Fidelis Denials

Members of the NYSPMA Insurance Committee, along with the NYSPMA consultant Arnie Tannen, had a conference call with the medical directors of Fidelis this past week.

CMS-Prior Authorization Exemption: Part B Provider Role

As per CMS, HOPDs (Hospital Outpatient Departments) are currently exempt from submitting prior authorization requests for all procedures within the Prior Authorization program.

Reminder-PHE Accelerated and Advance Payments are Due

If you received government loans during the public health emergency, they may already be due.

Noridian-Coordination of Benefits: Crossover Claims Issue

CMS reported a system issue on 04/08/21 - 04/15/21, that prevented Medicare Part A and B (including Durable Medical Equipment) crossover claims from crossing to certain supplemental payers.

Surgical Dressing Requirements

Recently both of the Durable Medical Equipment (DME) Medicare Administrative Contractors
(MACs) steered a post-payment service-specific medical review of encounters where certain
surgical dressings were supplied.

Palmetto to Reimburse DPMs for RPM Services

Palmetto will now reimburse DPMs for performing remote physiological monitoring (RPM) services as a result of combined efforts of APMA, DME Workgroup, and podiatric CAC representatives for Palmetto Jurisdiction.

PDAC Validation

Recent legislation requires information that we are accustomed to having in the LCD policies be removed and now placed in PA’s (Policy Articles).

DME-LCD and Policy Article Revisions Summary for March 18, 2021

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Do’s and Don’ts for Talking with Patients About Coronavirus Vaccines

Based on the poll findings published on the AMA website, the following is what is recommended regarding what to say—and avoid saying—when speaking about COVID-19 vaccines.

MCR-Policy Article Revisions Summary for March 1st 2021

Policy Article Revisions Summary for March 11, 2021

Billing for Services when Medicare is Secondary

Don’t deny treatment, entry to a SNF or hospital, or services based on an open or closed Liability (L), No-Fault (NF) or Workers’ Compensation (WC) Medicare Secondary Payer (MSP) record on the beneficiary’s Medicare file or if a claim was inappropriately denied.

10 Ways to Improve Medical Coding and Billing Accuracy

The best way to prevent claims denials and improper payments is to keep them from happening in the first place. Before submitting a claim, be on the lookout for the following 10 common errors:

6 Questions Ensure E&M Compliance

Using MDM to code office visits in 2021 from an auditor’s perspective there are four distinct portions of an auditor’s tool: diagnoses, data, risk, and calculation of medical decision making (MDM).

CMS Guidance Clarifies MIPS Measure Specifications

For the 2021 MIPS performance period, most of the available eCQMs include CPT® and HCPCS Level II encounter codes that Medicare will cover when furnished either in-person or via telehealth.

Diabetic Quality Measure Coding Changes for 2021 (MIPS)

2020 Reporting Codes:

APMA-Successful with Initiative to Increase MUE for CPT 28300

The APMA has requested that the National Correct Coding Initiative (NCCI) increase the Medically Unlikely Edit (MUE) of CPT 28300 (Osteotomy, calcaneus) from one to two,
stating their argument; that this was necessary to account for the situation when a double calcaneal osteotomy is needed.

Post-Op Global Period Changes From 90 to Zero Days for Common Digital Amputation Procedures

The global surgical package for CPT 28820 (amputation, toe: metatarsophalangeal joint) and CPT 28825 (amputation, toe: interphalangeal joint) includes all the necessary services normally furnished by a surgeon before, during and after a procedure.

Major Stimulus Bill Pumps Funds into Healthcare

A $1.4 trillion government spending bill and $900 billion COVID-19 relief package, signed into law Dec. 27, includes a slew of provisions directed toward the Department of Health and Human Services, but one in particular will put money back into the pockets of healthcare practitioners.

Medicare FFS Claims: 2% Payment Adjustment (Sequestration) Suspended Through March 2021

The Coronavirus Aid, Relief, and Economic Security (CARES) Act suspended the payment adjustment percentage of 2% applied to all Medicare Fee-For-Service (FFS) claims from May 1 through December 31.

COVID-19 Vaccine Scams

Medicare covers the COVID-19 vaccine at no cost to you, so if anyone asks you to share your Medicare Number or pay for access to the vaccine, you can bet it’s a scam .

Physicians/Practitioners: Medical Records Play a Vital Role in Ordering and Providing DMEPOS to Your Patients

For any DMEPOS item to be covered by Medicare, the patient’s medical record must contain sufficient information about the patient’s medical condition to substantiate the necessity for the type of equipment or supply, quantity and/or frequency of use or replacement, if applicable.

E&M 2021 Updates-Overview of Changes

New CPT 2021 guidelines for office and other outpatient E/M services were created to reduce administrative burden on provider documentation and to align code selection with how providers practice medicine.

DME-Policy Article Revisions for November 19, 2020

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TRICARE Regulations Updated to Allow DPMs to Refer for PT/OT Services

TRICARE released a final rule fixing its outdated regulations to allow DPMs to refer TRICARE patients to Physical Therapy and Occupational Therapy Services (PT/OT) as well as speech pathology.

EmblemHealth-New Claims Payment and Remittance Effective August 19, 2020

On Aug. 19, 2020, they will be implementing a new claims payment and remittance (CPR) service powered by ECHO Health, Inc. (ECHO) for Group Health Incorporated (GHI). Health Insurance Plan of Greater

HHS Provider Relief Fund Phase 2 General Distribution Now Accepting Additional Applicants

On July 31, 2020, HHS announced that certain Medicare providers would be given another opportunity to receive additional Provider Relief Fund payments

MACs Resume Medical Review on a Post-Payment Basis

Medicare Administrative Contractors (MACs) are resuming fee-for-service medical review activities.

Medicare-Include Multiple Dates of Service on Reconsideration Appeal Request

Suppliers may include multiple dates of service for the same beneficiary on one reconsideration request form instead of submitting separate reconsideration requests for each date of service.

Repayment of Accelerated and Advance Payments for Part B Providers Begins July 27th

For the first 120 days, claims should be submitted as normal. Claims will be processed by National Government Services and payments that were transmitted to the provider.

Medicare FFS Audits Resuming
August 3rd

CMS recently announced that it anticipates resuming audits on August 3, as related to CMS’ program integrity efforts. This decision was made based on states reopening regardless of the ongoing public health emergency status.

CMS Issues ABN Update

A new Fee-for-Service Advanced Beneficiary
Notification of Non-coverage (ABN) form is now effective, with an expiration date of June 30, 2023. The use of the old ABN (version 03/2020) will be considered invalid after Aug. 31, 2020.

MCR-Targeted Probe & Educate (TPE) Reviews Suspended

In response to COVID-19, Medicare has implemented the following actions pertaining to TPE reviews:

Proper Billing for Telehealth Services Claims

CMS received a high volume of paper CMS-1500 claim forms for telehealth services with dates of service during the PHE that they have to reject because they are improperly coded with two different POS codes on one claim.

Medicare-Article Revisions for July 1st, 2020

ICD-10 CODES THAT SUPPORT MEDICAL
NECESSITY: Added: ICD-10 diagnosis codes E08.610, E09.610, E10.610, and E11.610 to Group 2 Codes for L4631

Medicare-Article Revisions for June 2020

Due to the clinical findings and challenges presented by patients with COVID-19 the following diagnosis codes have been added to ICD-10 Codes that Support Medical Necessity.

UnitedHealthcare COVID-19 End Date and Billing Guidance

The following resources will help you quickly reference the effective dates for UnitedHealthcare’s temporary benefit, program and procedure changes related to COVID-19, as well as billing guidelines for services such as COVID-19 testing, treatment and telehealth.

House Votes to Ease Restrictions on Coronavirus Small Business Loans

The House passed a bill Thursday designed to give small businesses owners more flexibility in how they spend money from a key coronavirus aid program.

UnitedHealthcare is Waiving Cost Share for Medicare Advantage Members

UnitedHealthcare is waiving cost share (copays, coinsurance and deductibles) for UnitedHealthcare Medicare Advantage plan members for all covered office-based professional services performed by...

CMS’ Interim Final Rule-COVID-19

CMS distributed a new interim final rule (IFR) on April 30 that entailed more regulatory waivers and rule changes. These changes are meant to increase access to care and provide added flexibility to providers in delivering that care.

Modifier 95 as it Relates to Medicare Part B and COVID-19 Billing

Modifier 95 Defined: Synchronous telemedicine service rendered via real-time interactive audio and video telecommunications system.

Additional Funding from HHS

$50 billion of the Provider Relief Fund is allocated for general distribution to facilities and providers that billed Medicare in 2019,

CMS Reevaluates Accelerated Payment Program and Suspends Advance Payment Program

On April 26th, CMS announced that it is reevaluating the amounts that will be paid under its Accelerated Payment Program and suspending its Advance Payment Program

CMS Sets up Accelerated and Advanced Medicare Payments Due to Coronavirus

On Saturday, CMS detailed how providers can access accelerated or advanced Medicare payments under the new economic stimulus package.

CMS: Providers can Skip 2019 MIPS Reporting Due to Coronavirus Crisis

As part of the federal government’s response to the COVID-19 pandemic, CMS has announced relief measures for providers who are bound to participate in its quality reporting programs, including the

Medicare-Protect Yourself and Your Patients from COVID-19 Fraud/Scammers

Scammers may use COVID-19 as an opportunity to steal your identity and commit Medicare fraud. In some cases, they might tell you they'll send you a Coronavirus test

CMS Announces the 2020 Medicare Part B Deductible

On November 8, 2019, the Centers for Medicare & Medicaid Services (CMS) released the 2020 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs

Coronavirus Disease 2019 (COVID-19)- How to Protect Yourself

Medicare Beneficiary Identifiers (MBIs) should be used now to avoid claim and eligibility transaction rejects. Effective January 1, 2020, regardless of the date of service

LCD and Policy Revisions Summary-February 20, 2020

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Did You Know that the Medicare Part B Overpayment Form has been Retired?

Some providers are still using the retired Medicare Part B Overpayment Form. The new process for provider-initiated non MSP overpayments is as follows:

Accepting Payment from Patients with a Medicare Set-Aside Arrangement

Medicare is always a secondary payer to liability insurance (including self insurance), no-fault insurance, and workers’ compensation benefits.