News Alerts

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

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