The following is quoted from the October 2010 issue of the American Medical Association's publication, "CPT Assistant" related to the subject matter.

"Because there is no specific CPT code for open osteochondral alllograft or repairs with industrial grafts of the ankle, report code 28899, Unlisted procedure, foot or toes, for this procedure.  When reporting an unlisted code to describe a procedure or service, it is necessary to submit supporting documentation (eg, a procedure report) along with the claim to provide an adequate description of the nature, extent, and need for the procedure, and the time, effort and equipment necessary to provide the service."

Debra A. Farley
Billing Director
BILLPro Management Systems
11-6-2010

BILLPro currently has its 2011 CPT Coding Books on order.  Any changes including additions, revisions, deletions will be effective with 1-1-2011 dates of service.  If you have not ordered yours yet, we suggest this be done as soon as possible.

There are two new and EXCITING features in the 2011 Edition --

1)  "CODING TIP" -- tips will be located throughout the book for selected services/procedures that may be a bit
     difficult to report.  These tips are frequent in the Musculoskeletal System.

2)  "EVALUATION AND MANAGEMENT TABLES" --  Requirements for Evaluation and Management (E/M) services will be
     summarized!   As published in the October 2010 "CPT Assistant," published by the American Medical
     Association, "the key to using these tables is to identify the location of the patient's care, and then refer to
     these tables, which will help yo quickly determine the key components (history, examination, and medical
     decision making), the contributory factors (counseling, coordination of care,  nature of presenting problem),
     and the final component, time.  It's important to note that you w ill still need to refer to the E/M section
     within the codebook for the complete code descriptors, including the detailed explanation of the
     appropriate interpretation and reporting of time."

Debra A. Farley
Billing Director
BILLPro Management Systems
11-6-2010

CLIENTS:

As you have been previously made aware, due to recent Medicare legislation, it is now required that all Private Fee-For-Service (PFFS) Medicare Advantage (MA) plans contract with or build a contracted provider network.

This communication addresses a letter (first attachment) and its enclosures (second attachment) many providers have received dated 10-15-10 from the Sterling Health Plans inviting them to participate as a contracted provider in their provider network for their Medicare PFFS Plan and MA PPO Plan.

BILLPro does not review contract content as that must necessarily be the responsibility of the provider and his/her legal counsel.  However, we did have a few questions to which we just received a response from Sterling –

1)   Why in the contract for both plans is the reimbursement for pathology/labs only 60% of the Medicare Fee Schedule and not 100%?  The response received was that is the standard contract language but it can be changed to 100%.  We procured contract pages reflecting the 100% reimbursement and they are in the attachment, pages 15 and 18.  We have NOT included  pages 15 and 18 of the contract providers were mailed.

2)    It was confirmed that Sterling follows CMS guidelines in that ALL locations where patients receive services must be enrolled and any change must be reported within 30 days.  This includes office locations as well as nursing facilities, hospitals, assisted living facilities, etc

Other items of interest:

1)   We ask that providers pay particular attention to page 17 related to the MA PPO Plan, related to referrals, hospital admissions/discharges and services.

2)   For those providers who are members of the Cleveland Clinic PHO, we confirmed with the PHO that Sterling is NOT one of their contracts – providers must contract on their own if interested.

3)    Claims must be filed within 90 days from the date of service.

For those interested in contracting with Sterling and who have not received a letter from them, please print the first and second attachment in their entirety, execute the contract accordingly and, we suggest,  forwarding the original contract to your account manager at BILLPro who will deliver it to one of our credentialing specialists for review for completeness and forwarding to Sterling.  Please leave pages 21 and 22 blank as our credentialing specialists will complete and may contact you for any information that may be needed.   If BILLPro does not have a current listing of all locations where services are provided, please provide a listing on a separate sheet to include the legal name of the facility, telephone number and fax number (if available) which we will incorporate on the Provider Information Sheet which must be completed for each provider within the practice.  Our charge for this service is a flat $35.00 and will be added to your BILLPro invoice when the contract is accepted by Sterling.



   NOTE:  For those who are interested in contracting and have received a letter from Sterling, only pages
             15 and 18 need be printed of the second attachment related to the reimbursement by both
             plans then  follow the remaining instructions as outlined in the paragraph above.  Of course, if
             you prefer  to handle the contracting yourself, please do make sure to inform your account
             manager at BILLPro so she is aware that you will be contracting with Sterling.

IF YOU ARE A LABORATORY OR DME SUPPLIER, A SEPARATE CONTRACT IS REQUIRED.  Please see the third attachment below for the “Lab DME Agreement .”  If interested in contracting, we ask that you follow the instructions above.  Please leave page 18 blank as we shall complete.

Any questions you have related to the Sterling contract(s) including any portion of the contract you would like to negotiate, can be directed to Arti Bhatt at Arti.Bhatt@sterlingplans.com (phone: 360-961-6651).  If it was that easy for us to obtain an increase from 60% to 100% of the pathology/lab fee schedule, it may behoove you to attempt to negotiate at reimbursement to 110% or 105% of the Medicare fee schedule!


Debra A. Farley
Billing Director
BILLPro Management Systems
11-3-2010

From: Jurisdiction B DME MAC <dmemaclistserve@anthem.com>
To: debra@billpro.net
Date: 10/25/2010 04:31 PM
Subject: Jurisdiction B News: NGSMedicare.com Improvements Will Enhance User Experience


NGSMedicare.com Improvements
Will Enhance User Experience

As part of our drive for continuous improvement, National Government Services will move the NGSMedicare.com Web site to a new technology platform offering improved usability, greater flexibility, and a new look and feel.

What’s in it for you, the users of NGSMedicare.com?

    * Fewer clicks to access content
    * Time-sensitive information will be brought to the forefront through new Production Alerts and Hot Topics features
    * Easy access to helpful information about using the site

Please check the Resources > Initiatives > Exciting Changes Coming to NGSMedicare.com page on the
www.NGSMedicare.com          Web site often to learn more about the new site’s enhancements and features.

Watch for additional communications on these exciting enhancements to the NGSMedicare.com site.

Debra A. Farley
Billing Director
BILLPro Management Systems
11-2-10

National Supplier Clearinghouse
Chain DMEPOS Supplier Closing a Practice Location

All DMEPOS suppliers, including a chain supplier, are required to notify the National Supplier Clearinghouse (NSC) regarding the closure of a Medicare enrolled supplier practice location within 30 days of the closure. Accordingly, if a chain DMEPOS supplier is closing a practice location enrolled in the Medicare program, then the chain supplier must notify the NSC about this change (voluntary termination) by submitting the Medicare enrollment application (CMS-855S) within 30 days of the closure.

Any DMEPOS supplier, including a chain supplier, that does not comply with its reporting responsibilities is subject to a Medicare revocation and the loss of Medicare billing privileges. In addition, the imposition of Medicare revocation requires that the NSC establish a Medicare enrollment bar for a period of not less than one year. A Medicare enrollment bar will prohibit a revoked supplier, including a chain supplier, from enrolling new practice locations under the same legal business name or with the same authorized or delegated officials. Finally, the imposition of a Medicare revocation may impact the cost associated with obtaining a surety bond.

 
last updated on 09/07/2010
© 2010 Palmetto GBA, LLC.

Date: 10/29/2010 02:23 PM
Subject: CARESOURCE MEDICAID MANAGED CARE & BALANCE BILLING

CLIENTS:

REMINDERS RELATED TO BALANCE BILLING CARESOURCE MEMBERS:

1)  There is only one CareSource plan in which you are PERMITTED TO BALANCE BILL A PATIENT -- that is the
     Caresource Buy-In program.

     It is suggested that a separate payer be created for this Buy-In program and the copay, if listed on the
     beneficiary's Caresource card, be entered in the subscriber screen.  By creating this Buy-In specific payer, if
     a claim is processed with a copay/deductible/coinsurance, one will know NOT to write off that amount but to
     bill the beneficiary.   The words "Buy-In" are listed on the CareSource card if the beneficiary is enrolled in this
     program.

2)  One is NEVER permitted to balance bill any other CareSource Medicaid recipient including Caresource
     Advantage (Medicare/Medicaid Managed Care).

Debra Farley
Billing Director
BILLPro Management Systems, Inc.
debra@billpro.net
440-854-0205 OR 1-800-736-0587 ext 0205
FAX 440-516-3783

Date: 10/21/2010 05:11 AM

CLIENTS:

Please see the Medicare e-mail below concerning Medicare DME enrollment.

Debra Farley
Billing Director
BILLPro Management Systems, Inc.
debra@billpro.net
440-854-0205 OR 1-800-736-0587 ext 0205
FAX 440-516-3783
MB

    From: padministrator@webmail.palmettogba.com
    To: debra@billpro.net
    Sent: Wed, 20 Oct 2010 20:19:32 -0400
    Subject: Palmetto GBA E-mail Update

    *************************************************************************************
    Please do not reply to this message. This is an announcement e-mail only.

    *************************************************************************************

    Notifying the NSC of Deceased Owners, or Authorized and Delegated Officials

    DMEPOS suppliers are reminded to notify the National Supplier Clearinghouse
    within 30 days of deceased owners, or authorized and delegated officials.
    This rule is published in 100-08 of the PIM, Chapter 10, Section 16,
    Subsection D. Please submit this information to
    decease.notification@palmettogba.com.


    http://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/8ADJKZ1422?opendocument


    Applies to:
    National Supplier Clearinghouse (NSC)//General - NSC
    ---------------------------------------------------------------------------

To ADD a bookmark
    -> click on the subject desired
    -> click "ADD BOOKMARK"
      and it will immediately appear in your "Bookmarks"

To  DELETE a bookmark
    -> click the box to the far right (a check mark shall appear) on that subject
    -> click  "Delete selected bookmarks"

Debra Farley
Billing Director
BILLPro Management Systems, Inc.
debra@billpro.net
440-854-0205 OR 1-800-736-0587 ext 0205
FAX 440-516-3783

CLIENTS:

Medicare just released the first edition of the "Medicare Quarterly Provider Compliance Newsletter Guidance to Address Billing Errors."

Please see the e-mail below -- just click on the link to view/print this publication.

Debra Farley
Billing Director
BILLPro Management Systems, Inc.
debra@billpro.net
440-854-0205 OR 1-800-736-0587 ext 0205
FAX 440-516-3783

    From: CMS CMSProviderResource [mailto:CMSProviderResource@CMS.HHS.GOV]
    To: ALL_FFS_PROVIDERS@LIST.NIH.GOV
    Sent: Tue, 05 Oct 2010 16:29:52 -0400
    Subject: Medicare Quarterly Provider Compliance Newsletter Released

    New from the Medicare Learning Network

    Medicare Quarterly Provider Compliance Newsletter - First Edition Released!
   

    The Medicare Learning Network® (MLN) has developed a new educational tool, the Medicare Quarterly Provider Compliance Newsletter, to advise physicians, suppliers, and other FFS providers about how to avoid common billing errors and other erroneous activities when dealing with the Medicare Program.  The newsletter will be issued on a quarterly basis and highlight the “top” issues of that particular quarter as identified through a variety of sources.  In this first edition, a number of issues that impact a variety of provider types are presented in order to introduce the newsletter to a wide audience of providers.  For more information, please read the first edition of the newsletter at http://www.cms.hhs.gov/MLNProducts/downloads/MedQtrlyComp_Newsletter_ICN904943.pdf on the CMS website.

     

CLIENTS:

Please see the e-mail below which is from and only pertains to Medicare DME.

It is up to the Medicare carriers (Part B and DME are separate entities and may, at times, have separate guidelines) whether to use the JW modifier or not.  Medicare DME will NOT.

We have not received any official word from Part B as to their billing requirements regarding use of this modifier.

Debra Farley
Billing Director
BILLPro Management Systems, Inc.
debra@billpro.net
440-854-0205 OR 1-800-736-0587 ext 0205
FAX 440-516-3783


    From: Jurisdiction B DME MAC [mailto:dmemaclistserve@anthem.com]
    To: debra@billpro.net
    Sent: Tue, 05 Oct 2010 16:02:39 -0400
    Subject: Jurisdiction B News: Modifier JW for Discarded Drugs and Biologicals

    Modifier JW for Discarded Drugs and Biologicals
     
    The Medicare Claims Processing Manual (Internet Only publication 100-4), Chapter 17, Section 40, contains instructions for the use of the JW modifier for discarded drugs and biologicals. The descriptor for the JW modifier reads:
     
    JW - DRUG AMOUNT DISCARDED/NOT ADMINISTERED TO ANY PATIENT
     
    National Government Services, the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC), does not require use of the JW modifier for discarded drugs and biologicals.
     
    Suppliers with additional questions should refer to MLN Matters articles MM6711 and MM7095 at http://www.cms.gov/MLNMattersArticles/downloads/MM7095.pdf and http://www.cms.gov/MLNMattersArticles/downloads/MM6711.pdf.
     
 

    Remember! National Government Services' Jurisdiction B DME MAC List serv is for out going messages only. Please do not respond back to messages as your response will not be answered, as this is not an authorized mode of communication at this time, Thank You!