News Alerts

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.

As of May 22nd, Cigna stated they will delay the
implementation to require the submission of documentation to support the use of modifier 25 when billed with E&M codes 99212 – 99215 and a minor procedure.

As of May 22nd, Cigna stated they will delay the implementation to require the submission of documentation to support the use of modifier 25 when
billed with E&M codes 99212 – 99215 and a minor procedure.

Reimbursement will require you to know which waivers to Medicare coverage and payment policies ended May 11.

It has been brought to our attention by several doctors that they have been receiving denials from UnitedHealthCare Oxford for missing prior auth for RFC codes.

As of February 15, 2023 the following codes are
Considered Experimental/Investigational/Unproven when used for the treatment of pain conditions as outlined in the above coverage policy statement

We have all been seeing RFC denials for Aetna, Humana, BCBS and probably other carriers. It is critical that your documentation meets the CMS requirements as stated below so that these denials can be appealed.

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

On January 1, 2023, Empire BlueCross BlueShield HealthPlus
(Empire) stated that they would begin to implement additional steps to review claims for Evaluation & Management (E/M) services submitted by providers

Several providers have been receiving rejections from Medicare for CPT 99343. Please note that this code has been deleted as of January 01, 2023.

As a result of a recent review conducted by Cigna, effective for dates of service on or after May 25, 2023, they will require the submission of office notes with claims submitted with...

MIPS IN 2023

ICD-10 Changes for 2023

The patient is at the center of the 21st Century Cures Act. Putting patients in charge of their health records is at the center of the Department of Health and Human Services’ (HHS’) work toward a value-based healthcare system.

When National Government Services requests specific documentation, you must send them only what has been requested.

It has been brought CMS’s attention again that there are some providers, physicians and other suppliers who are denying services to beneficiaries due to an open Medicare Secondary Payer record on the beneficiary Medicare record.

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. The new coding changes went into effect as of January 1, 2023.

Many podiatrists have expressed concerns with the Surgical Treatment of Nails policy which establishes the utilization limitations regarding the use of 11730, 11732, and 11750.

This guidance amends the previous “Calendar Year 2023 Fee Guidance for the Federal Independent Dispute Resolution Process under the No Surprises Act” released on October 31, 2022

As the population of older adults is expanding, the number of physician/hospital visits may also increase, and an influx of appointments can lead to a decrease in patient care if you’re not careful.

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.