News Alerts

The federal government’s 2023 spending plan will hurt seniors’ access to medical care when physician reimbursement for Medicare drops in 2023.

The Centers for Medicare & Medicaid Services (CMS) released the 2023 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Medicare fee schedule with an increase of 8.7 percent.

CMS is discontinuing Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs) effective January 1, 2023.

Due to the rise in Same or Similar denials, it is highly recommended that you utilize the Noridian DME denial code resolution tool to assist in resolving those denials.

The information contained in this article is only a summary of revisions to the LCDs and/or PAs. For complete information on any topic, you must review the LCDs and/or PAs.

National Government Services periodically receives reopening requests to change the diagnosis on a paid claim.

The 2023 Medicare Physician Fee Schedule (MPFS) and Quality Payment Program final rule was released Nov. 1. But while the Centers for Medicare & Medicaid Services (CMS) continues its focus on promoting population health

For all items requiring a WOPD and face-to-face encounter, a practitioner visit is required within six months preceding the
WOPD.

Research shows that patients are leaving both providers and payers because of bad customer experiences. Nearly 80% of people who switched doctors said “ease of navigation” factors were the cause.

Medicare’s Open Enrollment period gives people with Medicare the opportunity to make changes to their health plan or prescription drug plan, pick a Medicare Advantage plan, or return to Original Medicare (also referred to as Medicare Part A and Part B).

UnitedHealthcare follows Medicare guidelines and orthotics are only covered when permanently attached to a brace.

The Consolidated Appropriations Act (CAA) contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days.

One of the primary goals of the 2021 evaluation and management (E/M) guidelines was to reduce administrative burden on clinicians and their practices.

A leading physician organization is lining up against one of the nation’s largest health insurers in a legal fight over insurance billing.

Recently, there has been an issue with Excellus BC/BS with the coverage of orthotics (HCPCS L3000). The problem is specifically for patients enrolled in their Medicaid
Managed Care plan (known as the Blue Choice Option where the patient’s ID number starts with VYT).

Under the Limitations section, the active care requirement for systemic conditions has been revised to remove “qualified non-physician practitioners” to conform with the Centers for Medicare & Medicaid Services (CMS) Internet -Only Manual (IOM) Publication 100-02

Activities have resumed with revalidation due dates starting with 1/31/2022. Don’t wait to revalidate if CMS assigned a 2022 due date.

CMS identified a national system issue, which may have inadvertently adjusted previously processed Part B claims with dates of service (DOS) on or after January 1, 2021.

CMS identified a national system issue, which may have inadvertently adjusted previously processed Part B claims with dates of service (DOS) on or after January 1, 2021. These adjustments processed on July 29 through August 2, 2022.

The Right of Access Initiative was implemented in 2019 to help patients obtain their medical records in a timely manner and at a reasonable cost in accordance with the HIPAA Privacy Rule.

NGS has reported an increase in invalid overpayment requests related to the MIPS program. MIPS is part of the QPP that determines Medicare performance-based payment adjustments.

The DHHS (Department of Health & Human Services), of whom the CMS reports to, published a brief last week from the OIG regarding telehealth and the PHE expansion of services.

Effective Sept. 23, 2022, overpayment notification letters sent by UnitedHealthcare for most commercial and UnitedHealthcare Medicare Advantage plans to network health care professionals (primary and ancillary) and facilities are going paperless:

When a Medicare Beneficiary enrolls in a MA Plan, that MA plan takes the place of Traditional Medicare benefits.

The AMA summary contains a number of proposed E/M changes to several categories/service types that will have a major impact on many different provider types.

Effective July 1, 2022, health care providers are required to include the injured worker's

Reporting Period 3 Is Open! Providers who are required to report during Reporting Period 3:

Ingrown nails can be a medically necessary diagnosis for podiatry care, even in the absence of a systemic condition. Coverage depends on the procedure that is being performed, and the type of insurance the patient has.

According to the CPT codebook, a “new” patient is, “one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.”

Surgical Dressings Benefits-Simple wounds are not covered. These include the following wounds:

The AMA released their CPT Editorial Summary. It contains a number of proposed E/M changes to several categories/service types that will have a major impact on many different provider types.

This update directly affects downstate NY/NJ providers. Please note that although members were made aware of the changes, there doesn’t seem to be an official notice that was sent to participating providers.

As a result of a recent review, CIGNA will require the submission of office notes with claims submitted with evaluation and management (E&M) codes 99212, 99213, 99214, and 99215 and modifier 25 when a minor procedure is billed.

CMS is discontinuing Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs) effective January 1, 2023.

Recipients still have time to report Provider Relief Fund payments if they can prove extenuating circumstances.

MIPS eligible clinicians, groups, and virtual groups may submit an application to reweight any or all MIPS performance categories if they've been affected by extreme and uncontrollable circumstances that impact these performance categories.

Patients with certain UHC Community plans must obtain a referral from their PCP to see a specialist

For Medicare to cover any Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) item, the patient’s medical record must include enough documentation to justify the need for:

Ankle-Foot/Knee-Ankle-Foot Orthosis. PA. Revision Effective Date: 02/01/2021
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 FED. REG VOL 217):

NPs and PAs who are practicing under the supervision of an MD or DO (i.e., “incident to”) as the certifying physician can provide therapeutic shoes to beneficiaries with diabetes if certain criteria are met

Although this issue is not related to billing and coding, we are receiving many calls, questions and concerns regarding the letters from the HRSA Provider Relief Fund

The 42 Code of Federal Regulations Section 424.515(b): requires that a provider/supplier must submit a CMS-855 application with complete information for revalidation by the due date.

NGS is receiving calls from providers with regards to the usage of the new POS 10 code.

On 2/23 and 2/24/2022, National Government Services presented webinars titled “2022 CMS Evaluation and Management Regulation Modifications”.

Billing and Coding: Peripheral Nerve Blocks (A57452). This article has been updated due to a provider request to add diagnosis code G58.0 to Group 1 in the "ICD-10 codes that support medical necessity" section.

As of February 4, 2022, Excellus BlueCross BlueShield has discontinued its practice of sending paper notification when certain billing errors occur. This change is part of their overall effort to reduce the amount of paper sent to provider practices.

Top Medical Necessity Denial Reasons. Medical record documentation does not support the beneficiary is ambulatory.

When billing Medicare for RFC- Do not use ICD-10 code E11.9. This is not a covered diagnosis for any of the RFC codes

President Joe Biden signed S. 610 Protecting Medicare and American Farmers from Sequester Cuts Act on Friday, December 10th. The signed bill makes the following adjustments to Medicare reimbursement

CMS has finalized 2022 payments and policies under the Medicare Physician Fee Schedule (MPFS). The rule includes updates to payment rates for physicians and other healthcare professionals for calendar year (CY) 2022