Medicare published  the updated April 2015  fact sheet titled "Power Mobility Devices:  Complying with Documentation & Coverage Requirements."

It is available at

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1243510.html?DLPage=1&DLEntries=10&DLFilter=complying%20with%20documentation&DLSort=0&DLSortDir=ascending

The fact sheet is designed to provide education on basic coverage criteria and documentation requirements, as well as detailed coverage guidelines for the specific type of PMD provided.

Debra Farley
Billing Director
BILLPro Management Systems
10-9-15

Below is the link to the 8-6-13 CGS article titled "CPT Modifer 50" for bilateral procedures which includes information on lateral modifiers, i.e., RT (right), LT (left).

   http://cgsmedicare.com/partb/pubs/news/2013/0813/cope22855.html

Attached to this post is BILLPro's Updated Major Payer Billing Guidelines as it relates to Modifier 50.  The only change is adding a note stating "The only update is that the information below does not include billing guidelines respective to lateral modifiers RT (right) or LT (Left)."
         
                                                *********************************************************************************************

On 10-5-15 Jurisdiction B DME MAC released the following "Tip of the Week":

"Jurisdiction B Tip of the Week - Billing Clarification for Lateral Modifiers

"We have received inquiries regarding ICD-10-CM and billing of items that require the lateral modifiers. When submitting claims to the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for an item described by the same Healthcare Common Procedure Coding System (HCPCS) code and the item is ordered for the right (RT) and left (LT) side, you should submit one claim line with the correct HCPCS code with the RT, LT modifiers appended and bill two units of service. If there are two ICD-10-CM codes that specify right and left, both diagnosis codes should be submitted on the claim.

"On 9/24/2015, the Centers for Medicare & Medicaid Services (CMS) published MLN Matters Connects® Provider eNews. Implementation of ICD-10-CM will not change billing guidelines if you are providing items for the right and left side. While ICD-10-CM codes have expanded detail, including specification of laterality for some conditions, you will continue to follow Common Procedure Coding (CPT) and CMS guidance in reporting CPT/HCPCS modifiers for laterality."

   
Debra Farley
Billing Director
BILLPro Management Systems
10-6-15   

   

Please see the attached article published in the October issue of Anthem's publication, "Network Update" as it relates to Behavioral Health.

Debra Farley
Billing Director
BILLPro Management Systems
10-6-15

ATTENTION ONLY THOSE WHO BILL FOR CASTING, CAST SUPPLIES AND SPECIAL CASTING MATERIALS WITH CUSTOM FOOT ORTHOTICS.

Please see the attached which was published in the 10-2015 issue of Anthem's publication "Network Update."  Please pay particular attention to the last bulleted item on the page where it states that come November S0395 (casting) and A4580 (cast supplies) will no longer be eligible for separate reimbursement when billed with L3000, L3010, L3020 and L3030


Debra Farley
Billing Director
BILLPro Management Systems, Inc.
10-6-15

 Please scroll down to information provided by our software developer related to ICD-10 dated 9-30-15.  We had an item to clarify and that is the reason you are receiving it today.  Some of the information may not pertain to you but wanted all to be aware of it to provide assurance that we were and are "ready to go."

    Debra Farley
    Billing Director
    BILLPro Management Systems
    10-2-15



        From: RSL Helpdesk [mailto:no_reply@powerbill.com]
        To: apbp@powerbill.com
        Sent: Wed, 30 Sep 2015 09:57:53 -0500
        Subject: Announcement ICD

September 30, 2015

Today is the last date of service for ICD9.

The ICD9 and ICD10 codes exist in the system at the same time. The ICD9 codes will remain in the system as there is data against them. The ICD9 codes can be used after 10/1 if the DOS is before 10/1.

Please remember to split your claims if you are billing September and October dates of service. You can use the repeat visit feature when done with September claim and starting October claim just change ICD codes.

ICD 10 codes are entered into RSL using all lower case characters. For example:
 s128xxa = Fracture of other parts of neck, initial encounter

ICD9 codes will remain in the system in upper case (i.e. V700). ICD10 codes are lower case. When the claim files the code is changed to upper case.


Suffix popup

        You can use the suffix popup feature in the ICD field: s128*

        You will get:
        s128
        s128xxa
        s128xxd
        s128xxs


        No edits - YET!

        There are no edits in the system to stop ICD9 or force ICD10 - YET!

        After the smoke clears from the transition edits will be released. Should the edits need to be rolled back we will place overrides to be able to disable
        the edits.

Professional Service Preference option

        When entering characters, if you only see 4 diagnosis fields (ICD-1, ICD-2, ICD-3, ICD-4), you can enable a new version of the Professional Service
         screen to see all 12:
        Medical Billing menu
        Medical Billing User Preferences

        Set Professional Service to New (edit, change, save, close).


 How to point to ICD 10, ICD 11, and ICD12

        Since the diagnosis pointer is a single position, we have an alpha workaround for 10, 11, and 12:
        A = 10
        B = 11
        C = 12

        Example point to 1, 2, 10, 11, and 12: 12ABC

        Remember you can change the preference order: BC2A1

        FYI all 12 diagnosis codes are submitted on the claim. Each line can only use up to 4 pointers. When you point to 12345 only 1234 pointers are sent.
        This is a limitation in the structure of the ANSI 5010 format.    CLARIFICATION:  THE LIMITATION IS THE NUMBER OF POINTERS TO A CPT/HCPCS
        CODE ON THE CLAIM LINE LEVEL, BUT, IF APPLICABLE, ALL  DIAGNOSIS CODES UP TO 12 ARE ALSO SUBMITTED BUT ON THE CLAIM LEVEL.


ICD10 print issues

      If you find an area in the system where the ICD10 is cut off please let BILLPro know.

The Jurisdiction B DME MAC just released a Revised article, "Face-to-Face Examination and Prescription Requirements Prior to the Delivery of Certain DME Items Specified in the Affordable Care Act."

Please visit https://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/news-alerts/news-articles/news-detail/f2f%20examination%20and%20prescription%20requirements%20prior%20to%20the%20delivery%20of%20certain%20dme%20items%20specified%20in%20the%20aca%20-%20revised/!ut/p/a1/vZLLboMwEEW_CI0JhpileZS8CA1tRO0NcoxTWXmAmoqo-foaqaXpIk2yqVdzrSvPmesBDi_A96LVr-Jd13ux7TT3SkzHsW2HaJqREUJ0GlFM54lDljYUwIEfRKtkXW-06pTcKvH2I_M4GWdzYAHwZvKRHY7dZSN1Bcyt_GqoxMByCSYWXgtp-b7wLSFXyveESwjxOvcsC4BFaWxwmMFBFw5FN9H-sjgZQRQ_BFG0eHSSYPBl-KMFMwzDi01sG566N4owLRfLODfus3SMOk_HyO90gPVD3hfPFRznn3EmV78g7PegiPqy2W3yeHVaz7ycoCMN3Pb0TOloV6aafgLeBJRY/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?clearcookie=&savecookie=&REGION=&LOB=DME

As stated in the first paragraph, "The original provisions requiring that a physician co-sign a face-to-face examination that was performed by a PA, NP or CNS is removed."  Please read the entire article.

Debra Farley
Billing Director
BILLPro Management Systems
10-2-15

                                                                 LOCUM TENENS BILLING

          PREPARED BY DEBRA FARLEY, BILLING DIRECTOR, BILLPRO MANAGEMENT SYSTEMS UPDATED 9-29-15

What is billing under Locum Tenens Provisions?

CGS Medicare states in an article revised* on 9-29-15 titled “Services Provided Under Locum Tenens Provisions” that “The practice of retaining a substitute physician when the regular physician is away from the practice is known as ‘locum tenens,’ for Medicare purposes.  Under the locum tenens provisions of Medicare, the regular physician’s absence (and the need for a locum tenens physician) may be due to reason such as illness, pregnancy, vacation, or continuing medical education.”

      *this 9-29-15 article is just a re-issuance of the 11-9-12 article.  There were no changes to the provisions.

“In these situations, services performed by the substitute physician may be submitted and paid under the regular physician’s National Provider Identifier (NPI).  The ‘regular physician’ is considered the physician that is normally scheduled to see a patient and may be a primary care physician or a specialist.

“Claim Submission Guidelines

“CMS guidelines specify that, in order to submit a claim under the locum tenens provisions, all of the following criteria must be met:

•   The regular physician is unavailable to provide the visit services (due to absence for illness, vacation, etc.).

•   The Medicare beneficiary has arranged or seeks to receive the visit services from the regular physician.

•   The regular physician pays the locum tenens for his/her services on a per diem or similar fee-for-time basis (note:  this arrangement is between the
        regular physician and the substitute physician, and is not presided over by Medicare).

•   The substitute physician does not provide the visit services to Medicare patients over a continuous period of longer than 60 days.

•    Submit the locum tenens services under the regular physician’s NPI with HCPCS code modifier Q6 (service furnished by a locum tenens physician).

“Please note:  documentation in the patient’s medical record should clearly show who actually rendered the service, as the claim itself will reflect the NPI of the regular physician.

“Provider Enrollment and Locum Tenens

•    In true ‘locum tenens’ situations, do not enroll the locum tenens physician through the Medicare Provider Enrollment process.

•    If you anticipate that the locum tenens physician will provide services for longer than 60 days, follow the normal Provider Enrollment guidelines and
        submit the appropriate CMS-855 forms to enroll the physician and reassign his/her benefits to the group, if appropriate.”

“Reference:  CMS Medicare Claims Processing Manual (pub 100-04), Chapter 1, Section 30.2.11”
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html?DLPage=1&DLSort=0&DLSortDir=ascending

                    Locum Tenens and Reciprocal Billing Ask-the-Contractor Teleconference Q&A’s” (see attachment to this post)

With respect to the first question on the attachment, BILLPro questioned Vanessa Williams, Provider Relations Senior Analyst at CGS Medicare, and she stated that one may want to seek legal advice regarding this as the physician who left the practice may not want their information listed as the rendering provider.

Also, per Vanessa in November 2012, “if one who is billing under locum tenens orders or refers a pt (patient), they must indicate their individual NPI in that line item or loop field as the ordering or referring provider.  They can only use the locum tenens for the rendering service lines.” 

In August 2013 Vanessa confirmed that, “the guidelines for locum tenens identify ‘The Regular Physician’ therefore the physician substituting would NOT see a new patient.”

Below are portions of an article written by John R. Outlaw, CHC, CHBME  (vice president for regulatory affairs and compliance for Pathology Service Associates, LLC,  has more than 27 years of experience in healthcare claims administration, is a member of the HBMA {Healthcare Billing and Management Association} Board of Directors and chairs the HBMA Ethics and Compliance Committee) and published on 12-5-12 titled “The Lowdown on Locum Tenens”:

“The regular physician or group (as the case may be) cannot bill for the services of a locum tenens physician for a continuous period of longer than 60 days.  Therefore, a locum tenens physician providing coverage three days a week beginning on September 1 can still only provide services for the same absentee physician through October 31.  This also applies even if several different locum tenens physicians provide coverage during the 60-day period!  This is a very important point and the source of much of the confusion around the proper use of billing for these services, because the limitation is tied to the billing of the Q6 modifier, not to the number of days that any particular locum tenens physician provides coverage.  Therefore, a new 60-day period for billing the services of a locum tenens physician does not commence because of a break in service of the substitute or locum tenens physician.  Starting a new 60-day period requires a break in the absence of the physician for whom a substitute physician is necessary.  After the regular physician returns to work and provides services for at least one day, then a locum tenens physician can again provide services as a substitute for that regular physician for up to 60 consecutive days…However, regardless of circumstances, at the end of 60 consecutive days, the substitute or locum tenens physician may no longer bill under the regular physician’s NPI with a Q6 modifier.  Beginning on the 61st day, the substitute or locum tenens physician must submit claims under his or her own NPI.

“Finally, it is important to note that a locum tenens physician can only provide services in connection with the absence of a regular physician.  These rules do not support the use of a contracted physician to provide part-time or ‘temp’ services for any reason unrelated to the absence of a regular physician for whom the contracted physician is substituting.  A physician who is contracted on a part-time basis for any purpose other than to fill in when the regular physician is out of the office and not performing services for a period of time must be enrolled as a member of the group and his or her services must be billed under his or her own NPI.”

__________________________________________________________________________________________

If hiring a locum tenens physician, ensure your professional liability insurance covers locum tenens services.

__________________________________________________________________________________________


All of the preceding information addresses Medicare guidelines. BILLPro recently concluded its investigation with many of the major insurance carriers as to their guidelines related to Locum Tenens.  With that information, BILLPro is able to provide billing guidelines below.  Please note that this information is subject to change based on payer updates. It is VITAL for recordkeeping purposes and proper claims submission that this instruction be followed.

                           BEFORE CONTINUING, IF PLANNING TO BILL LOCUM TENENS, PLEASE CONTACT DEBRA
                           FARLEY AT BILLPRO FOR GUIDANCE AT 440-854-0205, 1-800-736-0587 EXT 0205 OR
                           DEBRA@BILLPRO.NET.

_________________________________________________________________________________________________________________________
             
                                                     HOW TO BILL LOCUM TENENS (LT) CLAIMS

The Q6 modifier, denoting that an LT performed the service, must be appended to each line item on a claim.  Claims are to be submitted for services by a LT physician under the REGULAR physician’s name as the RENDERING provider.

Ohio Medicaid is the only payer to date that DOES NOT RECOGNIZE LT.  Claims must be submitted under the LTs name/NPI as the RENDERING provider – NO Q6 modifier!  This means the LTs individual Medicaid provider number must be linked to the REGULAR physician’s practice. NOTE CONCERNING CROSSOVER CLAIMS FROM MEDICARE:  Medicaid will process crossover claims from Medicare containing the Q6 modifier.
         
There are a few payer variances in billing LT services and they involve Anthem and three (3) Medicaid Managed Care plans (Caresource, Molina and Paramount): 

•   Anthem does not credential/contract LTs but recognizes LT billing -- a provider ID must be assigned to the LT for billing purposes only; claims billed
        under LTs name and NPI with Q6 modifier
     
•   Caresource recognizes LT billing but also must be credentialed as an LT; however, claims are submitted under  REGULAR  physician’s name as the
        RENDERING provider with the Q6 modifier.

•   Molina and Paramount do not credential/contract LTs but recognize LT billing -- LT must be loaded “temporarily” in their systems; claims billed
        under LTs name and NPI with Q6 modifier   

How to accomplish proper recordkeeping and proper claim submission under the correct provider

•   A specific provider ID assigned in the billing system denoting claims submitted with the REGULAR physician’s name/NPI but the LT was the actual
        RENDERING provider (used for all payers except Anthem, Molina, Ohio Medicaid and Paramount).

•   A specific provider ID assigned in the billing system denoting claims submitted with the LTs name/NPI as the RENDERING provider (used for Anthem,
        Molina, Ohio Medicaid and Paramount). 

•   The REFERRING physician MUST be entered with the REGULAR physician’s name on all claims EXCEPT

        REGARDING REGULAR PHYSICIANS WHO ARE MEDICARE DURABLE MEDICAL EQUIPMENT, PROSTHETICS AND  SUPPLIES (DMEPOS) ENROLLED SUPPLIERS:

                         If a CERTIFYING provider is required on DMEPOS claims, the CERTIFYING provider’s name MUST be entered
                         as the REFERRING provider. For instance, if supplying diabetic shoes, the name of the actual CERTIFYING
                         provider MUST be entered as the REFERRING. 

       IF ANY SERVICES ARE ORDERED AT THE VISIT, I.E, EKG, LABS OR X-RAYS, FOR INSTANCE, THE NAME OF THE LT ORDERING SAME MUST BE ENTERED AS
       THE REFERRING provider.

                        Currently with all payers there is no ability to report on claims both the name/NPI of the REGULAR physician,
                        who provided the initial service, and the name of the LT who ordered testing at the visit.  Per Vanessa
                        Williams, it must be documented in the medical record that the REGULAR physician initially treated the
                        patient and the physician who actually ordered the test is to be entered as the REFERRING physician on
                        claims.

•   Only on DMEPOS claims is the name of the ORDERING physician to be entered, which may either be the REGULAR  physician or the LT – whomever
        ordered the supply.




(locum09292015)

Below are two articles appearing in the "Part B Insider (Multispecialty) Coding Alert" which are very interesting.


Patient Privacy: Report: Data Breaches Increase in Early 2015-
 Published on Mon, Sep 21, 2015

Breaches rose by 10 percent in first half of this year versus last year’s numbers.

The United States is home to about 320 million people, which may sound like a high number—until you hear that nearly 246 million records were compromised in the first half of this year. That staggering number came as the result of 88 data breaches in early 2015, most of which occurred in the healthcare field, said digital security company Gemalto in its report, “2015: First Half Review—Findings from the Breach Level Index.”


Anthem Leads Breaches

Among the many breaches was the hack into Anthem Insurance’s servers, which compromised 78.8 million records that included protected health information (PHI). Because the Anthem breach was so massive, the leading source of data breaches in the first half of this year was malicious outsiders, which remains a growing threat, Gemalto said in its report.

Some 22 percent of breaches were attributed to accidental loss—a commonly-seen problem within Part B practices. This could include misplacing a laptop with medical records on it, losing an external hard drive that contains patient social security numbers or losing track of a box of papers with patient names on it.
The report underscores the fact that healthcare organizations should constantly be finding new ways to secure PHI. “It’s apparent that a new
approach to data security is needed if organizations are to stay ahead of the attackers and more effectively protect their intellectual property, data, customer information, employees and their bottom lines against data breaches in the future,” the report notes.


Prep Now for HIPAA Audits

With HIPAA breaches growing despite continued education and regulations, the government is getting ready to institute its HIPAA audits, which will allow the feds to determine exactly what practices are doing wrong. But the problems could lie in the fact that HIPAA has been an ever-evolving bundle of regulations that practices have trouble following.

Although the initial HIPAA laws have been in place since 1996, the first privacy regulations covering PHI didn’t come into play until 2003, followed by the security rule in 2005, said Paul Hales, Esq., a healthcare attorney in St. Louis, MO. Unfortunately, not every medical entity was on board with the law at that point.

“I’ve found that the only people who were really paying attention were big organizations like health plans, hospitals, etc., and they already had the compliance, IT staffs and attorneys to handle it,” Hales says. “The dentists, doctors, chiropractors, podiatrists and other small practices just didn’t have the resources to comply, and the Department of Health and Human Services (HHS) didn’t really enforce it, so breaches were occurring.”

However, HHS prepared modifications during the Bush administration that were passed into law as part of the Stimulus Act in 2009. HIPAA now covers not only Business Associates who handle PHI, but even subcontractors working for those Business Associates. In addition, the Breach Notification Rule came into effect, HIPAA penalties skyrocketed, and HHS did a pilot audit of HIPAA programs in anticipation of a nationwide audit plan, Hales said. The HIPAA audits will likely start late this year or early next year, he added.
If the pilot audit results are any indication, the nationwide audit program could spell trouble for unprepared practices. “In 2012, HHS conducted a pilot HIPAA compliance audit in preparation for the mandatory, random HIPAA compliance audits that will begin soon,” Hales says. “HHS found 80 percent of the providers had not conducted a risk analysis although it had been mandatory since 2005. HHS also found that small providers have serious HIPAA compliance issues and ‘struggle’ with compliance.”


Even Baby Pictures Could Violate HIPAA

Many practices fall victim to HIPAA violations due to keeping unencrypted PHI on portable devices. “Encryption is an algorithmic process that scrambles the drive and scrambles electronic data that is being transmitted,” Hales says. “You need the key in order to unscramble it. So if you have a laptop that’s encrypted in a way that meets the federal standard and it’s stolen and it contains the PHI of 50,000 patients, that’s not a breach because the encryption makes it impossible to read the information.” Encryption is very inexpensive and simple to do, so practices that don’t take advantage of that feature could be putting themselves at risk of a breach.

Other, less obvious issues could lead to a breach as well. For instance, if you hire a marketing company to create a website for your practice, chances are that you’re going to include patient testimonials on it. “But what many people don’t realize is that the patient must execute a HIPAA-compliant authorization for that testimonial,” Hales says.
In the same vein, you can’t paper your practice in patient photos—which is particularly common with obstetricians. “A fertility specialist in Manhattan had to remove photographs of babies that his patients had conceived, and HHS said in order to post these, you have to have a HIPAA-compliant authorization,” Hales says. “A picture of a face is one of the 18 identifiers that constitutes PHI.”


Create Authorization Forms

In addition to your standard HIPAA lingo, your practice should create additional authorization forms such as those for patient testimonials to put on your website or on social media like your Facebook page. You might also need authorization forms for unexpected reasons. “Let’s say a patient is in a car accident and there’s a lawsuit involved—the doctor has to have an authorization to release the information to the lawyer,” Hales says.

To alleviate the problem for smaller practices, Hales created the HIPAA E-Tool on the internet to make HIPAA compliance affordable, accessible and complete. It has all required forms, policies and procedures and interactive step-by-step risk analysis to help a practice comply with the law.

“The E-Tool also includes sample Business Associate agreements as well as state health privacy and breach notification laws, which are more stringent than the national standards,” Hales adds.

Resource: To read Gemalto’s complete report, visit www.gemalto.com/brochures-site/download-site/Documents/Gemalto_H1_2015_BLI_Report.pdf.


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


Check Out This Sample Social Media Testimonial Authorization
- Published on Mon, Sep 21, 2015

If your HIPAA compliance stops with the standard form you printed off the internet, you could be selling yourself short. Check out the following form authorizing social media testimonials created by said Paul Hales, Esq., a healthcare attorney in St. Louis, MO, which he includes in his HIPAA E-Tool:

Dr. Smith
Authorization for Testimonials - Social Media

Date: __________________________________________

Name of Patient:___________________________________

Date of Birth:________________________________________

Last 4 numbers of SSN: XXX-XX- ______ _____ _______ _____


Address: _____________________________________________________

We very much appreciate the fact that you are pleased with your experience at Dr. Smith and Associates and wish to provide a testimonial expressing satisfaction with your experience. Your testimonial may be posted on our website, used in social media or printed materials and may be released to the media. Please understand that a testimonial may involve the use or disclosure of information that is protected by health privacy law. In order for you to make a testimonial you must authorize the use or disclosure of information about you in your testimonial. You may use this form to provide the necessary authorization.

Authorization:

I hereby authorize the use and disclosure of information I describe in this form for testimonial purposes by Dr. Smith. My authorization to use my information extends to any persons and agents working on behalf of Dr. Smith to create or maintain materials in any format that may include my testimonial including but not limited to printed materials, websites and social media.

1. Description of the information to be used or disclosed in my testimonial:

Please describe the information that will be in your testimonial - for example, your name, picture, a video of you talking about your experience, etc. - in this box:

2. Name or Identification of persons to whom I authorize Dr. Smith to make the requested use or disclosure:

I authorize Dr. Smith to use my information as a testimonial for disclosure to the general public who may view or read my testimonial on materials created by or for Dr. Smith and Associates including but not limited to printed materials, websites and social media.

3. Purpose

The purpose of the requested use or disclosure is “At My Request.”

4. Expiration Date of this Authorization

This authorization shall be valid - unless I revoke it earlier in writing - for ten (10) years from the date I sign it. I understand that:

1. I may revoke this authorization at any time in writing and that Dr. Smith will furnish me with a form to make my written revocation if I ask for the form but I am not required to use that form to make my written request for revocation.

2. My revocation will not apply to the information that has already been released as permitted by this authorization.

3. Dr. Smith may not condition my treatment or payment, enrollment or eligibility for benefits on whether I sign this authorization.

4. The persons to whom this information is disclosed may re-disclose the information and it will no longer be protected by federal health information privacy law.

5. I have a right to request and receive a copy of this authorization.

I have read and understand this Authorization for Testimonials - Social Media, signed it voluntarily and received a copy.

Signature of Individual or Personal Representative___________________________________________________________

Printed Name of Personal Representative, if any_____________________________________________________________

Personal Representative Authority to act for the Individual (Documentation may be requested)_____________________
¨ Identity of the Individual verified

¨ Identity and Authority to Act of Personal Representative verified

Received and confirmed for Dr. Smith by:                                                                                                                                  _______________________________________
                                                                                                                                                                                                                     Signature                              Printed Name/Title

Resource: To review Hales’ HIPAA E-Tool, visit http://thehipaaetool.com/index/contents.


Debra Farley
Billing Director
BILLPro Management Systems
9-23-15

Below are two articles appearing in the "Part B Insider (Multispecialty) Coding Alert" related to ICD-10 fracture diagnoses.

ICD-10: Master Your Pathologic/Traumatic Fracture Code Diagnoses With 2 Scenarios
- Published on Mon, Sep 21, 2015

Discover this new tool to help you ‘build’ a traumatic fracture code.

If you’re panicking about the upcoming ICD-10 implementation date and coding fracture codes, you’re not alone. Simplify these complicated seven character codes by breaking them down into pathologic and traumatic fractures.

Perfect Your Pathologic Fractures With Scenario 1

Scenario 1: My orthopedic provider saw a 72 year old man for a fracture of the right femur shaft. He was originally diagnosed with left upper lobe carcinoma 5 years ago, and then several months ago, he was diagnosed with metastatic bone cancer (from the lung). This femur shaft fracture is a result of the metastatic cancer. The patient’s lung cancer has already been treated with radiation, and the patient no longer has any evidence of an existing primary malignancy. What ICD-10 code(s) should I report?

Definition: First, you need to define this type of fracture. A fracture is either traumatic or pathologic. A pathologic fracture occurs when a bone breaks in an area that is weakened by another disease process. Causes of weakened bone include tumors, infection, and certain inherited bone disorders. There are dozens of diseases and conditions that can lead to a pathologic fracture or dislocations. A pathologic fracture usually occurs with normal activities — patients may be doing very routine activities when their bone suddenly fractures or dislocates. The reason for a fracture is that the underlying disease process weakens the bone to the point where the bone is unable to perform its normal function.

Important: ICD-10-CM has three pathologic fracture categories:

- Due to neoplastic disease

- Due to osteoporosis

- Due to other specified disease

Solution: In this scenario, the pathologic fracture to the shaft of the femur was due to neoplastic disease. Therefore, the solution is:

M84.551A — Pathological fracture in neoplastic disease, right femur, initial encounter for fracture

C79.51— Secondary malignant neoplasm of bone

Z85.118 — Personal history of other malignant neoplasm of bronchus and lung

Z92.3 — Personal history of irradiation.

Now, check out traumatic fractures.

Highlight These Traumatic Fracture Details for Scenario 2

Traumatic fractures include much greater specificity in ICD-10-CM. For example, some of the information that may be found in fracture codes include:

- the type of fracture,

- specific anatomical site,

- whether the fracture is displaced,

- laterality,

- routine versus delayed healing,

- nonunions and malunions,

- identification of type of encounter.

Red Flag: In ICD-10-CM, a fracture not indicated as displaced or nondisplaced should be coded to displaced. A fracture not designated as open or closed should be coded to closed.

Scenario 2: Your physician sees a patient for increased pain in her ankle. She has had a previous trimalleolar fracture of the left ankle. After evaluation, he diagnoses a nonunion of her left trimalleolar fracture. What should you do?

Tool: Fracture scenarios are complicated, but here is a tool using the PCS coding logic to break down these traumatic fractures into simple charts. (Note: For this example, you will not review the full chart, just the row you need-- please see the attachment to this post for this tool.

So in this scenario, we know that we’re looking at the lower leg, specifically the ankle. The best root code we have is S82.8---. Following that row, you will find “trimalleolar” (character 5). You would stay in that row again, to find “displaced/left” (character 2). Finally, you would apply K (Subsequent encounter for closed fracture with nonunion).

Heads up: Did we know if this fracture was displaced or nondisplaced? Coding guidelines specify that if displaced versus nondisplaced is not indicated, the default is displaced.

Solution: You should report S82.852K (Displaced trimalleolar fracture of left lower leg, subsequent encounter for closed fracture with nonunion).

Do you think you need an aftercare code? No. Aftercare Z codes should not be used for aftercare of fractures. For aftercare of a fracture, assign the acute fracture code with the correct seventh character indicating the type of aftercare. (See “Here Are Your Seventh Character Possibilities for Fracture Codes.”)

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

Here Are Your Seventh Character Possibilities for Fracture Codes
- Published on Mon, Sep 21, 2015

Your physicians need to document according to the Gustillo classification.

The first code (M84.551A) mentioned in the article “2 Scenarios Untangle Your Pathologic/Traumatic Fracture Code Diagnoses” has a seventh character of A. In the second solution, code S82.852K has a seventh character of K. Do you know the difference? You need to be careful about your seventh characters.

In the pathological or stress fracture category (M84.3-M84.6), you have the following options:

    A – Initial encounter for fracture
    D – Subsequent encounter for the fracture with routine healing
    G – Subsequent encounter for the fracture with delayed healing
    K – Subsequent encounter for fracture with nonunion
    P – Subsequent encounter for fracture with malunion
    S – Sequela

For instance, you would use the seventh character A at the first encounter with a physician. This includes surgical treatment, ED encounter, and treatment by a new physician.

You would use the seventh character D for follow-up visits. Examples of subsequent treatment include cast change or removal, removal of external or internal fixation device, medication change, other follow-up visits.

Traumatic Fractures Seventh Characters Differ

Seventh characters assigned in this chapter are identified at the category level to indicate initial encounter, subsequent encounter, or sequela.

Fracture seventh characters are expanded to include:

A – initial encounter for closed fracture

B – initial encounter for open fracture

D – subsequent encounter for fracture with routine healing

G – subsequent encounter for fracture with delayed healing

K – subsequent encounter for fracture with nonunion

P – subsequent encounter for fracture with malunion

S – sequela

Some fracture categories provide for seventh characters to designate the specific type of open fracture (these designations are based on the Gustilo open fracture classification):

B – initial encounter for open fracture type I or II (open NOS or not otherwise specified)

C – initial encounter for open fracture type IIIA, IIIB, or IIIC

E – subsequent encounter for open fracture type I or II with routine healing

F – subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing

H – subsequent encounter for open fracture type I or II with delayed healing

J – subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing

M – subsequent encounter for open fracture type I or II with nonunion

N – subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion

Q – subsequent encounter for open fracture type I or II with malunion

R – subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion

Make certain that you know what seventh character to apply to your fracture care code.

Debra Farley
Billing Director
BILLPro Management Systems
9-23-15

CLIENTS:

Well, we are nearing October 1st, the implementation date for ICD-10.  We are all hopeful we have best prepared for this monumental change in the healthcare industry.  We are providing information below that may assist you.  Please do read the entire content of this e-mail and share with your office/billing staff.
                                                     
TRANSLATION WEBSITE FOR CONVERTING ICD-9 TO ICD-10

      There is a wonderful translation website for converting ICD-9 to ICD-10 and vice versa.   It is available at

                             http://www.icd10data.com /

       To convert a code, under "Conversion," click on "Convert 2015 ICD-9CM -> ICD-10-CM/PCS."  This site holds much other information including coding
       rules.

      CAUTION:   As we know with ICD-9, coding to the highest level of specificity should be a priority.  However, come ICD-10, payers may modify the
      terms of their contracts and may require reporting the code with the highest specificity.  This may lead to altering their payment schedules and
      reimburse differently for higher vs lesser specific codes.  Unless the provider documents a diagnosis/condition as unspecified, every attempt should
      be made not to use unspecified codes.

      Please remember that any translation program from ICD-9 to ICD-10 is to be used as a tool -- this does not in any way negate the necessity for
      purchasing and using an ICD-10 book.  The translation program can assist in guidance on where to locate the general diagnosis, but then one must
     go to the ICD-10 book to determine the definitive code for that condition/diagnosis.  Also, any "converted" code provided from the above website is
     followed by "converts approximately to" which is further evidence that one must reference the ICD-10 code book.

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

LOCAL COVERAGE DETERMINATIONS (LCD'S) FOR OHIO MEDICARE

        All of Ohio's LCD's have been converted to ICD-10.  The link is:   

https://www.cms.gov/medicare-coverage-database/indexes/lcd-list.aspx?Cntrctr=238&ContrVer=2&CntrctrSelected=238*2&name=CGS+Administrators%2c+LLC+(15202%2c+MAC+-+Part+B)&s=42&bc=AggAAAAAAAAA&

       Until October 1st, when you access the above site, under "*Document types to further refine your search by" click on "Future LCDs/Future
       contract number LCDs" then click "Submit."  This is where all the LCD's translated to ICD-10 are held.  Once October 1st comes, under "*Document
       types to further refine your search by," click on "Active LCDs."

       IMPORTANT:   I participated in the CGS Provider Outreach and Education Ohio Part B Advisory Committee meeting on 9-8-15 where it was stated
      that claims will be denied if there is an LCD policy for the service rendered and an ICD-10 code(s) that supports medical necessity is not submitted. 
      Your documentation in the medical record must support that medical necessity allowable diagnosis(es).  If not, one must code the diagnosis that was
      established. Respective to Medicare and Railroad Medicare, below is the link to the most current edition (August 2014) Advance Beneficiary Notice
      of Noncoverage (ABN) Booklet which includes information on when an ABN should be used and how it should be completed.     

                            http://www.cms.gov/mlnproducts/downloads/abn_booklet_icn006266.pdf


      Most payers follow or closely follow Medicare policy respective to allowable diagnoses.  Saying this, it is suggested that, if there is an LCD that
      pertains to your practice, one follow the Medicare LCD as it relates to said diagnoses for all payers.  Yes, there will be payers that have their own
      policies and those should be followed as they are published.

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

HOW AN ICD-10 DIAGNOSIS IS ENTERED IN THE BILLING SYSTEM VS AN ICD-9 DIAGNOSIS

     The first digit of all ICD-10 codes is an alpha character and digits 3-7 are alpha or numeric -- all alpha characters MUST be entered in lower case
     letters. The only ICD-9 codes that begin with an alpha character are "V" or "E" and they MUST continue to be entered in upper case letters.  As with
     both ICD-9 and ICD-10, no decimals are to be entered.

     ICD-9 and ICD-10 codes CANNOT be entered on the same claim.

     It has always been our policy NOT to span multiple dates with the same CPTcode on a single claim line and not have months overlap on a claim.   Why? 
     Should a claim require an appeal for one date of service, it is much easier to appeal when date spanning is not involved. Also, a patient may have
     coverage with one carrier one month but a different carrier the following month.

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

ICD-10 CM FREQUENTLY ASKED QUESTIONS (FAQS)

   CMS frequently asked questions are available at:   https://questions.cms.gov

        ->  Click on "Coding" and then the applicable subtopic

                                                    *******************************************************************************
                                  ****  I M P O R T A N T  ****

 ICD-10 codes are NOT to be submitted to any payer before 10-1-15. If this is not heeded, all claims will reject in that batch.

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

We are all so hopeful that ICD-10 will be a smooth conversion.

 

Debra Farley
Billing Director
BILLPro Management Systems
9-23-15

CLIENTS:

Please scroll down to a BWC e-mail received this morning.  It contains important information on:

-  ICD-10

-  Website replaces the electronic data access (EDA) service effective 10-1-15

-  New and updated MEDCO-14 is now available including information respective to nurse practitioners and physician assistants

Please share this e-mail with your office and billing staff.


Debra Farley
Billing Director
BILLPro Management Systems
9-22-15



    From: Ohio Bureau of Workers' Compensation [mailto:donotreply@bwc.state.oh.us]
    To: debra@billpro.net [mailto:debra@billpro.net]
    Sent: Tue, 22 Sep 2015 08:01:16 -0500
    Subject: Provider eNews - September 2015


    Sept. 22, 2015
       

 BWC, MCOs, providers: Oct. 1 begin taking ICD-10 codes

    The national implementation for the International Classification of Diseases (ICD-10) is almost here – it starts Oct. 1. BWC and our managed care
    organizations (MCOs) will be ready to accept ICD-10s on First Report of Injury, Occupational Disease and Death (FROIs), other BWC forms with
    diagnosis codes and bills.

IVR changes

    The conversion to ICD-10 will impact those individuals using BWC’s phone-based, interactive voice recognition (IVR) system to retrieve diagnosis
    codes. As of Oct. 1, 2015, this service will provide ICD-10 codes only for new claim allowances occurring that date or after. For claim allowances
    dating prior to Oct. 1, the IVR will provide only the ICD-9 code.   

    During the conversion, we expect an increase in calls, which could result in longer wait times for you and your staff members. For quicker service,
    we encourage you to use your e-account and log in to our website for your BWC claim needs. 

Website info for ICD-9 to ICD-10 codes

    To help you with this transition for workers’ compensation claims, please use our website, www.bwc.ohio.gov to view the disease codes that we
    converted from ICD-9 to ICD-10. You can submit ICD-10 codes to BWC and the MCOs beginning Oct. 1.  To use this site, you will need to use your
    BWC e-account or create a new e-account from our home page at  https://www.bwc.ohio.gov/SelfSvcAccountAdmin/newacc.asp. For ease in
   coding, please designate appropriate personnel such as your office manager to have e-account privileges. Please view this link to follow the needed
   processes for sharing account privileges:  https://www.bwc.ohio.gov/SelfSvcAccountAdmin/E-AccountDetails.asp

Code groupings

    BWC will only allow initial encounter ICD-10 codes in a workers’ compensation claim. Subsequent office visits and condition sequelae codes are
    grouped with initial encounters so additional allowance requests are not needed. See the ICD-10 groupings document at
    https://www.bwc.ohio.gov/provider/services/ICD9.asp. Please only submit ICD-10 codes on or after Oct. 1 whenever you are communicating
    with BWC (forms, bills, etc). For more information, review BWC’s ICD-10 implementation site at
    https://www.bwc.ohio.gov/provider/brochureware/ICD/Details.asp to find our ICD-10 Implementation Guiding Principles fact sheet and other
    information, or email BWC’s provider relations department .

Oct. 1: Website replaces EDA service

    As we discussed in the April edition of Provider eNews, BWC is taking steps to retire its electronic data access (EDA) service. The effective date
    for this change is Oct. 1.

Web enhancements

    In preparation, enhancements are being made to our website, www.bwc.ohio.gov, to enable it to ultimately serve as one of the main replacements
    to the EDA service. We incorporated these updates/changes.
   
    -  MCO employer look-up – If an employer policy is combined, we will show the policy it is combined into on the website.
 
   -   Injured worker demographics – We added the date of death (if available) and the injured worker’s address effective dates.
     
   -   Claim party contacts – We added the injured worker’s address effective date.
   
   -   Claim status – We added the claim filing date.

    BWC wants to ensure you experience a smooth transition once EDA is no longer available. If you have any questions or concerns, please email
     BWCEDASunsetAssistance@bwc.state.oh.us.

    BWC’s website will be your go-to-place for claim and employer information. However, keep in mind BWC evaluates what may be available and cross
    references it against what is legally permitted to be viewed by certain parties. Create an e-account today at
          https://www.bwc.ohio.gov/SelfSvcAccountAdmin/newacc.asp

New, updated MEDCO-14 is available

    The Physician’s Report of Work Ability (MEDCO-14) is a vital tool to help Ohio’s injured workers safely return to work. The MEDCO-14 allows you to give a medical snapshot of the injured worker’s restrictions/capabilities at a specific point in time.

MEDCO-14’s purpose

    The form’s questions capture relevant data which enable BWC and the MCOs to:

       -  Understand the injured worker’s ability or inability to perform any work as well as barriers to returning to work and his or her capabilities and
           restrictions when needed;
       
       -   Capture relevant information to make a determination on temporary total compensation;   Understand the treatment plan and vocational
           issues that need to be addressed to help the injured worker return to the workforce;
   
       -   Determine what the provider may do to assist in lessening the injured worker’s disability.

    Each question serves a specific purpose that’s reflected in its wording and the context referenced.

Responding to our customers

      On July 1, we posted a revised MEDCO-14 on BWC’s website that replaces the previous MEDCO-14 we last updated in June 2012. Based on
      customer feedback, the BWC team immediately evaluated and addressed your concerns. We posted the modified MEDCO-14 online on Aug. 28. But,
      the form’s official revision date is Aug. 21.

       BWC will publish an additional informational tool that will aid providers in interpreting and completing the posted MEDCO-14.

Time frames to use the form

    The MEDCO-14 posted on Aug. 28, is the final update to be made with revisions. Therefore, all providers will have 60 days from Aug. 28, to fully
    convert to this new MEDCO-14 or its equivalent. All equivalent forms must within that 60-day time frame reflect at a minimum the data elements
    shown on the current MEDCO-14.

Form improvements

    Some of the form changes include:

    1. In Section 1, if a provider submitted a previous MEDCO-14 and all the information remained the same, they may now check box 2 and move on to
        the form’s signature box.

    2. Updating certain sections and providing a check box in each section to indicate whether or not a section has updates.

    3. Based on the provider’s responses, other sections may be bypassed because they are unnecessary to complete.

    4. In section 3C we expanded the inquiry of “If the injured worker is taking prescribed…” to include “*Perform other critical job tasks as defined
        by any source listed above in section 2.”

    5. Streamlining and where necessary and clarifying form language.

Nurse practitioners and physician assistants

    By revising the MEDCO-14, we are considering how to handle the increasing challenge of nurse practitioners (NPs) and physician assistants (PAs)
    completing the form and using it as a basis for a temporary total disability benefit award for injured workers.

    While NPs and PAs can treat our injured workers, and do complete the MEDCO-14, the statue and the rule require a physician to complete the
    MEDCO-14 that determines indemnity payments for injured workers. Therefore, when MEDCO-14s are completed and signed by a NP or a PA, this
    may result in a delay when awarding injured workers benefits.

    BWC and the Industrial Commission of Ohio are reviewing how to address this issue.
       
 
 Questions? Call 1-800-644-6292
 
     

     

ATTN THE FOLLOWING MEDICARE PROVIDERS: MDs, DOs, DPMs, OPTOMETRISTS,  CHIROPRACTORS, PAs, NPs, LISWs, PSYCHOLOGISTS AND PHYSICAL/OCCUPATIONAL/SPEECH-LANGUAGE THERAPISTS

CLIENTS:

If you are participating in PQRS (Physician Quality Reporting System) through the PQRSwizard or wish to be, please scroll down to an e-mail from them.

Quoted from their frequently asked question (FAQ) page "PQRSwizard is an easy to use online tool to help physicians and other eligible professionals quickly and easily participate in the Physician Quality Reporting System (PQRS). Similar to online tax preparation software, the PQRSwizard helps guide professionals through a few easy steps to rapidly collect, validate and submit their results to CMS. PQRSwizard is powered by the CECity registry, a CMS Qualified Registry for PQRS reporting."   

To view all the FAQs, visit  https://pqrswizard.com/user/support.aspx#FAQs

Debra Farley
Billing Director
BILLPro Management Systems
9-16-15



    From: PQRSwizard [mailto:noreply@CECitybroadcast.com]
    To: debra@billpro.net
    Sent: Wed, 16 Sep 2015 10:54:06 -0500
    Subject: More Individual Measures are Now Available!
      

    Start reporting for PQRS 2015 today
    PQRSwizard is continuously rolling out Individual Measures throughout the summer months. Any report which has already selected measures is able to retrospectively choose additional measures and continue reporting.

    Latest Additions to the PQRSwizard Measure Library:

       65, 66, 112, 116, 118 126, 145, 167, 187, 191, 204, 217, 218, 219, 220, 221, 222, 223, 224, 236, 329, 330, 335, 336, 337, 342, 348, 358, 384, 385, 387, 388, 389, 393, 398, 400

    Other Available Measures:

       1, 5, 6, 8, 12, 14, 19, 21, 22, 23, 24, 32, 33, 39, 40, 41, 43, 44, 47, 48, 50, 51, 52, 54, 67, 68, 69, 70, 71, 72, 76, 81,82, 91, 93, 99, 100, 102, 104, 109, 110, 111, 113, 117, 119, 121, 127, 128, 130, 131, 134, 137, 138, 140, 141, 143, 144, 146, 147, 154, 155, 156, 163, 164, 165, 166, 168, 172, 173, 178, 181, 182, 185, 192, 193, 194, 195, 205, 225, 226, 243, 249, 250, 251, 254, 255, 257, 258, 259, 260, 261, 262, 263, 264, 265, 268, 270, 271, 274, 303, 304, 317, 320, 322, 323, 324, 325, 326, 327, 328, 331, 332, 333, 334, 343, 344, 345, 346, 347386, 390, 395, 396, 397, 401, 402

    Coming Soon:

       7, 46, 53, 122, 238, 242, 275, 349, 383, 391, 383, 384, 385, 387, 388, 389, 391, 392, 394, 399
     
      
         
       Questions? Click on the following link to access additional resources or to contact our Support Team

                 https://pqrswizard.com/user/support.aspx
         
       Interested in a PQRSwizard Individual Measure Demonstration? View the Individual Measure Demo at

                https://www.cecity.com/videoPlayer/videoPlayerWindow.html?whatVideo=guided_tour_individual_measures_2015&whatPath=pqrs/2015
                  
       Do you have questions about Individual Measures? View the PQRSlearn session "Understanding Individual Measures" View Now at

               https://www.cecity.com/videoPlayer/videoPlayerWindow.html?whatVideo=8_19_2015&whatPath=pqrs/2015
         
       To get started on your 2015 PQRS report, click on

                https://www.pqrswizard.com/default.aspx
         

Below is an article from the August 2015 edition of "BWC eNews."   It is important to view the attachment to this post for the fact sheet for "ICD-10 Implementation Guiding Principles" as it contains extremely important information including 12 "Frequently asked questions and their answers."   Also, please share this information with your office staff.

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

BWC is ready for ICD-10

BWC will be ready for the International Classification of Diseases (ICD-10) national implementation on Oct. 1. BWC, along with its managed care organizations (MCOs), will implement ICD-10 so Health Insurance Portability Act (HIPAA)-compliant providers do not need to make special accommodations.

To facilitate a smooth transition to ICD-10, BWC and the MCOs are implementing measures that allow them to continue processing claims and bills using ICD-9 codes, if necessary, for 90 days past the Oct. 1, 2015, effective date.

Injury descriptions

Remember for workers’ compensation, claims determinations are based on injury descriptions, not disease codes. Therefore, claims determinations should not be affected by the ICD-10 implementation.

For more information, check out our ICD-10 Implementation Guiding Principles fact sheet or email BWC’s provider relations department at Feedback.Medical@bwc.state.oh.us

Debra Farley
Billing Director
BILLPro Management Systems
9-16-15

Diana Irvin, provider service representative at Medical Mutual (MMO), called me regarding my e-mail below.  She said MMO does not have anything specific in its guidelines related to biometric screening (employers who want their  employees to have this screening performed).   Based on her reading the information contained in the links in my e-mail, the clearest path would be to bill a preventive exam with a V70.0 (routine general medical examination at a health care facility) for an adult.

She stated MMO does not pay for 96150 "Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment" and doesn't believe this code represents the biometric screening.


From: Debra <debra@billpro.net>
To: Diana Irvin <Diana.Irvin@mmoh.com>
Date: 09/08/2015 05:44 AM
Subject: Biometric screening

    We have a practice that is performing biometric screening for employers who want their potential employees to have this.  We are looking for your advice on how to submit these to Medical Mutual, i.e., ICD-9 and CPT codes.

    I have done some research and am uncertain.

    Below are some links I found on the internet

http://www.concentra.com/employers/health-wellness/health-screenings/biometric-screenings/

http://www.physicianspractice.com/coding/merging-em-guidelines-screening-codes-phoneinternet-consults

https://www.supercoder.com/my-ask-an-expert/topic/biometrics-screening

https://www.aapc.com/memberarea/forums/showthread.php?t=64317

Any help you can give will greatly be appreciated.Thanks

Debra Farley
Billing Director
BILLPro Management Systems
9-9-15


 

Below is an e-mail from CMS in which it has published a new article, "National Site Visit Verification (NSV) Initiative."  Please click on the link for the full article. 

Please see my note that I have typed below the article.

Debra Farley
Billing Director
BILLPro Management Systems
8-12-15


    From: CMS MLNMatters-L [mailto:MedlearnMatters-L@CMS.HHS.GOV]
    To: MLNMATTERS-L@LIST.NIH.GOV
    Sent: Wed, 12 Aug 2015 05:38:22 -0500
    Subject: New Article Posted to MLN Matters

           

    New:

     
    SE1520 – National Site Visit Verification (NSV) Initiative

    http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1520.pdf

 NOTE:  Back in 2009 BILLPro provided our clients who billed Medicare information from CMS stating "Medicare enrollment must include any location billed on a claim form including offices, hospitals, nursing facilities and the like.  Any location no longer applicable to your practice must be deleted from your enrollment file."  We also provided a CMS transmittal with the  subject "Site Verifications."  According to the transmittal, "All providers and suppliers are subject to unannounced site visits prior to receiving Medicare billing privileges or subsequent to receiving Medicare billing privileges."  The regulations most likely target sham operations but could carry over to affect legitimate providers who simply haven't updated an address.
 
The NEW article above, SE1520, "provides the latest information about the Centers for Medicare & Medicaid Services (CMS) National Site Visit Verification (NSV) initiative."

Once again, we must stress the importance of your Medicare enrollment files being kept current with ANY and ALL locations submitted on a claim.  This includes deleting those locations where you no longer see  beneficiaries.

 It must be stated that it is considered FRAUD to submit a claim with an incorrect location address.  BILLPro cannot and will not be a party to this.