News Alerts

Beginning in CY 2024, physicians may receive either the facility or the non-facility payment rate for an eligible Medicare telehealth service, depending on whether POS code 02 or POS code 10 is selected.

Cigna is sending providers the attached letter regarding payments being issued via Zelis.

Performant is now the RAC for all of National Government Services Part A and Part B lines of business in Jurisdiction K.

On April 1, the Centers for Medicare & Medicaid Services (CMS) released its first quarter Healthcare Common Procedure Coding System (HCPCS) update with revisions for methylprednisolone.

Outlined below are the principal changes to the DME MAC Policy Articles (PAs) that have been revised and posted.

Availity Essentials is now the provider portal for Horizon Blue Cross Blue Shield of New Jersey, Braven Health, and Horizon NJ Health transactions, such as Eligibility & Benefits, Claims, Authorizations, and more.

Change Healthcare: Senate Hearing for Single Citrix Compromised Credential Resulting in $22,000,000 Ransom

UnitedHealth Group has stated the following:

When a claim is filed with Medicare, the beneficiary’s permanent address on file
with the Social Security Administration (SSA) determines which Medicare jurisdiction should be billed.

Considering the recent cyber security incident at Change Healthcare and an
increasing number of suppliers reverting to paper claims submission, Noridian
has experienced an increase in paper claims.

In accordance with CMS, as of 3/27/2024, NGS may grant extensions for responses to ADRs (Additional Documentation Requests) to providers under active medical review if they attest, they have been negatively impacted by the CHOPD.

If you are in-network for The Empire Plan you are also in-network for The Excelsior Plan and Student Employee Health Plan (SEHP).

Outlined below are the principal changes to the DME MAC Policy Article (PA)
that has been revised and posted. Please review the entire Local Coverage
Determinations (LCDs) and related PAs for complete information.

On February 21st, Change Healthcare disclosed that it had experienced a cybersecurity incident involving unauthorized access to its information systems.

In the event of a lost or stolen Medicare card, beneficiaries will be issued a new Medicare Beneficiary Identifier (MBI) number

CMS finalized the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) Jan. 17, 2024.

The No Surprises Act (NSA), which went into effect Jan. 1, 2022, has had many obstacles since its commencement; mainly four lawsuits challenging the Independent Dispute Resolution (IDR) process.

Annual deductible for all Medicare Part B beneficiaries is $240, an increase of $14 from the annual deductible of $226 in 2023.

Effective January 1, 2024, Empire BlueCross BlueShield and Empire BlueCross will become Anthem Blue Cross and Blue Shield and Anthem Blue Cross. This will take place across Commercial, Medicaid, and Medicare lines of business.

Surgical Dressings. LCD. Revision Effective Date: 01/01/2024

Prior to January 1, 2024, the definitions of the hallux valgus correction CPT codes were defined as follows...

Outlined below are the principal changes to the DME MAC Policy Articles (PAs) that have been
revised and posted.

CMS has released the January 2024 Healthcare Common Procedure Coding
System (HCPCS) File

UnitedHealthcare and Cigna are facing lawsuits from members and/or their families alleging the organizations use automated data tools to wrongfully deny members' medical claims.

Providers Ask CMS to Enforce Rules on Zero-Fee EFT Payments:

If strapping is done on a different site and your documentation supports it, then you may bil the strapping with a 59 Modifier:

Billing Medicare for bilateral injections:

Beginning Nov. 3, 2023, UHC will no longer mail claim letters to most medical network health care professionals and
facilities for UnitedHealthcare Community Plans (Medicaid) in Minnesota, New York and North Carolina.

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Code descriptor revisions are about time. After the extensive changes made to the evaluation and management (E/M) codes and guidelines over the last few years, you’ll be pleased to know that the 2024 E/M changes are minimal.

CMS pays MA plans a fixed monthly amount per beneficiary but adjusts these monthly payments based on patients’ risk factors to ensure that

Novitas, First Coast, and CGS Part B MACs announced on September 28th, 2023, that their previously finalized new skin substitute policies “will not become effective on October 1.”

Effective for services rendered on or after 10/1/2023, due to the annual ICD-10 updates for 2024, the following updates were made:

It was originally stated on August 3 that Novitas, First Coast Service Options, and CGS Part B Medicare Administrative Contractors (MAC) finalized skin substitute policies for the treatment of diabetic foot ulcers (DFC’s) and venous leg ulcers (VLU’s) that would have gone into effect September 17, 2023.

If you are seeing patients in a nursing facility, it is important to include the correct POS (place of service) on your claims.

Making physicians pay to get paid is a bad idea, according to a national trade organization for health care management.

Don’t Say: “Let’s not worry about that for now!"

Billing and Coding: Non-Invasive Vascular Studies (A56758)

In May 2023, the OIG released the final report titled “Medicare Paid Millions More for Physician Services at Higher Non-facility Rates Rather Than at Lower Facility Rates While Enrollees Were Inpatients of Facilities” (A-04-21-04084).

We have come across many DME denials for prefabricated orthoses for insufficient documentation. It is crucial that you document the following:

Effective July 1, 2023, Humana partnered with two national durable medical equipment (DME) providers— AdaptHealth and Rotech.

On August 3, Novitas, First Coast Service Options, and CGS Part B Medicare Administrative Contractors (MAC) finalized skin substitute policies for the treatment of diabetic foot ulcers (DFC’s) and venous leg ulcers (VLU’s) that become effective September 17, 2023.

The proposed 2024 Medicare Physician Fee Schedule sets a 3.4% reduction to the conversion factor for Medicare payment rates, further increasing the gap between practice expenses and reimbursement.

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15004-1-unit FYI-This code should only be used once with the initial preparation of the wound site-

The Advance Beneficiary Notice of Noncoverage (Form CMS-R131) has been approved for renewal. This renewed form expires January 31, 2026.

Aetna has informed APMA that effective July 23, it will drop its external review program regarding use of -59 Modifier when submitted with CPT 11719-11721, G0127, and 11055-11057.

The following plans have updated policy changes:

You are considered in-network for a Bridge Program member if you are part of any of the five networks listed below and the word “Bridge” appears on the member’s ID card.

Effective July 1, 2023, mandatory reporting of all single-use containers as used (JZ Modifier) or wasted (JW Modifier) amounts must be reported on Part B claims.