and Medicaid Services (CMS) implemented new guidelines for determining the place of service (POS) for diagnostic tests. These guidelines were supposed to clarify billing instructions but have instead muddied the issue even more.... http://www.shopingenix.com/CodingCircleArticles/?id=209 Clinical diagnostic laboratories and other providers that bill Medicare for laboratory tests welcomed recent publications clarifying appropriate billing for certain tests.... http://www.shopingenix.com/CodingCircleArticles/?id=210 Medicare providers should take note of a special edition article alerting providers that certain Medicare payment provisions expired on December 31, 2009. In the article, the Centers for Medicare and Medicaid Services (CMS) also notes that potential new legislation that affects the Medicare program may extend these provisions.... http://www.shopingenix.com/CodingCircleArticles/?id=207 Effective August 3, 2009, warfarin responsiveness pharmacogenomic testing is covered only when provided to Medicare beneficiaries in the context of a prospective, randomized, controlled clinical study when that study meets certain criteria as outlined in Pub 100-03, section 90.1, of the National Coverage Determination Manual.... http://www.shopingenix.com/CodingCircleArticles/?id=208 In an ongoing effort to reduce waste, fraud, and abuse, the Centers for Medicare and Medicaid Services (CMS) is requiring certain durable medical equipment suppliers to post a surety bond and has revoked the billing privileges of more than 1,100 medical equipment suppliers in south Florida and southern California.... http://www.shopingenix.com/CodingCircleArticles/?id=203 The Centers for Medicare and Medicaid Services (CMS) has released new numbers for Part A and Part B contractors for Florida, Puerto Rico, and the United States Virgin Islands when that workload is transitioned to the Jurisdiction 9 A/B Medicare administrative contractor (MAC). Below are the changes and their effective dates.... http://www.shopingenix.com/CodingCircleArticles/?id=204 The Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations require that a provider be appropriately certified for each test performed. There are some tests, however, that are classified by the Food and Drug Administration (FDA) as being waived under CLIA. This means that any provider who has a certificate of waiver may perform these tests.... http://www.shopingenix.com/CodingCircleArticles/?id=205 On January 1, 2010, the Centers for Medicare and Medicaid Services (CMS) will roll out one of the most comprehensive revisions to OASIS since its original release in 1999.... http://www.shopingenix.com/CodingCircleArticles/?id=200 In addition to a new conversion factor and payment rates for 2010, ambulatory surgery centers are gearing up for changes that affect covered surgical procedures, payment indicators for office-based procedures, and newly created Level II HCPCS codes and payment rates for separately payable drugs and biologicals.... http://www.shopingenix.com/CodingCircleArticles/?id=201 In November, the Centers for Medicare and Medicaid Services detailed expansion of the number of reporting options eligible professionals (EPs) can use to report quality data when participating in the Physician Quality Reporting Initiative (PQRI) for 2010. Specifics are on the CMS website in the 2010 PQRI Implementation Guide and GPRO Narrative Measure Specifications for 2010.... http://www.shopingenix.com/CodingCircleArticles/?id=202 Medicare’s revamp of consultation coding policies has thrown many providers for a loop.... http://www.shopingenix.com/CodingCircleArticles/?id=197 Anesthesiologists and certified registered nurse anesthetists (CRNA) need to know about new payment rules effective for services furnished on or after January 1, 2010, if they bill Medicare for providing teaching anesthesia services for residents and student nurse anesthetists.... http://www.shopingenix.com/CodingCircleArticles/?id=198 E-prescribing is defined as a prescriber’s ability to electronically send an accurate, error-free and understandable prescription directly to a pharmacy from the point of care. It is an important element in improving patient quality of care.... http://www.shopingenix.com/CodingCircleArticles/?id=199 The calculations of Medicare fee-for-service error rates in 2009 will be significantly improved by the Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services, with an eye toward reducing waste, fraud, and abuse in the Medicare entitlement program. The new calculations will reflect a more complete accounting of Medicare’s improper payments than in previous years so that CMS can target improper payments more efficiently.... http://www.shopingenix.com/CodingCircleArticles/?id=194 Changes in Store for Cardiac and Pulmonary Rehabilitation for 2010... http://www.shopingenix.com/CodingCircleArticles/?id=195 To incorporate changes in current medical practice, the Centers for Medicare & Medicaid Services (CMS) adopted new inpatient rehabilitation facility (IRF) coverage requirements in the fiscal 2010 final rule.... http://www.shopingenix.com/CodingCircleArticles/?id=196 If the final changes to policies and payment rates for the 2010 Medicare physician fee schedule go through as they are, physicians are looking at a negative 21.2 percent update to payments unless Congress takes action. The negative update is the result of the sustainable growth rate (SGR) update formula. This update has resulted in negative updates since 2003, but Congress has prevented the negative update legislatively since 2004.... http://www.shopingenix.com/CodingCircleArticles/?id=191 Consultation CPT codes will no longer be covered by Medicare, according to the Centers for Medicare and Medicaid Services (CMS). The agency has redistributed the value of the consultation codes across the other evaluation and management (E/M) codes for Medicare services.... http://www.shopingenix.com/CodingCircleArticles/?id=192 The Centers for Medicare and Medicaid Services (CMS) has released the details concerning changes to the Physician Quality Reporting Initiative (PQRI) for 2010. The agency has outlined how those changes will simplify participation in the program through expanded reporting options and increased numbers of individual measures as well as measure groups and additional reporting periods available for claims-based reporting.... http://www.shopingenix.com/CodingCircleArticles/?id=193 The American Medical Association (AMA) has released CPT® 2010; in addition to the 224 new codes, 155 revised codes and 76 deleted codes, the AMA has also begun a new numbering methodology that could be confusing initially.... http://www.shopingenix.com/CodingCircleArticles/?id=188 A wording change in the national coverage determination for magnetic resonance procedures (MRI) means that contractors can decide coverage for four procedures.... http://www.shopingenix.com/CodingCircleArticles/?id=189 Effective October 1, 2009, providers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) must be accredited and licensed for the product category they intend to submit a bid for to qualify for Medicare reimbursement.... http://www.shopingenix.com/CodingCircleArticles/?id=190 Those providing lab services should take particular note of the latest update of the edit module for clinical diagnostic laboratory services. Among the updates are several that affect some frequently used codes.... http://www.shopingenix.com/CodingCircleArticles/?id=185 Adverse events, home health resource group assignment, inpatient rehabilitation facility payment, and policies related to the American Recovery and Reinvestment Act of 2009 are just a few of the items on the Office of Inspector General’s list of issues to study in 2010. Being familiar with the OIG’s work plan each year helps health care providers assess their own compliance risks.... http://www.shopingenix.com/CodingCircleArticles/?id=186 Beginning October 1, the Centers for Medicare & Medicaid Services (CMS) is expanding its claim editing to ensure that items and services are ordered or referred only by physicians and other providers who are eligible to order/refer such services. Claims for services that require an ordering or referring provider must contain the national provider identifier (NPI) of the ordering/referring provider or the claim will not be paid.... http://www.shopingenix.com/CodingCircleArticles/?id=187 The Centers for Medicare and Medicaid Services (CMS) has released a memorandum detailing when the contractor can apply an exception to the clinical reasonable and necessary requirements of a local coverage determination.... http://www.shopingenix.com/CodingCircleArticles/?id=182 After months of providers wondering what types of claims the recovery audit contractors (RACs) would be examining, the Centers for Medicare and Medicaid Services has finally approved a number of issues to be audited. This allows providers of all types to see the areas that will receive the most focus so that they can perform internal audits to ensure that the correct coding and billing requirements have been followed.... http://www.shopingenix.com/CodingCircleArticles/?id=183 Under Medicare’s conditions of participation (CoP) and conditions of coverage (CfC), criteria for medical record authentication by physicians as well as on-call requirements have been revised. To continue participating in the Medicare and Medicaid programs, health care providers and accredited facilities must comply with these revisions.... http://www.shopingenix.com/CodingCircleArticles/?id=184 The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS) released updated guidelines for ICD-9-CM coding which were created on 8/27/2009 and are effective as of 10/01/2009. The Official Guidelines for ICD-9-CM coding are approved by the Cooperating Parties for ICD-9-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS.... http://www.shopingenix.com/CodingCircleArticles/?id=171 The American Medical Association (AMA) has posted on its website coding advice on how to report the H1N1 (swine flu) vaccine and administration. According to the AMA, code 90663 is the appropriate code for reporting H1N1 vaccine administration.... http://www.shopingenix.com/CodingCircleArticles/?id=180 The Centers for Medicare and Medicaid Services (CMS) has released the October 2009 update to the HCPCS Level II coding system. This update contains only one new code and no deleted codes.... http://www.shopingenix.com/CodingCircleArticles/?id=181 Providers of durable medical equipment, prosthetics, orthotics, and supplies have to keep their eyes on a few dates in the next couple of months if they want to maintain their Medicare privileges or participate in the Medicare DMEPOS competitive bidding program.... http://www.shopingenix.com/CodingCircleArticles/?id=164 Hospitals will receive a 2.1 percent payment increase rather than an anticipated 1.9 percent reduction under the inpatient prospective payment system (IPPS), according to the final rule for fiscal year (FY) 2010, which was released on July 31st. The final rule policy changes and payment rates will affect inpatient services in general acute care hospitals, as well as long-term care hospitals (LTCHs), beginning with discharges on October 1, 2009.... http://www.shopingenix.com/CodingCircleArticles/?id=165 The Centers for Medicare & Medicaid Services (CMS) is contemplating coverage of HIV and genetic screening.... http://www.shopingenix.com/CodingCircleArticles/?id=166 Hospital outpatient departments, particularly those providing diagnostic and therapeutic services, would be significantly affected if proposed changes to the physician supervision regulations become final. The Centers for Medicare and Medicaid Services (CMS) proposed these changes in the 2010 hospital outpatient prospective payment system (HOPPS) proposed rule that updates policies and payment rates for hospital outpatient departments and ambulatory surgery centers for calendar year (CY) 2010.... http://www.shopingenix.com/CodingCircleArticles/?id=161 A recent Medicare transmittal has specified the proper billing of bilateral facet joint injections. The transmittal, published in July, addresses more than $100 million in improper payments to physicians and facilities identified by the Office of Inspector General (OIG).... http://www.shopingenix.com/CodingCircleArticles/?id=162 Computed tomography colonography has not been proved to be an appropriate colorectal cancer screening test under §1861(pp)(1) of the Social Security Act, the Centers for Medicare and Medicaid Services (CMS) announced in a final decision memorandum published on May 12, 2009.... http://www.shopingenix.com/CodingCircleArticles/?id=163 Under the recently released proposed rule for the Medicare physician fee schedule, physicians could see a whopping 21.5 percent decrease in payments for 2010, with a conversion factor of $28.3208.... http://www.shopingenix.com/CodingCircleArticles/?id=158 In addition to the projected 1.9 percent increase in Medicare payments for providers paid under the outpatient prospective payment system, the Centers for Medicare and Medicaid Services is proposing a number of additional policies that will affect payments.... http://www.shopingenix.com/CodingCircleArticles/?id=159 The Department of Health and Human Services (HHS) has rescinded three Medicaid regulations that limited outpatient hospital and clinic benefits and restricted access to case management services.... http://www.shopingenix.com/CodingCircleArticles/?id=160 Changes to the covered diagnosis codes for laboratory services are effective for services furnished on or after July 1, 2009.... http://www.shopingenix.com/CodingCircleArticles/?id=155 The latest version of the Correct Code Initiative (CCI) has been released by the Centers for Medicare and Medicaid Services (CMS).... http://www.shopingenix.com/CodingCircleArticles/?id=156 On June 16 the Health Information Technology Policy Committee took its first crack at trying to create a standard definition for “meaningful use” in relation to electronic health records (EHRs). This is significant because a provider must meet the criteria for meaningful use of a certified EHR if he or she wants to receive any incentive payments from Medicare authorized by the American Recovery and Reinvestment Act (ARRA).... http://www.shopingenix.com/CodingCircleArticles/?id=157 The Centers for Medicare and Medicaid Services (CMS) has released a new national coverage determination (NCD) indicating that effective January 15, 2009, CMS does not cover a particular surgical or other invasive procedure to treat a particular medical condition when the physician: <ul> <li>Should have performed a different procedure altogether</li> <li>Performed the correct procedure but on the wrong body part</li> <li>Performed the correct procedure but on the wrong patient</li> </ul>... http://www.shopingenix.com/CodingCircleArticles/?id=152 Minimal changes were made to the ICD-9-CM for 2010 in comparison to last year. The 2010 code updates were released earlier this month by the National Center for Health Statistics’ (NCHS) and the Centers for Medicare and Medicaid Services (CMS). The changes are effective October 1, 2009.... http://www.shopingenix.com/CodingCircleArticles/?id=153 The second six-month reporting period for Medicare’s Physician Quality Reporting Initiative(PQRI) begins July 1. This reporting period runs through December 31, 2009, and gives providers who have not already started a chance to meet the PQRI reporting criteria for 2009 and receive an incentive payment when reporting thresholds are met.... http://www.shopingenix.com/CodingCircleArticles/?id=154 The proposed inpatient prospective payment system (IPPS) rule for fiscal 2010 issued by the Centers for Medicare & Medicaid Services (CMS) on May 1 includes changes to payment rates and policies for inpatient services beginning October 1, 2009. The proposed payment and policy changes affect inpatient stays in acute care and long-term care hospitals (LTCHs).... http://www.shopingenix.com/CodingCircleArticles/?id=149 The Centers for Medicare and Medicaid Services has released a transmittal clarifying how to bill for routine foot care when payment ceases for loss of protective sensation (LOPS) evaluation and management.... http://www.shopingenix.com/CodingCircleArticles/?id=150 From now until the summer of 2011, 14 selected communities have been chosen to participate in the pilot Care Transitions Project to determine the reasons for unnecessary hospital readmissions and eliminate them. Data have demonstrated that one in five patients discharged from a hospital with be readmitted within the month, and as many as 75 percent of these admissions could be prevented.... http://www.shopingenix.com/CodingCircleArticles/?id=151 Although the official ICD-9-CM addendum for volumes 1, 2, and 3 has not been released, we can still get a glimmer of the changes we will face for fiscal year 2010. The code count below is based upon the new and revised code list released with the proposed rule for the inpatient prospective payment system (IPPS) for fiscal 2010 and as posted on the Centers for Medicare and Medicaid Services ICD-9-CM website. There may still be modifications made once the addendum is released.... http://www.shopingenix.com/CodingCircleArticles/?id=146 The Centers for Medicare & Medicaid Services (CMS) is changing all national coverage determinations (NCDs) that address coverage of FDG (fluoro-2-deoxy-D-glucose) positron emission tomography, or PET scan, for specific oncology conditions, while maintaining current coverage.... http://www.shopingenix.com/CodingCircleArticles/?id=147 The Centers for Medicare and Medicaid Services is revising its criteria for approving or denying a request for a new physician specialty code.... http://www.shopingenix.com/CodingCircleArticles/?id=148 The Joint Commission has refined the scoring and decision process for the Hospital Accreditation Program, as detailed in a March addendum to its accreditation standards.... http://www.shopingenix.com/CodingCircleArticles/?id=143 The Centers for Medicare and Medicaid Services has indicated that, as of October 5, 2009, claims will be edited to determine that the ordering/referring provider identified by the national provider identifier (NPI) on a claim is enrolled in Medicare and is eligible to order or refer services. The edits will be phased in in two parts.... http://www.shopingenix.com/CodingCircleArticles/?id=144 The Centers for Medicare and Medicaid Services has recently updated the list of procedures approved as telehealth services. This update was necessary since in 2009 several new CPT procedure codes related to end-stage renal disease (ESRD) services were added, replacing previous HCPCS level II G codes, which were then deleted. Telehealth services must be reported with modifiers GT or GQ appended to the code to identify the type of technology used.... http://www.shopingenix.com/CodingCircleArticles/?id=145 The Centers for Medicare & Medicaid Services (CMS) is soliciting nursing homes and skilled nursing facilities in New York, Arizona, Mississippi, and Wisconsin to participate in a three-year, pay-for-performance demonstration program beginning in summer 2009.... http://www.shopingenix.com/CodingCircleArticles/?id=140 In a recent Physician Quality Reporting Initiative (PQRI) open door forum, the Centers for Medicare & Medicaid Services (CMS) listed some of the most common errors in claim-based reporting along with tips to help physicians meet the criteria for receiving the 2 percent incentive payment.... http://www.shopingenix.com/CodingCircleArticles/?id=141 The Centers for Medicare & Medicaid Services (CMS) has just released a national coverage determination (NCD) that states that certain bariatric procedures will be covered when specific criteria are met.... http://www.shopingenix.com/CodingCircleArticles/?id=142 The Centers for Medicare and Medicaid Services (CMS) issued changes to the Ambulatory Surgical Center (ASC) Payment System beginning April 1, 2009. These policy revisions include payment rates for new Level II Healthcare Common Procedure Coding System (HCPCS) codes for drugs and biologicals (e.g., C9249, Injection, certolizumab pegol, 1 mg). CMS also updated covered surgical procedures and ancillary services to include new HCPCS codes.... http://www.shopingenix.com/CodingCircleArticles/?id=137 The Office of Inspector General (OIG) has released a report indicating that after a review of high-dollar payments for inpatient services processed by National Government Services in Illinois, Indiana, Kentucky, and Ohio for calendar years 2004 through 2006, only 39 of the 303 services were paid correctly. This audit was performed as part of a nationwide review of payments for inpatient services of $200,000 or more (high-dollar payments).... http://www.shopingenix.com/CodingCircleArticles/?id=138 Part B providers can no longer deny that they will be undergoing scrutiny by Recovery Audit Contractors (RAC audits)—the Centers for Medicare and Medicaid Services will be holding an Open Door Forum on April 14 from 2:00-3:30 PM ET. The purpose of this special open door forum is to discuss the program and introduce the contractors. For more information about how to participate, go to the CMS website at <a href="http://www.cms.hhs.gov/OpenDoorForums/23_ODF_PNAHP.asp" target="_new">http://www.cms.hhs.gov/OpenDoorForums/23_ODF_PNAHP.asp... http://www.shopingenix.com/CodingCircleArticles/?id=139 Upcoding and other fraudulent and abusive practices contributed to an alarming increase in overutilization of and Medicare spending on home health services between 2002 and 2006, according to a study completed by the Government Accounting Office.... http://www.shopingenix.com/CodingCircleArticles/?id=134 The House and Senate recently announced the formation of the United States Bipartisan Commission on Access to Emergency Medical Services. This commission was formed to identify and examine factors that affect delivery of screening and stabilization services in hospitals with emergency departments.... http://www.shopingenix.com/CodingCircleArticles/?id=135 The Centers for Medicare and Medicaid Services has released version 15.1 of the correct coding initiative (CCI) edits. This latest version, effective April 1, includes all previous versions and updates from January 1, 1996, to the present.... http://www.shopingenix.com/CodingCircleArticles/?id=136 The stimulus bill signed into law last month provides up to $44,000 per provider in financial incentives to encourage physicians and hospitals to fully adopt electronic records by 2015. The American Recovery and Reinvestment Act of 2009 (ARRA) allocates approximately $19 billion to Medicare and Medicaid to fund health information technology (HIT).... http://www.shopingenix.com/CodingCircleArticles/?id=131 The Centers for Medicare and Medicaid Services (CMS) has released the April update to the Medicare physician fee schedule. These revisions go into effect April 1.... http://www.shopingenix.com/CodingCircleArticles/?id=132 The Centers for Medicare and Medicaid Services (CMS) has released the latest round of CLIA waived tests. These tests may be performed by providers who have a certificate of waiver under the Clinical Laboratory Improvements Act.... http://www.shopingenix.com/CodingCircleArticles/?id=133 A recent Centers for Medicare and Medicaid Services (CMS) transmittal instructs contractors to more stringently enforce current policies aimed at preventing separate payment for procedures performed during the global surgery period.... http://www.shopingenix.com/CodingCircleArticles/?id=128 A recent review of facet-joint injections performed in 2006 revealed that approximately 63 percent of these services did not meet Medicare guidelines and resulted in an estimated $96 million dollars in improper payments to providers and $33 million to facilities. These injections are a type of interventional pain management technique used to diagnose or treat back pain.... http://www.shopingenix.com/CodingCircleArticles/?id=129 The Centers for Medicare and Medicaid has issued instructions to contractors outlining when anti-markup payment limitations apply to diagnostic services. These guidelines are effective July 1, 2009.... http://www.shopingenix.com/CodingCircleArticles/?id=130 Three recently released national coverage determinations aim to eliminate specific preventable surgical errors and payments for services relating to them. The errors these NCDs address are included in the National Quality Forum’s (NQF) list of 28 “serious reportable events,” which are both serious and preventable. These events are commonly known as “never events.”... http://www.shopingenix.com/CodingCircleArticles/?id=125 The Correct Coding Initiative edits that went into effect for professional claims on January 1, 2009 (version 15.0), include thousands of changes that are already affecting claims. As bundling is frequently the reason for claim denials, it is essential for providers to keep up-to-date with the quarterly updates to CCI edits.... http://www.shopingenix.com/CodingCircleArticles/?id=126 The 2007 United States health care spending increased at the lowest rate of growth in nearly a decade, the Centers for Medicare and Medicaid Services announced in January. Even so, health care spending consumed a larger share of our gross domestic product.... http://www.shopingenix.com/CodingCircleArticles/?id=127 October 1, 2013, is the new compliance date for use of ICD-10-CM and ICD-10-PCS (inpatient services only) code sets for all covered entities, according to a final rule published January 16 in the Federal Register. A 60-day delay in the effective date of the rule is a requirement of the original Health Insurance Portability and Accountability Act (HIPAA) regulations to allow Congress and the Administration a chance to review the rules.... http://www.shopingenix.com/CodingCircleArticles/?id=122 On January 1, Medicare announced that there would be an emergency update to the physician fee schedule. The change affects all providers who file claims with Medicare contractors.... http://www.shopingenix.com/CodingCircleArticles/?id=123 It has never been easier to enroll in Medicare or change your enrollment information, thanks to a new, secure internet-based program.... http://www.shopingenix.com/CodingCircleArticles/?id=124 In an ongoing effort to reduce waste, fraud, and abuse, the Centers for Medicare and Medicaid Services (CMS) is requiring certain durable medical equipment suppliers to post a surety bond and has revoked the billing privileges of more than 1,100 medical equipment suppliers in south Florida and southern California.... http://www.shopingenix.com/CodingCircleArticles/?id=119 The Centers for Medicare and Medicaid Services (CMS) has released new numbers for Part A and Part B contractors for Florida, Puerto Rico, and the United States Virgin Islands when that workload is transitioned to the Jurisdiction 9 A/B Medicare administrative contractor (MAC). Below are the changes and their effective dates.... http://www.shopingenix.com/CodingCircleArticles/?id=120 The Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations require that a provider be appropriately certified for each test performed. There are some tests, however, that are classified by the Food and Drug Administration (FDA) as being waived under CLIA. This means that any provider who has a certificate of waiver may perform these tests.... http://www.shopingenix.com/CodingCircleArticles/?id=121 The CPT^&reg; book has two groups of psychotherapy services. One group should be used to report office or outpatient therapy, and the other should be used for inpatient, residential, and partial hospitalization services. CPT^&reg; codes 90816 through 90829 should only be reported for inpatient, residential, and partial hospitalization program (PHP) services. CPT^&reg; instructions direct to report codes 90804 through 90815 for office or hospital outpatient individual psychotherapy services that are not part of PHP services.... http://www.shopingenix.com/CodingCircleArticles/?id=116 Skilled therapy services usually require the skills of qualified therapists, are performed for restorative purposes, and generally involve ongoing treatments as part of a therapy plan of care. In contrast, a non-therapy service is a service performed by non-therapist and without an appropriate plan of care or goals.... http://www.shopingenix.com/CodingCircleArticles/?id=117 In the transition from charged-based to cost-based relative weight calculations, CMS has significantly revised the MS-DRG relative weight (RW) values for fiscal year 2009. Coding professionals and other hospital staff should be aware of these revisions because previous optimization strategies may no longer be valid. In general, DRG subgroups with a “with MCC” split had the most substantial RW changes, with the “with MCC” RW values rising, in some cases very dramatically.... http://www.shopingenix.com/CodingCircleArticles/?id=118 The dozens of new HCPCS Level II codes released in the 2009 update are wide ranging. They were added to 10 chapters and describe such diverse things as compression wrap, saliva analysis, and pelvic fracture treatment.... http://www.shopingenix.com/CodingCircleArticles/?id=109 In part one of this series, we discussed the many new codes that have been added to HCPCS for 2009, as well as some of those that were deleted but then replaced. This article lists the codes that were reinstated, added and deleted the same year, and revised since the 2008 annual update. HCPCS codes are updated quarterly. To see a complete list of all of the 2009 HCPCS codes, refer to the CMS website at: <a href="http://www.cms.hhs.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp" target="_new">http://www.cms.hhs.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp</a>.... http://www.shopingenix.com/CodingCircleArticles/?id=110 It comes as no surprise that the annual HCPCS code update affects many of the codes relevant to the method of reporting data for the Physician Quality Reporting Initiative (PQRI), which includes groups of clinically related measures rather than individual measures.... http://www.shopingenix.com/CodingCircleArticles/?id=111 The latest update to the remittance advice remark codes (RARC) includes four new codes, one deactivated code, and one modified code. The update is effective January 5th.... http://www.shopingenix.com/CodingCircleArticles/?id=106 The Centers for Medicare and Medicaid Services has announced that effective January 5, 2008, a hospital-based or critical access hospital-based renal dialysis center (including satellites); a skilled nursing facility, and a community mental health center will be considered originating entities for payment of telehealth services.... http://www.shopingenix.com/CodingCircleArticles/?id=107 The changes to the Medicare deductible and coinsurance amounts for next year are not as significant as they have been in past years.... http://www.shopingenix.com/CodingCircleArticles/?id=108 The update to the physician fee schedule for 2009, released in a final rule on October 30, includes a 1.1 percent increase mandated by Congress in the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). This means that, beginning January 1, 2009, the conversion factor for determining Medicare payments will be $36.0666.... http://www.shopingenix.com/CodingCircleArticles/?id=103 Among the most significant elements of the October 30 final rule updating the outpatient prospective payment system and the ambulatory surgery center payment rates for 2009 are reduced payment for lack of quality measures, and new quality measures, imaging composite ambulatory payment classifications, and emergency visit APCs.... http://www.shopingenix.com/CodingCircleArticles/?id=104 The final rule for the Medicare physician fee schedule has greatly expanded the Physician Quality Reporting Initiative for 2009.... http://www.shopingenix.com/CodingCircleArticles/?id=105 Although the revisions to the 2009 edition of CPT® may look less intimidating than those from past years, the nature of the changes are anything but (for example, the evaluation and management section alone has 15 deletions and 17 new codes). The changes, released by the American Medical Association this month, affect all practices, regardless of their specialty.... http://www.shopingenix.com/CodingCircleArticles/?id=100 When the Centers for Medicare and Medicaid Services announced it would be replacing Medicare fiscal intermediaries and carriers with the new Medicare administrative contractors (MACs), it said one of the benefits would be that claims processing would be quicker and easier for providers. Physicians are finding quite the opposite.... http://www.shopingenix.com/CodingCircleArticles/?id=101 If the Centers for Medicare and Medicaid Services decides to cover computed tomography colonography, other payers could follow suit. The agency is conducting a national coverage analysis and plans to release a proposed decision in February 2009.... http://www.shopingenix.com/CodingCircleArticles/?id=102 Influenza or pneumococcal vaccine claims submitted as roster bills need not include a national provider identifier (NPI), according to the Centers for Medicare and Medicaid Services.... http://www.shopingenix.com/CodingCircleArticles/?id=97 Once a provider starts receiving electronic funds transfer payments under Medicare, receiving a paper check is rarely an option, according to the Centers for Medicare and Medicaid Services. CMS requires electronic funds transfer payments for all new providers as well as existing providers who have submitted a change to their existing provider file but are not currently enrolled in EFT.... http://www.shopingenix.com/CodingCircleArticles/?id=98 On October 1, 2008, the Centers for Medicare and Medicaid Services published more than a quarter of the medically unlikely edits. In the past the agency has maintained the proprietary nature of the edits. Edits intended to detect and discourage any questionable payments will not be published, as the agency feels the efficacy of these edits would be compromised.... http://www.shopingenix.com/CodingCircleArticles/?id=99 In an August 22 report, the Office of Inspector General recommended that the Centers for Medicare & Medicaid Services expand the review process for its Comprehensive Error Rate Testing program to ensure accurate measurement of payment errors for durable medical equipment, prosthetics, orthotics and supplies (DME POS).... http://www.shopingenix.com/CodingCircleArticles/?id=94 Providers should determine which of 32 registries recently approved for quality reporting meets their specific needs.... http://www.shopingenix.com/CodingCircleArticles/?id=95 In a recent transmittal, the Centers for Medicare and Medicaid Services clarified which diagnostic services do not require an order with a physician signature under the Medicare program. The agency went on to note that even for those services, there still must be documentation in both the ordering and performing providers’ records indicating the ordering physician’s intent to have the tests performed.... http://www.shopingenix.com/CodingCircleArticles/?id=96 This year 331 new ICD-9-M codes become effective October 1, 2008. Of those, 30 cover the numerous variations of headaches and migraines. One thing to note is there will be new and revised fifth-digit options for these new codes. These fifth-digit options will allow the provider to indicate the presence of status migrainosus, which is an acute migraine headache that lasts 72 hours or longer.... http://www.shopingenix.com/CodingCircleArticles/?id=91 If the federal government gets its way, by the fall of 2011, ICD-10-CM will replace ICD-9-CM, volumes 1 and 2, as the standard code set for covered entities for reporting and coding diseases, injuries, impairments, other health problems and their manifestations.... http://www.shopingenix.com/CodingCircleArticles/?id=92 The Food and Drug Administration announced that it has approved this year's influenza vaccines, which include new strains of the virus during the 2008–2009 season.... http://www.shopingenix.com/CodingCircleArticles/?id=93 The Centers for Medicare and Medicaid Services proposes changing the way multiple imaging procedures are paid to reflect and promote efficiencies in performing multiple imaging procedures during a single session.... http://www.shopingenix.com/CodingCircleArticles/?id=88 Continuous positive airway pressure (CPAP) based upon a diagnosis of obstructive sleep apnea (OSA) confirmed by home sleep testing (HST) is now covered by Medicare.... http://www.shopingenix.com/CodingCircleArticles/?id=89 There’s a new ICD-9-CM category and 20 new codes describing secondary diabetes for fiscal 2009. Category 249 Secondary diabetes mellitus closely parallels category 250 Diabetes mellitus.... http://www.shopingenix.com/CodingCircleArticles/?id=90 The Centers for Medicare and Medicaid Services (CMS) announced a revision to National Coverage Determination 190.11 on July 25 that provides coverage for the use of home PT (Prothrombin Time) /INR (Internation Normalized Ratio)monitoring for chronic, oral anticoagulation management for patients with mechanical heart valves, chronic atrial fibrillation, or venous thromboembolism (inclusive of deep venous thrombosis and pulmonary embolism) who are on warfarin. Prior to this revision, coverage was mandated only for patients with mechanical heart valves.... http://www.shopingenix.com/CodingCircleArticles/?id=85 The Centers for Medicare & Medicaid Services (CMS) has announced that more than $36 million in bonus payments has been made to providers who met the reporting criteria for participating in the 2007 Physician Quality Reporting Initiative (PQRI).... http://www.shopingenix.com/CodingCircleArticles/?id=86 It seems like such a simple thing to do but the Office of Inspector General has stated that 85 out of 100 claims processed by First Coast Service Options, Inc. during 2004 and 2005 could have possible place of service (POS) errors. This could result in an estimated $1.5 million in claims were paid that may have had an incorrect place of service indicated. As a result, Providers in Florida and Connecticut may be seeing a request for refund of overpayments soon.... http://www.shopingenix.com/CodingCircleArticles/?id=87 On July 9 Congress passed the Medicare Improvement for Patients and Providers Act of 2008, legislation that, among other things, not only prevents the 10.6 percent cut in physician payment that was supposed to take effect July 1, but replaces it with a 0.5 percent increase effective until December 31, 2008.... http://www.shopingenix.com/CodingCircleArticles/?id=81 The results are in: The Recovery Audit Contractors (RACs) Demonstration Program was a whopping success with $693.6 million in improper Medicare payments returned to the Medicare trust funds between 2005 and March 2008.... http://www.shopingenix.com/CodingCircleArticles/?id=74 Billing of the technical portion of pathology services has just gotten simpler—or more complex—depending on which side of the fence you are on. As of June 30, independent laboratories will no longer be paid separately by Medicare for services performed for a hospitalized patient, either in- or outpatient.... http://www.shopingenix.com/CodingCircleArticles/?id=80 Billing of the technical portion of pathology services has just gotten simpler—or more complex—depending on which side of the fence you are on. As of June 30, independent laboratories will no longer be paid separately by Medicare for services performed for a hospitalized patient, either in- or outpatient.... http://www.shopingenix.com/CodingCircleArticles/?id=77 Once again, providers face a possible reduction in rates, according to the proposed revisions to the 2009 Medicare physician fee schedule (MPFS) released on June 30th. The Centers for Medicare & Medicaid Services (CMS) is proposing a reduction of 5.4 percent in physician fee schedule payment.... http://www.shopingenix.com/CodingCircleArticles/?id=75 The Centers for Medicare &amp; Medicaid Services (CMS) is proposing to expand the physician quality reporting initiative (PQRI) by adding 62 new measures and expanding reporting methodologies.... http://www.shopingenix.com/CodingCircleArticles/?id=76 For calendar year 2008, Medicare Part B will provide benefits for a specimen collection fee as well as a travel allowance for a laboratory technician to draw a specimen from a nursing home patient or homebound patient, with payment based on the clinical laboratory fee schedule.... http://www.shopingenix.com/CodingCircleArticles/?id=71 Below is a list of the latest waived tests approved by the Food and Drug Administration under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). These test codes will include a QW modifier to be attached to the appropriate CPT® code to flag waived tests billed by facilities.... http://www.shopingenix.com/CodingCircleArticles/?id=72 A new demonstration project will reward physician practices that deliver high-quality care supported by the adoption of electronic health records.... http://www.shopingenix.com/CodingCircleArticles/?id=73 So far 2009 looks like a record-breaking year for the number and breadth of changes to the ICD-9-CM code set.... http://www.shopingenix.com/CodingCircleArticles/?id=68 The American Medical Association has released a summary of where the code revisions to the 2009 CPT® code book are to occur, and the changes appear to be substantial with more than 500 revisions. When combined with the more the 300 new ICD-9-CM codes, providers will have their hands full updating systems with the new and revised codes over then next few months.... http://www.shopingenix.com/CodingCircleArticles/?id=69 PQRI final feedback reports for 2007 will be made available in mid-July on a secure website. Reports will be available to each practice using the taxpayer identification number (TIN) under which at least one eligible provider reported 2007 PQRI quality measures data. The reports will include information on reporting rates, clinical performance, and incentives earned by individual providers as well as a summary on reporting success and incentives earned at the practice (TIN) level.... http://www.shopingenix.com/CodingCircleArticles/?id=70 As of this September, all providers—including independent laboratories, physicians, practitioners, and suppliers—will be required to use the revised advance beneficiary notice (ABN) for all situations in which Medicare payment is expected to be denied.... http://www.shopingenix.com/CodingCircleArticles/?id=65 The Centers for Medicare and Medicaid Services (CMS) released the inpatient prospective payment system (IPPS) proposed rule on April 30, 2008, continuing the transition to Medicare severity (MS) diagnosis-related groups (DRGs), along with other ongoing payment revisions.... http://www.shopingenix.com/CodingCircleArticles/?id=66 The Centers for Medicare & Medicaid Services (CMS) is proposing to expand the list of conditions that are reasonably preventable through proper care and for which Medicare will no longer pay at a higher rate if the patient acquires them during a hospital stay.... http://www.shopingenix.com/CodingCircleArticles/?id=67 The Centers for Medicare and Medicaid Services (CMS) has made revisions to the Physician Quality Reporting Initiative (PQRI) program that should make participating and meeting the reporting threshold easier for providers—which in turn should make your receiving the 1.5 percent incentive payment more likely.... http://www.shopingenix.com/CodingCircleArticles/?id=62 New guidelines released by the Centers for Medicare and Medicaid Services (CMS) address the increase in the number of services reported as “incident to.”... http://www.shopingenix.com/CodingCircleArticles/?id=63 Treatment of chronic nonhealing wounds using platelet-rich plasma (PRP) is still noncovered, according to a coverage policy recently updated by The Centers for Medicare and Medicaid Services (CMS).... http://www.shopingenix.com/CodingCircleArticles/?id=64 In a further advance towards value-based purchasing, the Centers for Medicare and Medicaid Services (CMS) is initiating an acute care episode (ACE) demonstration project effective for admissions occurring on or after October 1, 2008.... http://www.shopingenix.com/CodingCircleArticles/?id=59 After a careful review of the medical evidence, the Centers for Medicare and Medicaid Services (CMS) determined that Medicare coverage of PTA of the renal arteries and PTA concurrent with renal artery stent placement should not be changed. Therefore, PTA with concurrent stent placement coverage is at the discretion of local Medicare contractors.... http://www.shopingenix.com/CodingCircleArticles/?id=60 The Centers for Medicare and Medicaid Services (CMS) has released the latest update to the HCPCS Level II code system. There changes, effective April 1, include:... http://www.shopingenix.com/CodingCircleArticles/?id=61 Are you correctly reporting the present-on-admission (POA) indicator for all diagnoses on claims for inpatient visits? It matters because effective April 1, 2008, if the POA indicators are missing, Medicare will return the claim and delay payment.... http://www.shopingenix.com/CodingCircleArticles/?id=56 National Government Services is the latest Medicare administrative contractor to be selected through competitive bidding to administer claims in one of 15 national jurisdictions. The bulk of jurisdictions have yet to be awarded.... http://www.shopingenix.com/CodingCircleArticles/?id=57 Cardiologists and radiologists got a reprieve from further cuts to medical imaging reimbursement when the Centers for Medicare and Medicaid Services (CMS) announced it will not implement proposed changes that would have drastically limited Medicare coverage of computed tomographic angiography (CTA). CMS released “Coverage Decision Memorandum for Cardiac Computed Tomographic Angiography for the Diagnosis of Coronary Artery Disease” (CAG-00385N) on March 12, 2008.... http://www.shopingenix.com/CodingCircleArticles/?id=58 The Centers for Medicare and Medicaid Services (CMS) announced that it will begin conducting onsite reviews and investigations to evaluate Health Insurance Portability and Accountability Act (HIPAA) Security Rule compliance; violations are subject to penalties. Information was posted on the CMS Web site on February 20 regarding these onsite HIPAA security investigations and compliance reviews.... http://www.shopingenix.com/CodingCircleArticles/?id=53 The Centers for Medicare and Medicaid Services (CMS) has revised its Advance Beneficiary Notices (ABN) form (CMS 141G). In order to clarify the purpose of the form, it is now titled the Advance Beneficiary Notice of Noncoverage. Providers, suppliers, independent laboratories, physicians, and other practitioners began using the new ABN on March 3, 2008. The revised ABN replaces the existing ABN-G (Form CMS-R-131G) and ABN-L (Form CMS-R-131L).... http://www.shopingenix.com/CodingCircleArticles/?id=54 Medicare has recovered millions of dollars from physicians and nonphysician practitioners (NPP) who incorrectly bill professional Evaluation and Management (E/M) services or bill E/M levels that are not supported by the documentation of the encounter or by the patient`s actual condition. So physicians and NPPs may want to closely review the billing and documentation requirements before billing inpatient hospital visits and critical care services provided on the same day.... http://www.shopingenix.com/CodingCircleArticles/?id=55 On February 28, the Centers for Medicare and Medicaid Services (CMS) announced that the Recovery Audit Contractor (RAC) program identified $371.5 million in improper Medicare payments in just three states in 2007.... http://www.shopingenix.com/CodingCircleArticles/?id=46 The Centers for Medicare and Medicaid Services (CMS) has issued a final rule providing for medical necessity determination of coverage for certain physician services before these services are rendered. The intention is to enable the physician and beneficiary to know the financial liability for a service before expenses are incurred.... http://www.shopingenix.com/CodingCircleArticles/?id=47 Certain covered bone mass measurement (BMM) tests are being denied in error, despite an established national coverage determination. In response, the Centers for Medicare and Medicaid Services has issued a transmittal clarifying the claims processing instructions for BMM tests.... http://www.shopingenix.com/CodingCircleArticles/?id=50 What seemed to be established policy regarding separate billing for critical care services is now up in the air if a new communication from the Centers for Medicare and Medicaid Services (CMS) is correct.... http://www.shopingenix.com/CodingCircleArticles/?id=34 Effective April 1, 2008, the Centers for Medicare and Medicaid Services (CMS) will implement a recurring edit module in the carrier processing system to allow program safeguard contractors (PSCs) or CMS to monitor beneficiary and provider numbers they have identified as problematic. The new edits will be especially helpful when identity theft is suspected, but it may slow down legitimate claims.... http://www.shopingenix.com/CodingCircleArticles/?id=35 Beginning April 1, 2008, a new HCPCS Level II K code becomes effective for replacement interface material. This code should be used when submitting claims for the replacement of lower extremity removable soft interfaces only.... http://www.shopingenix.com/CodingCircleArticles/?id=36 Medicare fee-for-service transactions will require providers to report only the national provider identifier (NPI) beginning May 23, 2008; legacy provider identifier numbers will no longer be permitted on form CMS-1500 or form CMS-1450 claims (except in certain the situations defined below). Claims containing legacy provider identifiers will be returned, without appeal rights.... http://www.shopingenix.com/CodingCircleArticles/?id=31 A demonstration project starting up this October will dramatically change the way providers in the project will be paid. The Acute Care Episode (ACE) Demonstration is specifically designed to align incentives and provide flexibility to hospitals and physicians by bundling all related services into an “episode of care.” A single, global payment then will be used as the providers of care deem most appropriate.... http://www.shopingenix.com/CodingCircleArticles/?id=32 By correctly billing for a service many providers are already performing, practices could see increased revenues. Many providers are not aware that Medicare covers eight smoking and tobacco use cessation counseling sessions in a year—and that another eight sessions are paid for during a second or subsequent year once 11 full months have passed since the first covered visit.... http://www.shopingenix.com/CodingCircleArticles/?id=33 The Centers for Medicare and Medicaid Services (CMS) has released the most recent results of the latest Comprehensive Error Rate Testing Program (CERT), and included in the report is a list of the most overutilized codes. Topping the list once again are evaluation and management services.... http://www.shopingenix.com/CodingCircleArticles/?id=28 Although most physician practices perform some type of microscopy service, many do not understand the effects this can have under the Clinical Laboratory Improvement Act (CLIA).... http://www.shopingenix.com/CodingCircleArticles/?id=29 The Centers for Medicare and Medicaid Services (CMS) has updated its national coverage determination (NCD) for erythropoiesis stimulating agents (ESAs) treatment, saying that it is reasonable and necessary for treating anemia secondary to myelosuppressive anticancer chemotherapy in solid tumors, multiple myeloma, lymphoma and lymphocytic leukemia under specified conditions.... http://www.shopingenix.com/CodingCircleArticles/?id=30 The -10.1 percent change to the physician fee schedule conversion factor that was to be effective January 1 through June 30, 2008, has been changed to a 0.5 percent increase.... http://www.shopingenix.com/CodingCircleArticles/?id=25 On January 3rd, 2008, the Centers for Medicare and Medicaid Services (CMS) published a final rule that delays until January 1, 2009, the revised criteria of the anti markup provisions in section 414.50 of the Code of Federal Regulations (CFR).... http://www.shopingenix.com/CodingCircleArticles/?id=26 The Centers for Medicare and Medicaid Services (CMS) has made a number of changes to the standard codes that are used on the remittance advice to tell a provider why a claim was denied or processed differently from how it was submitted.... http://www.shopingenix.com/CodingCircleArticles/?id=27 Late December 19th, Congress passed legislation to prevent the negative 10.1 percent update to the physician fee schedule conversion factor and instead, allowed for a 0.5 percent increase. This means that the estimated conversion factor is 37.9165 instead of the 34.0682 published in the final rule.... http://www.shopingenix.com/CodingCircleArticles/?id=22 On the whole, version 14.0 of the National Correct Coding Initiative edits reflect the CPT® changes for 2008.... http://www.shopingenix.com/CodingCircleArticles/?id=23 New criteria for making a code subject to lower payment because of multiple procedures mean that the appropriate reductions will now apply to additional codes. This, in turn, means a reduction in payment and a hit to some providers’ bottom lines.... http://www.shopingenix.com/CodingCircleArticles/?id=24 The Centers for Medicare and Medicaid Services (CMS) published the 2008 final rule on changes to the outpatient prospective payment system (OPPS) in the Federal Register on November 27, 2007. As part of the rule, CMS made the following ambulatory payment classification (APC) reassignments effective January 1, 2008...... http://www.shopingenix.com/CodingCircleArticles/?id=19 The Centers for Medicare and Medicaid Services (CMS) will pay for brachytherapy sources separately on a prospective basis for 2008. As of December 31, 2007, brachytherapy sources will no longer be paid on the basis of their charges adjusted to cost and all codes will be assigned to status indicator K.... http://www.shopingenix.com/CodingCircleArticles/?id=20 The Centers for Medicare and Medicaid Services (CMS) will not recognize new CPT® codes 99408 and 99409 for reporting alcohol and/or substance abuse screening. Medicare does not cover screening services unless specifically mandated by statute, such as has been done for mammography, diabetes, and colorectal cancer screening.... http://www.shopingenix.com/CodingCircleArticles/?id=21 The Centers for Medicare and Medicaid Services (CMS) has decided to create two composite ambulatory payment classifications (APCs) that will provide payment to hospitals in certain circumstances when extended assessment and management of a patient occur.... http://www.shopingenix.com/CodingCircleArticles/?id=16 Effective April 1, 2008, providers will have another place of service (POS) code to choose from. The Centers for Medicare and Medicaid (CMS) has developed new place-of-service code 16 to indicate temporary housing.... http://www.shopingenix.com/CodingCircleArticles/?id=17 A new and a revised discharge status indicator will enable hospitals to report patient status in more detail beginning April 1, 2008.... http://www.shopingenix.com/CodingCircleArticles/?id=18 The final rule for updates to the physician fee schedule isn’t pretty, at least as far as physician payment is concerned. It looks like physicians will see a negative 10.1 percent update in Medicare fee-for-service payment rates unless Congress takes action.... http://www.shopingenix.com/CodingCircleArticles/?id=13 The final rule on the outpatient prospective payment system describes new payment policies and quality measure reporting, and updates the rates for the revised ambulatory surgery center (ASC) payment system. The rule applies to services furnished during calendar year (CY) 2008.... http://www.shopingenix.com/CodingCircleArticles/?id=14 The Physician Quality Reporting Initiative (PQRI) measures for 2008 include an increased number of measures, as well as guidelines for reporting technology enhancements.... http://www.shopingenix.com/CodingCircleArticles/?id=15 Beware—coders must be careful using the new CPT® codes for telephone services because they are assigned depending on provider type. The American Medical Association included the new codes as part of its update for 2008.... http://www.shopingenix.com/CodingCircleArticles/?id=10 Changes to the narrative of CPT® modifiers 22, 25, 32, 51, 58, 59, 76 and 78 clarify when it is appropriate to use the modifiers but do not affect code assignment. There is also one new modifier.... http://www.shopingenix.com/CodingCircleArticles/?id=11 The Centers for Medicare and Medicaid Services (CMS) has instructed contractors to begin rejecting Health Insurance Portability and Accountability Act (HIPAA) inbound claims if they contain legacy provider identifiers beginning January 8, 2008. However, if the shared system analysis work that will occur in January 8, 2008, is not completed, CMS provides an alternate date of April 4, 2008.... http://www.shopingenix.com/CodingCircleArticles/?id=12 The Office of Inspector General (OIG) has released the 2008 workplan, giving providers a peek at what areas OIG and Medicare contractors will scrutinize in the upcoming year for possible errors, fraud and abuse, or potential Medicare savings.... http://www.shopingenix.com/CodingCircleArticles/?id=7 Effective October 1, coding infections due to central venous catheters became more difficult with the creation of new code 999.31.... http://www.shopingenix.com/CodingCircleArticles/?id=8 The Centers for Medicare and Medicaid Services (CMS) has released the final 2007 updates to the Medicare physician fee schedule (MPFS). These updates became effective October 1.... http://www.shopingenix.com/CodingCircleArticles/?id=9 The changes to the CPT® coding system for 2008 will be massive, according to a preview of revisions released by the American Medical Association (AMA). There are more than 500 code changes affecting anesthesia, evaluation and management, radiology, path/lab, category III, and especially surgery, medicine, and category II codes.... http://www.shopingenix.com/CodingCircleArticles/?id=5 Medicare severity-adjusted diagnosis-related groups (MS-DRGs) will be implemented for discharges occurring on or after October 1, 2007, as was announced in the inpatient prospective payment system (IPPS) final rule (CMS-1533-FC).... http://www.shopingenix.com/CodingCircleArticles/?id=4 In the past week, the Centers for Medicare and Medicaid Services (CMS) has released or revised three national coverage determinations (NCDs). NCDs are the coverage policies all Medicare contractors must follow when processing Medicare claims. Information about each can be found below.... http://www.shopingenix.com/CodingCircleArticles/?id=6 Effective October 1, 2007, all claims submitted to Medicare Part A contractors must contain a present-on-admission (POA) indicator for every diagnosis on acute care hospital claims. Critical access hospitals, Maryland waiver, long-term care, cancer, and psychiatric hospitals, as well as inpatient rehabilitation and children’s inpatient facilities are exempt from this requirement.... http://www.shopingenix.com/CodingCircleArticles/?id=1 The National Plan and Provider Enumeration System (NPPES) data on health care providers that is disclosable under the Freedom of Information Act (FOIA) will be disclosed to the public by the Centers for Medicare & Medicaid Services (CMS).... http://www.shopingenix.com/CodingCircleArticles/?id=2 To protect Medicare patients from fraudulent providers of infusion therapy, Health and Human Services Secretary Mike Leavitt announced a two-year initiative that will focus on deterring deceptive practices.... http://www.shopingenix.com/CodingCircleArticles/?id=3