Please see the article below published on 6-6-14 in the publication, "Part B Insider Coding Alert."


Part B Mythbuster: Stabilization Doesn't Always Equal Fracture Care
- Published on Fri, Jun 06, 2014

Plus: Don’t forget to bill supply codes to Medicare.

A patient reports to your practice with a broken bone. The physician treats her and sends her home. This is automatically a fracture care claim ... right? Wrong: Even if the physician confirms a fracture, this does not guarantee you can choose a fracture care code.

When examining a claim, the coder should ask this question: Did the physician treat the patient’s fracture, or did he just make the patient more comfortable? If he just makes the patient comfortable, then you cannot code fracture care.

Example: The physician treats a patient with a suspected right leg fracture; she examines the leg, takes a pair of x-rays, and determines that he has a closed tibia fracture. She puts the leg in a splint, and then advises the patient to visit an orthopedist as soon as possible for additional treatment, including casting.

This is not fracture care. On the claim, you’d likely report an E/M code for the encounter. So if the physician provides mostly comfort measures and the patient is sent to a different specialist (such as an orthopedic surgeon) for more definitive care (such as casting), code only for the E/M. If the physician definitively treats the patient’s fracture, however, you’d report a fracture care code.

Example: The physician treats a patient with a suspected right leg fracture; she examines the leg, takes a pair of x-rays, and determines that he has a closed tibia fracture. She resets the bone and places his lower leg in a cast. She then advises the patient to schedule follow-up visits with an orthopedist.

For this encounter, you can report an E/M and a fracture care code. On the claim, report the following:

    27752 (Closed treatment of tibial shaft fracture [with or without fibular fracture]; with manipulation, with or without skeletal traction) for the fracture care
    The appropriate-level E/M code based on notes
    Modifier 54 (Surgical care only) appended to 27752 to show that you are not coding for the patient’s follow-up care (the orthopedist will bill this with modifier 55 (Postoperative management only).
    Modifier 57 (Decision for surgery) appended to the E/M to show that it was a separate service from the fracture care.

Note: Some payers (including most Medicare carriers) want you to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to specific fracture care E/M codes instead of modifier 57. That’s because these payers follow the rule that modifier 25 would be used if the global days were 0-10, and modifier 57 would be used when global days are 90 or greater.

So a fracture care code such as 21310 (Closed treatment of nasal bone fracture without manipulation), which has a 10-day global, might prompt you to append modifier 25 to the E/M instead of 57, depending on the insurer.

Report Casting Supplies

You can report supplies on the same date that you charge fracture care. Although you can bill the supplies, you cannot charge for casting/splinting on the same date as charging fracture care. The cost of the actual casting or splinting service is included in the fracture care charge.

Supply tip: When billing Medicare, remember to report only one unit of each Q code for the supplies. If you’re billing a different insurer, the payer may request that you report “A” codes instead of the Q codes.

Debra Farley
Billing Director
BILLPro Management Systems
6-11-14

Nothing has changed with Medicare's stance on the correct billing submission of bilateral ear was removal, 69210 -- below is the information published by CGS Medicare today, 6-5-14 clarifying their stance --

"Removal of Impacted Ear Wax: Claim Submission Information —There has been a recent surge in calls to our Provider Contact Center regarding CPT code 69210 (removal of impacted ear wax). The purpose of this article is to clarify claim submission instructions when this service is performed bilaterally. The 2014 CPT manual revised the description of this CPT code.

For services performed on or after January 1, 2014, CPT states that this code is considered unilateral and may be submitted with CPT modifier 50 to indicate a bilateral service. However, in the CMS Medicare Physician Fee Schedule Database (MPFSDB), CPT code 69210 has a bilateral indicator of 2, which signifies that Medicare payment is based on the service being performed bilaterally. Read more..."

http://www.cgsmedicare.com/ohb/pubs/news/2014/0614/cope25861.html

Debra Farley
Billing Director
BILLPro Management Systems
6-5-14

Please see the CMS e-mail below and click on the link.

Debra Farley
Billing Director
BILLPro Management Systems
6-4-14

From: Centers for Medicare & Medicaid Services <cmslists@subscriptions.cms.hhs.gov>
To: debra@billpro.net
Date: 06/03/2014 03:35 PM
Subject: An Alert titled Medicare Secondary Payer (MSP) Working Aged Policy for Group Health Plans (GHP) - Definition of “Spouse”; Same-Sex Marriages has been posted

 

An Alert titled Medicare Secondary Payer (MSP) Working Aged Policy for Group Health Plans (GHP) - Definition of “Spouse”; Same-Sex Marriages has been posted to the Downloads section of the Beneficiary Services page. The following link may be used to access the page,

 http://go.cms.gov/beneficiary.

Please see the article below published by Part B Insider Coding Alert on 6-2-14

Debra Farley
Billing Director
BILLPro Management Systems
6-3-14

Part B Revenue Booster: Late Effects Codes Could Be the Key to Reimbursement
- Published on Mon, Jun 02, 2014

5 strategies keep complications out and reimbursement in.

With ICD-10 delayed yet another year, it may be a good time to polish your ICD-9 late effects coding skills. Not only will this help improve your reimbursement when addressing and treating late effects, but it will also teach you these coding conventions that you’ll have to know under ICD-10 as well. Fortunately, recognizing late effects can be simple when you use the following five easy strategies that can support your physician’s services more accurately, and therefore increase the odds that you collect your full fee.

1. No Time Limits for Late Effects

Late effects are the long-term effects of an injury or illness after the acute phase is over. For example, a patient may have a vertebral fracture and continue to have pain years after the fracture heals. Some late effects present early, while others might only become apparent months or years later. Based on ICD-9 guidelines, there are no time limits for reporting and treating late effects.

The ICD-9 manual provides a separate subsection (905-909.9) describing “late effects of injuries, poisonings, toxic effects, and other external causes.” Depending on your specialty, late effects that your practice commonly sees may include 905.0-905.9 (Late effect of musculoskeletal and connective tissue injuries), 907.0-907.9 (Late effects of injuries to the nervous system) or 908.6 (Late effect of certain complications of trauma), for example.

Late effects tell the whole story of a patient’s condition, and they present a much clearer picture to the carrier of why a physician may choose to treat a patient in a particular way. Specifically, late effects codes link what is going on with the patient now with what happened in the past. Like E codes for external causes of injury and poisoning, late effects codes provide a more complete picture of the reason for treatment and can be very helpful in getting payment for patients who are injured in an auto accident or in workers’ compensation claims.

Certain specialties may see these conditions more than others, such as rehab practices that treat patients with residual problems from spinal cord injuries, traumatic brain injuries, orthopedic injuries as well as conditions such as cerebral vascular accident (CVA).

2. Use Keywords to Detect Late Effect

To determine if a condition is a late effect, you should look for keywords in the physician’s documentation. Such keywords might include the following:

    due to - such as "pain in right hip due to fracture last year”
    following - such as "personality changes following a brain injury in 2011”
    as a result of - such as "hemiplegia as a result of CVA”
    residual effect - such as "arthritis that is a residual effect of previous hip fracture.”

Heads-up: Don’t confuse late effects with complications. A complication is essentially not a part of a patient’s disease, condition or problem. A complication is typically associated with a difficulty or problem that occurs with a specific procedure (996.xx) and not the sequelae due to the original disease or injury.

3. Assign Secondary Diagnoses

When you evaluate late effects of an acute injury, you’ll report two separate diagnosis codes. “The condition or nature of the late effect is sequenced first. The late effect code is sequenced second,” according to section 12 of the Official ICD-9-CM Guidelines for Coding and Reporting.

For example: A patient fractures his tibia in a fall. Several months later, the patient develops numbness in the foot and continues to have pain in the knee. She visits the physician for testing and treatment. The physician’s documentation indicates that these symptoms are due to the past tibia injury. 

In this case, you should first report the knee joint pain (719.46, Pain in joint, lower leg) and numbness (782.0 Disturbance of skin sensation) and then code the late effect (905.4, Late effect of fracture of lower extremities).

4. Follow Other Rules for Stroke Coding

There are exceptions to the sequencing rules above, unfortunately. “Exceptions to the [sequencing] guidelines are those instances where the late effect code has been expanded (at the fourth and fifth-digit levels) to include the manifestation(s) or the classification instructs otherwise,” the Official Guidelines state. “The code for the acute phase of an illness or injury that led to the late effect is never used with a code for the late effect.”

For example, coding for CVA patients deviates from the general rule on coding late effects. When reporting late effects of a stroke, you need not report both the condition’s cause and the residual effect. Rather, you should use a single ICD-9 code to describe CVA late effects, because there are codes specifically assigned to the most common late effects of CVA.

Codes describing late effects of stroke appear in a separate section of the ICD-9 manual (438). These codes, such as 438.11 (Late effects of cerebrovascular disease; aphasia) and 438.21 (... hemiplegia affecting dominant side), describe both the residual condition and the cause of the condition.

Example 1: A patient is concerned about continued arm paralysis three months after a CVA and consults with your physician. You should report the late effect as the primary diagnosis. Therefore, you should report 438.30 (... monoplegia of upper limb affecting unspecified side) as the primary diagnosis.

Example 2: However, if the physician admits the patient for treatment of another CVA (new diagnosis), you should report the current CVA first (the 436 category), followed by any appropriate late effects code(s) (such as 438.30). This identifies those deficits that relate to the present CVA and from pre-existing conditions.

“Codes from category 438 may be assigned on a health care record with codes from 430-437, if the patient has a current cerebrovascular accident (CVA) and deficits from an old CVA,” the Guidelines note.

Example 3: If the patient has no residual problems from the first CVA, you may report V12.59 (Personal history of  other diseases of circulatory system;  not elsewhere classified) as the secondary diagnosis.

5. Describe Unnamed CVA Conditions

Two codes in the 438 series require you to add a secondary code because they are nonspecific and you need another code to be as specific as possible.

The first is 438.89 (Other late effects of cerebrovascular disease). When ICD-9 does not list the patient’s residual condition, use this along with a second code to provide further detail. For a patient who has urinary incontinence due to CVA, you should report 438.89 followed by 596.59 (Other functional disorder of bladder) and 788.39 (Other urinary incontinence).

The second code in this category is 438.5x (... other paralytic syndrome). ICD-9 may not specify the patient’s paralytic syndrome in the 438 series, so you might use 438.5x and another code, such as 344.00-344.09 (Quadriplegia and quadriparesis), to indicate the type of the patient’s paralysis.

Note: You can find the official ICD-9-CM Guidelines for Coding and Reporting at www.cdc.gov/nchs/data/icd/icd9cm_guidelines_2011.pdf. This was last updated in 2011. 

Below is my 5-23-14 e-mail which contained the new CMS Medicare article on the "Proper Use of Modifier 59."  Well, yesterday, CMS issued a revision of the article -- please click on the link below to access it.

Revised:   SE1418 – Proper Use of Modifier 59

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1418.pdf


Debra Farley
Billing Director
BILLPro Management Systems
6-3-14

    From: Debra [mailto:debra@billpro.net]
    To: kerio_bpm [mailto:bpm@billpro.net]
    Sent: Fri, 23 May 2014 05:54:46 -0500
    Subject: IMPORTANT: CMS: NEW ARTICLE TITLED "SE1418 – Proper User of Modifier 59"

    CLIENTS:

    Please scroll down to the CMS e-mail received this morning announcing publication of a new article titled "PROPER USE OF MODIFIER 59" and contains examples.  Even though this is directed to the Medicare community, it is standard for most payers.  For any provider that appends modifier 59 to a procedure this is a MUST READ and contains examples.

    No modifier should be used just to bypass an edit.  As the article states, "Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that is used."

    It is extremely important that the provider denote when modifier 59 is applicable.  It is also important that modifier 59 be appended to the correct procedure or it will be denied.   Saying that, one must understand CCI (Medicare's Correct Coding Initiative) edits.  Modifier 59 must be attached to the secondary, additional, or lesser service in the code pair.

    There is a wonderful 17 page January 2013 publication from CMS (Centers for Medicare and Medicaid Services) titled "How to Use the Medicare National Correct Coding Initiative (NCCI) Tools."  It is available under the DOWNLOADS section at

    http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1243274.html

    Please know that CCI edits are published quarterly where there are regular updates.  Just as an example, for the first quarter of 2014 there were

    -   48,013 NEW edit pairs

    -   13,107 TERMINATIONS

    -   137 changes to the modifier indicator, all but 4 went from 1 (modifier may be used if appropriate) to 0 (no modifier
        can be used to unbundle)


    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 MLNMatters-L [mailto:MedlearnMatters-L@CMS.HHS.GOV]
        To: MLNMATTERS-L@LIST.NIH.GOV
        Sent: Thu, 22 May 2014 10:25:34 -0500
        Subject: New Article Posted to MLN Matters   

         

        New:

         

        SE1418 – Proper User of Modifier 59

        http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1418.pdf

         

To stay in tune with ICD-10, even though it has been delayed until 10-1-2015, we wanted to provide the attached information which we recently were provided by Lake Health Systems in Lake County, OH.  It is titled ICD-10 "Clinical Documentation Improvement."

    Debra Farley
    Billing Director
    BILLPro Management Systems
    5-31-14

Please visit the link below which addresses clarification to the Medicare Benefit Policy Manual Regarding Antigens and also the revised "General Exclusions from Coverage."

    http://cgsmedicare.com/ohb/pubs/news/2014/0414/R_184_BP.pdf

     
Debra Farley
Billing Director
BILLPro Management Systems
5-30-14

Below is an article related to ICD-10 which appeared in the publication "Part B Insider Coding Alert."

    ICD-10:  CMS Answers ICD-10 Questions--By Not Answering

    - Published on Wed, May 21, 2014

    Representatives stay mum about the details of the delay.

    The recent delay of ICD-10 until 2015 has raised plenty of questions in the coding community, but unfortunately CMS is not ready to answer them all. Several Part B practices asked reps from the agency about the specifics of the delay, but didn’t get the answers they were seeking during CMS’s May 13 Open Door Forum.

    “On April 1, 2014, the Protecting Access to Medicare Act of 2014 was enacted, and it says that the secretary may not adopt ICD-10 prior to Oct. 1, 2015,” said CMS’s Chris Ritter during the call. “Accordingly, the US Department of Health and Human Services expects to release an interim final rule in the near future that will include a new compliance date that would require the use of ICD-10 beginning Oct. 1, 2015. The rule will also require HIPAA covered entities to continue to use ICD-9-CM through Sept. 30, 2015.”

    When a caller asked whether that Final Rule will be issued on Aug. 1 (which is when the Inpatient Prospective Payment Final rule is due to be issued), CMS reps declined to answer. “Actually, the handling of ICD-10 is a separate issue,” Ritter said. “The proposed IPPS rule does simply indicate that the recent legislation does delay ICD-10, and the secretary will be issuing a rule separately, but there will be a separate final rule for ICD-10. You can keep your eyes out for that.”

    When a caller asked whether the ICD-9 code freeze will stay in effect or whether new ICD-9 codes will be released in the wake of the ICD-10 delay, CMS’s Diane Kovach responded that the answer has not yet been determined and that CMS will speak on that at a later date.

    Another caller asked for rationale regarding the cancellation of ICD-10 end-to-end testing, but CMS stressed that “the agency has committed to end-to-end testing” and that it will happen in 2015. “Like everyone else that has done a lot of work to prepare for ICD-10 for the Oct. 1, 2014 date, we now have to turn our attention to reverting back to ICD-9 codes, so we’ll be doing that for the coming months, and as soon as we have information available, which we hope will be in the not too distant future, we’ll have information to you on end-to-end testing for next year,” Kovach added.

    Here’s What You Can Do

    Take the extra year to get to know the ICD-10 manual, if you haven’t already studied it. Each ICD-10 code begins with a letter and these letters indicate the tabular chapter from which the code comes. Use this list to begin familiarizing yourself with ICD-10’s organization.

        A & B – Certain Infectious and Parasitic Diseases.
        C – Neoplasms.
        D – Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism
        E – Endocrine, Nutritional, and Metabolic Diseases.
        F – Mental, Behavioral and Neurodevelopmental Disorders.
        G – Diseases of the Nervous System
        H – Diseases of the Eye and Adnexa, Ear and Mastoid Process
        I – Diseases of the Circulatory System
        J – Diseases of the Respiratory System
        K – Diseases of the Digestive System
        L – Diseases of the Skin and Subcutaneous Tissue
        M – Diseases of the Musculoskeletal System and Connective Tissue.
        N – Diseases of the Genitourinary System
        O – Pregnancy, Childbirth and the Puerperium
        P – Certain Conditions Originating in the Perinatal Period
        Q – Congenital Malformations, Deformations and Chromosomal Abnormalities
        R – Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified
        S & T – Injury, Poisoning and Certain Other Consequences of External Causes
        V, W, X, Y – External Causes of Morbidity
        Z – Factors Influencing Health Status and Contact with Health Services

Debra Farley
Billing Director
BILLPro Management Systems
5-24-14

Please scroll down to the IMPORTANT CMS e-mail titled "MM8667 – Posting the Limiting Charge after Applying the Electronic Health Record (EHR) and Physician Quality Reporting System (PQRS) Negative Adjustments."  Most of our clients are participating providers with Medicare which means they accept assignment on all claims.  This article explains the EHR and PQRS negative adjustments beginning on 1-1-2015.

For those clients who are non-participating providers, there is important information in the article respective to their practice respective to the negative adjustments.

Debra Farley
Billing Director
BILLPro Management Systems,
5-24-14

    From: Debra [mailto:debra@billpro.net]
    To: Debra [mailto:debra@billpro.net]
    Sent: Wed, 21 May 2014 10:45:55 -0500
    Subject: MM8667 – Posting the Limiting Charge after Applying the Electronic Health Record (EHR) and Physician Quality Reporting System (PQRS) Negative Adjustments

     

        From: CMS MLNMatters-L [mailto:MedlearnMatters-L@CMS.HHS.GOV]
        To: MLNMATTERS-L@LIST.NIH.GOV
        Sent: Wed, 21 May 2014 06:33:20 -0500
                   

         

        New:

         

        MM8667 – Posting the Limiting Charge after Applying the Electronic Health Record (EHR) and Physician Quality Reporting System (PQRS) Negative Adjustments

        http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8667.pdf

         

Please scroll down to the IMPORTANT CMS e-mail titled "MM8667 – Posting the Limiting Charge after Applying the Electronic Health Record (EHR) and Physician Quality Reporting System (PQRS) Negative Adjustments."  Most of our clients are participating providers with Medicare which means they accept assignment on all claims.  This article explains the EHR and PQRS negative adjustments beginning on 1-1-2015.

For those clients who are non-participating providers, there is important information in the article respective to their practice respective to the negative adjustments.

Debra Farley
Billing Director
BILLPro Management Systems,
5-24-14

    From: Debra [mailto:debra@billpro.net]
    To: Debra [mailto:debra@billpro.net]
    Sent: Wed, 21 May 2014 10:45:55 -0500
    Subject: MM8667 – Posting the Limiting Charge after Applying the Electronic Health Record (EHR) and Physician Quality Reporting System (PQRS) Negative Adjustments

     

        From: CMS MLNMatters-L [mailto:MedlearnMatters-L@CMS.HHS.GOV]
        To: MLNMATTERS-L@LIST.NIH.GOV
        Sent: Wed, 21 May 2014 06:33:20 -0500
                   

         

        New:

         

        MM8667 – Posting the Limiting Charge after Applying the Electronic Health Record (EHR) and Physician Quality Reporting System (PQRS) Negative Adjustments

        http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8667.pdf

         

    In the Thursday, 5-22-14, issue of CMS MLN Connects™ Weekly Provider eNews is the following information:

    The ICD-9-CM Coordination and Maintenance Committee implemented a partial freeze of the ICD-9-CM and ICD-10-CM codes prior to the implementation of ICD-10, which would end one year after the implementation of ICD-10. On 4-1-14 the Protecting Access to Medicare Act of 2014 was enacted which said that the Secretary may NOT adopt ICD-10 prior to 10-1-2015.  HHS is expected to release an interim final rule in the near future that will include a new compliance date that would require the use of ICD-10 beginning 10-1-2015.  The rule will also require HIPAA covered entities to continue to use ICD-9 through 9-30-15.

    The partial code freeze will continue through 10-1-2015.  Regular updates to ICD-10 will begin on 10-1-2016, one year after the implementation of ICD-10.

    Also, the 2015 ICD-10 CM file is now posted at http://www.cms.gov/Medicare/Coding/ICD10/2015-ICD-10-CM-and-GEMs.html
    There are NO new, revised, or deleted ICD-10-CM codes.

    The 2015 ICD-9-CM files are available at http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html
    As there will be NO ICD-9-CM updates, there is no FY 2015 addendum.   There are NO new, revised or deleted ICD-9-CM codes.

    Debra Farley
    Billing Director
    BILLPro Management Systems
    5-23-14

Please scroll down to yesterday's CMS e-mail titled "Prior Authorization to Ensure Beneficiary Access and Help Reduce Improper Payments."    Ohio has been added as a demonstration state!

Debra Farley
Billing Director
BILLPro Management Systems
5-23-14

    From: Centers for Medicare & Medicaid Services [mailto:cmslists@subscriptions.cms.hhs.gov]
    To: debra@billpro.net
    Sent: Thu, 22 May 2014 17:20:05 -0500
    Subject: CMS NEWS: Prior Authorization to Ensure Beneficiary Access and Help Reduce Improper Payments

     

    FOR IMMEDIATE RELEASE                                     Contact: CMS Media Relations

    May, 22, 2014                                                    (202) 690-6145 or press@cms.hhs.gov

     

    Prior Authorization to Ensure Beneficiary Access and

    Help Reduce Improper Payments

     

    The Centers for Medicare & Medicaid Services today announced plans to expand a successful demonstration for prior authorization for power mobility devices, test prior authorization in additional services in two new demonstration programs, and propose regulation for prior authorization for certain durable medical equipment, prosthetics, orthotics, and supplies. Prior authorization supports the administration’s ongoing efforts to safeguard beneficiaries’ access to medically necessary items and services, while reducing improper Medicare billing and payments. The proposed rule is estimated to reduce Medicare spending by $100 to $740 million over the next ten years.

     

    “With prior authorization, Medicare beneficiaries will have greater confidence that their medical items and services are covered before services and supplies are rendered. This will improve access to services and quality of care,” said CMS Administrator Marilyn Tavenner.

     

    The announcement builds upon lessons learned from the Medicare Prior Authorization of Power Mobility Device Demonstration. Launched in 2012, the demonstration established a prior authorization process for certain power mobility devices. Based on September 2013 claims data, monthly expenditures for certain power mobility devices decreased from $12 million in September 2012 to $4 million in August 2013 across the seven demonstration states (California, Florida, Illinois, Michigan, New York, North Carolina, and Texas) with no reduction in beneficiary access to medically necessary items.

     

    CMS seeks to leverage this success by extending the demonstration to an additional 12 states. These states include Arizona, Georgia, Indiana, Kentucky, Louisiana, Maryland, Missouri, New Jersey, Ohio, Pennsylvania, Tennessee, and Washington. This will bring the total number of states participating in the demonstration to 19.

     

    CMS also proposes to establish a prior authorization process for certain durable medical equipment, prosthetics, orthotics, and supplies items that are frequently subject to unnecessary utilization. Through a proposed rule, CMS will solicit public comments on this prior authorization process, as well as criteria for establishing a list of durable medical items that are frequently subject to unnecessary utilization that may be subject to the new prior authorization process. The proposed rule is currently on display at https://www.federalregister.gov/public-inspection and will be published in the Federal Register on May 28, 2014. The deadline to submit comments is July 28, 2014.

     

    CMS will launch two payment model demonstrations to test prior authorization for certain non-emergent services under Medicare. These services include hyperbaric oxygen therapy and repetitive scheduled non-emergent ambulance transport. Information from these models will inform future policy decisions on the use of prior authorization. 

     

    Prior authorization does not create additional documentation requirements or delay medical service. It requires the same information that is currently necessary to support Medicare payment, but earlier in the process. CMS believe prior authorization is an effective way to ensure compliance with Medicare rules for some items and services. 

     

    For more information, go to: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Overview.html.

     

    Additioanl Fact Sheets Links:

    http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-05-22-2.html

    http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-05-22-3.html

    http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-05-22-4.html

     

     

Please see the CMS e-mail directly below and click on the link for the full article


From: CMS MLNMatters-L <MedlearnMatters-L@CMS.HHS.GOV>
To: MLNMATTERS-L@LIST.NIH.GOV
Date: 05/21/2014 06:33 AM
 
New:

MM8730 – Additional States Requiring Payment Edits for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Suppliers of Prosthetics and Certain Custom-Fabricated Orthotics. Update to CR 3959 and CR 8390.

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8730.pdf

 
Debra Farley
Billing Director
BILLPro Management Systems
5-21-14

Please scroll down for a CMS e-mail publishing a new article "Update to Surety Bond Collection Procedures" for Medicare DMEPOS suppliers


Debra Farley
Billing Director
BILLPro Management Systems
5-21-14
debra@billpro.net

    From: CMS MLNMatters-L [mailto:MedlearnMatters-L@CMS.HHS.GOV]
    To: MLNMATTERS-L@LIST.NIH.GOV
    Sent: Wed, 21 May 2014 06:33:20 -0500
   
             

    New:

    MM8636 – Update to Surety Bond Collection Procedures

    http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8636.pdf

     

Please scroll down to the CMS e-mail received yesterday titled "CMS makes improvements to Medicare drug and health plans."   Amongst other items, CMS will require "Part D prescribers to enroll in Medicare" and will revoke "Medicare enrollment for abusive prescribing practices and patterns."

Debra Farley
Billing Director
BILLPro Management Systems
5-20-14

        From: Centers for Medicare & Medicaid Services [mailto:cmslists@subscriptions.cms.hhs.gov]
        To: debra@billpro.net
        Sent: Mon, 19 May 2014 16:39:58 -0500
        Subject: CMS NEWS:

       

        FOR IMMEDIATE RELEASE                                                    Contact: CMS Media Relations

        May 19, 2014                                                                     (202) 690-6145 | press@cms.hhs.gov

         

         

        CMS makes improvements to Medicare drug and health plans
         

        The Centers for Medicare & Medicaid Services (CMS) today issued final regulations (CMS-4159-F) for the Medicare Advantage and prescription drug benefit (Part D) programs that continue efforts to curb fraud and abuse and to improve benefits and the quality of care for seniors and people with disabilities enrolled in these programs. The final rule is projected to save an estimated $1.615 billion over the next ten years 2015 – 2024.

        “The policies finalized in this regulation will strengthen Medicare by providing better protections and improving health care quality for beneficiaries participating in Medicare health and drug plans,” said Marilyn Tavenner, CMS administrator. “The final rule will give CMS new and enhanced tools in combating fraud and abuse in the Medicare Part D program so that we can continue to protect beneficiaries and taxpayers.” 

        After careful consideration of over 7,500 public comments on a proposed rule displayed on January 6, 2014, key final provisions include:

            Requiring Part D prescribers to enroll in Medicare: CMS is requiring that physicians and eligible professionals who prescribe covered Part D drugs be enrolled in Medicare, or have a valid record of opting out of Medicare, in order for their prescriptions to be covered under Part D. Requiring prescribers to enroll in Medicare would help CMS ensure that Part D drugs are only prescribed by qualified individuals. The final rule allows more time – until June 1, 2015 – for implementation. 

            Revoking Medicare enrollment for abusive prescribing practices and patterns: CMS will have the authority to revoke a physician or eligible professional’s Medicare enrollment if CMS determines that he or she has a pattern or practice of prescribing that is abusive, represents a threat to the health and safety of Medicare beneficiaries, or otherwise fails to meet Medicare requirements. CMS will also be able to revoke a physician or eligible professional’s Medicare enrollment if his or her Drug Enforcement Administration (DEA) Certificate of Registration is suspended or revoked, or if the applicable licensing or administrative body for any state in which he or she practices suspends or revokes his or her ability to prescribe drugs.

            Expanded prevention and health improvement incentives: The final rule expands rewards and incentive programs that focus on encouraging participation in activities that promote improved health, efficient use of health care resources and prevent injuries and illness.

            Broadening the release of privacy-protected Part D data: CMS will expand the release of unencrypted, prescriber, plan and pharmacy identifiers contained in prescription drug event records to give the public broader access to health care data pursuant to CMS’ policies and procedures for release of such data while still preserving the privacy of Medicare beneficiaries. 

         
        To view a fact sheet on the final 2015 Part C and D rule, please visit: http://www.cms.gov/Newsroom/Search-Results/index.html?filter=Fact%20Sheets. 


        The final rule can be viewed at: www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1.