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Ohio Medicare (including managed care) / General Medicare Information / REV. JAN 2015 Educatonal Info on the AWV (Annual Well Visit) & IPPE Exam
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on: Apr 10, 2015, 04:40:53 am
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In the CMS MLN Connects Weekly Provider eNews dated Thrs., 4-9-15 it announced the publication of the January 2015 revisions to
a) “The ABCs of the Annual Wellness Visit (AWV)” Educational Tool. It includes a list of the required elements in the initial and subsequent AWVs, as
well as coverage and coding information.
b) “The ABCs of the Initial Preventive Physical Examination (IPPE)” Educational Tool. It includes a list of elements that must be included in the IPPE,
as well as coverage and coding information.
Both of these publications are attached to this post.
Debra Farley
Billing Director
BILLPro Management Systems
4-10-15
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117
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Prepare for ICD 10 / Are you ready / CMS: Rev. Medicare FFS Claims Processing Guidance for ICD-10
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on: Feb 25, 2015, 05:17:48 am
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Please scroll down to the CGS e-mail received yesterday publishing the "Revised: Medicare Fee-For-Service (FFS) Claims Processing Guidance for Implementing International Classification of Diseases, 10th Edition (ICD-10) - A Re-Issue of MM7492." ICD-10 implementation is still set for 10-1-15. Debra Farley Billing Director BILLPro Management Systems 2-25-15 From: MedicareEmailList@cgsadmin.com To: debra@billpro.net Sent: Tue, 24 Feb 2015 15:11:26 -0500 News from CMS Revised: Medicare Fee-For-Service (FFS) Claims Processing Guidance for Implementing International Classification of Diseases, 10th Edition (ICD-10) - A Re-Issue of MM7492 — For dates of service on and after October 1, 2015, entities covered under the Health Insurance Portability and Accountability Act (HIPAA) are required to use the ICD-10 code sets in standard transactions adopted under HIPAA. The HIPAA standard health care claim transactions are among those for which ICD-10 codes must be used for dates of service on and after October 1, 2015. Read more... http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1408.pdf |
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119
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General / General Discussion / Compliance: Do You Know How to Avoid These 5 Types of Medicaid Fraud?"
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on: Feb 20, 2015, 06:21:00 am
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Below is an article from "Part B Insider (Multispecialty) Coding Alert. Even though this addresses "Medicaid Fraud" it is true for all other payers.
Part B Insider (Multispecialty) Coding Alert
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Compliance: Do You Know How to Avoid These 5 Types of Medicaid Fraud?
- Published on Fri, Feb 06, 2015
Medicaid auditors could be reviewing your files—make sure you aren’t violating any of these common issues.
If you’re worrying about whether your state Medicaid provider might head your way for an audit, keep in mind that you only have to stress if you’re doing something you shouldn’t be—and one way to find out if that’s the case is to check in on the most common types of Medicaid fraud.
Fortunately, the Arkansas Medicaid Fraud Control Unit recently published five examples of common Medicaid fraud types. Read on for the list, as well as examples to help you steer clear of these issues.
1. Billing for Services Not Rendered: This type of fraud occurs when “a provider bills for treatments or procedures which are not actually performed,” the Arkansas Medicaid Fraud Control Unit says on its website.
An example would be physicians who automatically report 99211 when a patient comes to pick up a prescription and only the receptionist sees the patient. Since you didn’t actually render an E/M visit, 99211 would not be warranted.
2. Billing for Unnecessary Services: In this situation, the “provider misrepresents or falsifies a patient’s diagnosis and symptoms on recipient records and billing invoices to obtain payment for unnecessary services.”
For example, last year a Michigan physician was accused of falsely diagnosing skin cancer so he could perform surgeries and bill the government for the surgical procedures.
3. Kickbacks: This occurs when a Medicaid provider “offers or pays kickbacks to another Medicaid provider’s employees for referring a Medicaid recipient to the provider as a patient or a client,” the Arkansas Fraud Unit notes. “Kickbacks could be in the form of cash, trips or merchandise.”
For instance, if you tell a local urgent care center that for every five patients they send to your office, you’ll give them a $100 gift card to the local mall, that would constitute a kickback request.
4. Double Billing: In this situation, the “provider bills both Medicaid and the recipient (or private insurance) for the same service, or two providers bill for the same service,” Arkansas Medicaid says.
An example of this would be if you send a patient to an outside lab for a urinalysis, but then your practice and the lab both bill 81000 for the service. Only the lab should bill the charge if you didn’t perform the urinalysis.
5. Other Unauthorized Billing: This can happen when “a provider charges a Medicaid recipient for a service which is covered by and should be billed to Medicaid, or charges a recipient the difference between the provider’s usual fee and what Medicaid pays,” the Arkansas Medicaid payer says on its website.
Suppose a patient presents to your office for an allergy shot. Your state Medicaid provider has denied similar claims in the past, so you bill the patient for the shot. In actuality, this claim should be sent to Medicaid rather than being billed to the patient.
Debra Farley
Billing Director
BILLPro Management Systems
2-20-15
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120
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Ohio Medicare (including managed care) / General Medicare Information / Home Health Certification: Don't Delay When Completing Home Health Certification
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on: Feb 20, 2015, 06:14:34 am
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Below is an interesting article which is self-explanatory.
Part B Insider (Multispecialty) Coding Alert
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Home Health Certification: Don't Delay When Completing Home Health Certifications
- Published on Fri, Feb 06, 2015
Your best bet is to fill out the eligibility record at the time of hospital discharge
If your patient qualifies for home health coverage, it’s up to the physician to confirm the patient’s eligibility—and any delays in your documentation could create logjams for patients and the home health agencies planning to care for them.
To ensure that patients are able to smoothly move from the hospital or rehab facility to home health care, follow these steps that will keep the paperwork—and the reimbursement—flowing.
Background: Starting for episodes in 2015, medical reviewers will look to certifying physicians’ records to prove a patient’s eligibility for the Medicare home care benefit, CMS reviewed in a December National Provider Call, “Certifying Patients for the Medicare Home Health Benefit.” Physicians must show that the visit met these three elements for the face-to-face (F2F) encounter without any help from the home health agency:
1. Occurred within the required timeframe,
2. Was related to the primary reason the patient requires home health services; and
3. Was performed by an allowed provider.
The physician record must also show these two elements, but the physician can merely sign off on a home health agency (HHA) summary substantiating these items:
4. Need for skilled services, and
5. Homebound status.
Don’t Dilly-Dally
Industry veterans and even CMS itself all agree on the best strategy to ensure compliance with the new F2F rules—and it involves the physician giving the appropriate paperwork to the HHA from the get-go.
Here’s why: Under the new rules, HHAs must submit the physician’s substantiating documentation to the Medicare contractor reviewing the claim, said CMS’s Jill Nicolaisen during the call. But “the home health agency is not required to have a copy of the physician’s documentation prior to submitting a claim for reimbursement,” Nicolaisen acknowledged.
However: “Because eligibility for home health services is established by the physicians in the patient’s medical record, the home health agency may want to consider obtaining this documentation as early in the home health episode as possible to assure themselves that the Medicare home health patient eligibility criteria has been met,” Nicolaisen said. “While not a Medicare requirement, the home health agency may implement such a procedure as a sound business practice.”
The Illinois Homecare & Hospice Council recommends that “the agency ask for the physician’s note on the face-to-face encounter or the hospital/nursing home’s discharge summary at referral so that they get this documentation on every patient as early as possible,” says Chicago-based regulatory consultant Rebecca Friedman Zuber. “In this way, they will be able to assess their liability.”
Take the Next Step
Just providing the visit note isn’t enough to ward off F2F denials. You need to check it for the required five elements before you share it with the HHA. If the note is missing the three elements required to be furnished by the physician, the HHA will send it back for correction.
If your physician certifies a significant number of patients as eligible for home health, you should set up a procedure so it’s easy for the providers to include documentation of the necessary visit, homebound and skilled need information in every home health patient’s record.
Debra Farley
Billing Director
BILLPro Management Systems
2-20-15
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