The April 2013 issue of CMS’ Medicare Quarterly Provider Compliance Newsletter highlights two Comprehensive Error Rate Testing (CERT) issues that affect outpatient providers.
CMS corrected edit 84, added five APCs to the I/OCE, deleted two APCs, and changed the description of another as part of the April updates to the I/OCE. In addition, CMS deleted all of the genetic testing modifiers, retroactive to January 1.
Successful appeals can actually lead to CMS policy changes. Facilities have been successfully appealing to receive Part B payments after a Medicare review contractor denied a Part A stay as not medically necessary. As a result, CMS is changing its policy on rebilling for Part B services.
CMS corrected edit 84, added five APCs, deleted two APCs, and changed the description of another as part of the April updates to the I/OCE. Dave Fee, MBA, reviews the most significant changes CMS implemented
It was almost inevitable. The possibility of another ICD-10 delay was brought up during the AHIMA ICD-10-CM/PCS and CAC Summit in Baltimore April 24. And just as quickly as it was raised, the...
CMS added seven CPT ® codes to the conditionally bilateral list as part of the April update to the Integrated Outpatient Code Editor. When a provider performs a conditionally bilateral service bilaterally, coders must append modifier -50 (bilateral procedure) to the code.
Three out of four providers have completed only 25% or less of their ICD-10-CM/PCS conversion process, according to an ICD-10 snapshot survey conducted by the Aloft Group in February. However, CMS and others are busy helping to ensure that providers and payers are ready for the transition to ICD-10-CM/PCS.
Will you be ready for ICD-10? The ICD-10 implementation date draws closer by the day and CMS wants to help you make sure you’re ready. CMS is hosting a national provider call to discuss ICD-10...
CMS added numerous device/procedure edits as part of the April update to the Integrated Outpatient Code Editor . To avoid triggering the edits, coders must report particular procedure codes and device codes together on the claim form.
CMS is making a significant change to the Medically Unlikely Edits (MUE) by changing some of them from line-item edits to date-of-service edits, effective April 1. Jugna Shah, MPH, Kathy Dorale, RHIA, CCS, CCS-P, John Settlemyer, MBA/MHA, and Valerie Rinkle, MPA, explain how the change could affect coding and reimbursement.
CMS is making a significant change to the Medically Unlikely Edits (MUE) by changing some of them from line-item edits to date-of-service (DOS) edits, effective April 1.
CMS Transmittal 1199 updates the national coverage determination (NCD) hard-coded shared system edits to include ICD-10-CM codes. CMS included 30 spreadsheets with the transmittal. The spreadsheets...
Medical necessity for cardiovascular procedures is the top overpayment issue for three out of the four Recovery Auditors in FY 2013 first quarter (October 2012–December 2012), according to the most recent release of improper payment statistics .
On March 13, CMS issued a notice of ruling that establishes a policy that revises the current policy on Part B billing following the denial of a Part A inpatient hospital claim that a Medicare review contractor deemed to be not reasonable or necessary. The revisions are intended as an interim measure until CMS can finalize an official policy to address the issues raised by the Administrative Law Judge and Medicare Appeals Council decisions going forward.
CMS added 410 new codes and seven new therapy and patient condition modifiers to the Integrated Outpatient Code Editor (I/OCE) as part of the January 2013 update. Dave Fee, MBA, highlights the key changes to the I/OCE.
More than 450 healthcare organizations will participate in CMS’ Bundled Payments for Care Improvement Initiative . CMS announced the specific organizations in January, and some participants will begin receiving bundled payments as early as April. The program will be in effect for three years.
CMS is currently updating its ICD-10 implementation guides for practices, small hospitals, and payers. The agency has already posted the updated guide for small and medium practices .
Thirty-day readmissions for heart failure, heart attack, and pneumonia occur most frequently for reasons other than the cause of the initial hospitalization, according to a study published in the January 23 issue of the Journal of the American Medical Association (JAMA).
CMS is making a significant change to the Medically Unlikely Edits by changing the edits from line item edits to date of service edits. The change will become effective April 1.
One of AHIMA’s long-time goals is to empower HIM professionals to be heavily involved in the ICD-10 overhaul and perhaps even leading the transition in their facility.
As part of the 2013 OPPS Final Rule, CMS made major changes to how it will reimburse facilities for separately payable drugs and how it will calculate APC relative weights. Jugna Shah, MPH, and Valerie Rinkle, MPA, review the most significant changes in the final rule.
CMS rescinded Transmittal 2607 and replaced it with Transmittal 2636 to update the add-on code edit file to include a change in the list of primary codes for CPT add-on code 90785 (interactive complexity).
One of the major changes to the 2013 CPT ® Manual is the replacement of the term "physician" with "physician or other qualified healthcare professional" in a wide range of codes. Marie Mindeman and Andrea Clark, RHIA, CCS, CPC-H, discuss how this change affects code assignment.
If you’re curious about whether something you’ve heard or read about the Recovery Auditor program is true, be sure to check out new information published on the CMS Web site. The agency released a document that addresses 14 common myths about the program.
The FY 2013 Office of Inspector General (OIG) Work Plan includes plenty of new additions that might interest inpatient hospitals. Sara Kay Wheeler, Kimberly Anderwood Hoy, JD, CPC, Monica Lenahan, CCS, and William E. Haik, MD, FCCP, CDIP, review those new additions and offer tips for dealing with OIG scrutiny.
On January 9, the American Medical Association sent out a notification of errata in the 2014 CPT ® Manual . The AMA followed with a January 16 correction saying the errata file is for the 2013 CPT Manual .
National Government Services, under contract with CMS, will host a series of listening sessions about lessons learned from the Version 5010 upgrade to prepare providers, vendors, and payers for the transition to ICD-10-CM/PCS.
Coding for stent placement procedures will look very different in 2013. The American Medical Association deleted the two CPT ® codes used to report nondrug-eluting intracoronary stent placement procedures.
Hospitals earned a big win with drug payments this year in the 2013 OPPS final rule, released November 1. CMS decided to finalize its proposal to follow the statute and reimburse facilities at the average sales price (ASP) plus 6%.
As part of the 2013 OPPS final rule, CMS finalized a clarification to 42 CFR 419.2(b) that could cause confusion in the future if hospitals are audited by third-party payers or by Medicare contractors who do not fully understand the intent of the language or how CMS develops payment rates, says Jugna Shah, MPH, president of Nimitt Consulting based in Washington, D.C.
As part of the 2013 OPPS final rule, CMS finalized a clarification to 42 CFR 419.2(b) concerning packaged services. Jugna Shah, MPH, and Valerie Rinkle, MPA, explain how this clarification could cause confusion in the future if hospitals are audited by third-party payers or by Medicare contractors who do not fully understand the intent of the language or how CMS develops payment rates.
CMS recently posted an updated version of the National Correct Coding Initiative (NCCI) manual to the CMS NCCI website . The manual includes changes identified in red text and will be effective with dates of service January 1, 2013.
In a recent CMS email to providers, the agency reminded hospitals that any department, form, template, or other information that uses ICD-9-CM codes today will need to accommodate ICD-10-CM/PCS codes as of October 1, 2014.
Providers will continue to use the same definition of inpatient status that they already know. That’s because despite CMS’ consideration of various provider comments, the agency has not establish new criteria.
The Hospital Outpatient Payment Panel recommended CMS change the supervision requirements for 15 HCPCS and CPT codes during its second meeting this year in August. CMS released details of the meeting September 24.
Organizations looking for real-world examples of ICD-10 education can check out the plan created by Ginger Boyle, MD, of Spartanburg Regional Healthcare System in South Carolina.
Hospitals are overturning Recovery Auditor denials nearly 75% of the time, according to recent RACTrac data. That’s why the American Hospital Association adamantly supports a new proposed bill—the Medicare Audit Improvement Act of 2012 —aimed at holding Recovery Auditors accountable for inappropriate denials.
Although hospital infection rates continue to decline, Medicare payment penalties are not the cause, according to the New England Journal of Medicine article titled Effect of Nonpayment for Preventable Infections in U.S. Hospitals .
Providers are beginning to see some translation of CMS’ National Coverage Determinations (NCD) for ICD-10 with the release of Transmittal R1122OTN and Medlearn Matters Article MM7818 .
CMS has published two ICD-10-related Special Edition Medlearn Matters articles that may be of interest to providers and serve as tools to assist with implementation.
Getting physicians on board with the transition to ICD-10 won’t be easy, but CMS is trying to help. CMS will host a National Provider Call: Preparing Physicians for ICD-10 Implementation at 1:30 p.m...
The Hospital Outpatient Payment Panel recommended CMS change the supervision requirements for 15 HCPCS and CPT ® codes during its second meeting this year in August. CMS released details of the meeting September 24.
The OIG estimates that Medicare Administrative Contractors paid $8.4 million in overpayments to inpatient rehabilitation facilities (IRFs) because IRF and Medicare payment controls did not adequately identify late submissions of patient assessment instruments.
Providers may find themselves with a completely new definition of the term inpatient if CMS follows through with its intent to clarify this ever-confusing patient status, as explained in the 2013 OPPS proposed rule published July 30. The agency solicits input from providers on pp. 45155-45157 of the rule and suggests that it may implement fairly significant changes going forward.
Coders play a crucial role in ensuring compliance, and the FY 2013 IPPS final rule , released August 1, gives them many reasons to showcase their skills. William E. Haik, MD, FCCP, CDIP, and Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, detail the changes and how coders can take charge of them.
