News Alerts

Health and Human Services Office of Inspector General-Telehealth and Potential Fraud

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.

Provider Relief Fund Reporting Requirements and Auditing

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

RFC Billing & Coding Refresher

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.

How to Determine New vs. Established Patient

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.”

DME Policy Updates

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

E&M Changes Coming in 2023

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.

EmblemHealth Copays When Secondary to Medicare

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.

CIGNA-Reimbursement Policy Update Regarding E&M Codes Billed with Modifier 25 and Minor Procedures Effective August 13, 2022

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.

DME-Elimination of Certificates of Medical Necessity & Durable Medical Equipment Information Forms

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

PRF Period 2 Reporting Deadline
Approaches

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

2022 MIPS Extreme and Uncontrollable Circumstances Exception Application Now Open

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.

UnitedHealthcare Community Plan-Referral Reminder

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

DMEPOS Items: Medical Record
Documentation

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:

Noridian DME-Policy Article
Revisions Summary for 04.14.22

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):

Understand how Nurse Practitioners (NP) and Physician Assistants (PA) Qualify as Certifying Physicians for Therapeutic Shoes & Inserts

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

HRSA: Provider Relief Fund: Out of Compliance with Reporting Period 1

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

Medicare-Understanding Revalidation Application Requirement of Submission

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.

Place of Service 10 for Telehealth Services Not for Medicare Billing

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

2022 CMS Evaluation and Management Regulation Modifications

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

CMS-February and March 2022 Billing & Coding Article Updates

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.

Excellus BlueCross BlueShield-Discontinuation of Paper Notification for Claiming Billing Errors

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.

DME-Ankle-Foot-Orthosis Quarterly Results of Targeted Probe and Educate Review-Current Error Rate is 38%

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

Billing & Coding Reminders

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 Signs Law Postponing Medicare Cuts

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-Overview of 2022 Physician Fee Schedule Final Rule

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

CMS Issues 2022 MPFS Final Rule

CMS released the CY 2022 Medicare Physician Fee Schedule (MPFS) Final Rule. The rule finalized several proposals:

Medicare-New Modifications to the POS Codes for Telehealth

The POS code set provides setting information necessary to pay claims correctly. At times, the health care industry has a greater need for specificity than Medicare.

October 2021 LCD & Associated Billing & Coding Article Updates-Routine Foot Care and Debridement of Nails (A57759)

Based on annual ICD-10 updates for 2022, ICD-10 code E75.244 was added to Group 1 and Group 4 covered diagnoses.

Excellus BC-BS-Federal Requirements Effective January 1, 2022

The mandate applies to Commercial, Essential Plan and Federal Employee Program lines of business.

MGMA Comes out Against Insurer Charged EFT Fees

The Medical Group Management Association (MGMA) is calling for a ban on insurers charging electronic fund transfer (EFT) fees.

Why Providers Should Prioritize Billing & Coding Oversight

When a miscoded procedure is the result of substantial negligence or fraud, it can be detrimental to a medical practice or physician. That is why it is vital for medical practices to establish robust oversight, audit and remediation procedures that work to ensure accurate coding and billing.

The Complications of Medical Malpractice and the Pandemic

Since the first appearance of COVID-19 in the U.S., American healthcare providers have been working tirelessly to address every aspect of the pandemic.

MGMA Comes Out Against Insurer Charged EFT Fees

The Medical Group Management Association (MGMA) is calling for a prohibition on insurers charging electronic fund transfer (EFT) fees.

Anthem Agrees to Revise At-Risk Foot Care and –59 Modifier Coding Policy

Anthem has agreed to the APMA’s recommendation to amend its At-Risk Foot Care and -59 Modifier Coding Policy.

Correct Utilization of ABNs for Aetna Medicare Advantage Members

Providers should be aware that an Advance Beneficiary Notice of Noncoverage (ABN) is not a valid form of denial notice for a Medicare Advantage member.

2020 MIPS Targeted Review Deadline October 1st

Practitioners who participated in 2020 MIPS can now review their payment adjustment factor(s) on the Quality Payment Program website.

2022 ICD-10-CM Guidelines
Released

Released earlier than usual, the fiscal year (FY) 2022 ICD-10-CM Official Guidelines for Coding and
Reporting became available online Monday, July 12, and include instructions for assigning novel code
U09.9 Post COVID-19 condition (found under Section I.C.1.g.1).

CMS Proposes MPFS Payment Policies for 2022

The effects of COVID-19 are still being felt in the states and influencing the Centers for Medicare & Medicaid Services’ (CMS’) decisions for policy changes, as evident in the 2022 Medicare Physician Fee Schedule (MPFS) proposed rule.

Anthem to Fix At-Risk Foot Care and Modifier 59 Coding Policy

APMA wrote to Anthem, Centene, and Humana to address podiatrists’ concerns with these carriers denying correctly coded at-risk foot care claims.

NGS-Nail Debridement: CPT Codes 11719, 11720, 11721 and Paring or Cutting of Benign Hyperkeratotic Lesions: CPT Codes 11055, 11056, 11057

CPT code 11055 (Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion) and CPT code 11720 (Debridement of nail(s) by any method(s); one to five) should not be reported together for services performed on skin distal

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