The following information appeared on oig.hhs.gov “With respect to the six high-risk groups covered by our audit, most of the selected diagnosis codes that Highmark submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 160 of the 226 sampled enrolleeyears, the diagnosis codes were not supported in…
The 405(d) Program and Task Group is a collaborative effort between industry and the federal government, which aims to raise awareness, provide vetted cybersecurity practices, and move organizations towards consistency in mitigating the current most pertinent cybersecurity threats to the sector. Please explore their website to learn more about these efforts and all products and…
The following information appeared on aha.org The MGMA urged Congress to provide a positive update to the Medicare conversion factor in 2023 and all future years. The association said it is concerned with the estimated reduction to the conversion factor and how it would affect medical groups that are already challenged with rising costs, inflation,…
The following information appeared on reuters.com October 3 (Reuters)- A federal judge ordered Anthem Inc to face a U.S. government lawsuit claiming it submitted inaccurate diagnosis data, enabling the health insurer to fraudulently collect tens of millions of dollars in annual overpayments from Medicare. To read the full article, visit reuters.com
PCG has added the new 1,468 new diagnosis codes to the ICD-10-CM code set for fiscal year (FY) 2023 to the Virtual Examiner® database. 251 codes will be deleted, 35 code descriptors will be revised, and 36 codes will be converted to parent codes. The changes went into effect October 1, 2022.
The following information appeared on cms.gov CMS released a September 29, 2022 MLN with a retro-dated change in the copays related to a screening colorectal procedure to a diagnostic colonoscopy or sigmoidoscopy. While the notice states that it is effective January 1, 2022, the reductions do not become effective until 2023. To read the full…
The following information appeared on justice.gov “The investigation of Public Consulting Group LLC (PCG) was initiated through the filing of a complaint under the whistleblower provision of the False Claims Act. To read the full article, visit justice.gov
The following information appeared on oig.hhs.gov As we all are aware of the number of health care fraud prosecutions in the telehealth arena, the OIG has stepped up their audits and reviews of telehealth claims. To read the full article, visit oig.hhs.gov
The following information appeared on ngsmedicare.com National Government Service recently sent out a provider notification that the MAC was receiving robo-like calls from billing companies so that the billing company could show that they had followed up with the MAC on billing issues. “These types of calls do not result in additional payments for the…
The following information appeared on justice.gov “A federal jury convicted a Michigan man today for his role in devising and executing a $1.8 million scheme to defraud Medicare by billing for services under another doctor’s name after Medicare revoked his privileges to participate in the program. To read the full article, visit justice.gov
The following information appeared on oig.hhs.gov “We (OIG) sampled 270 unique enrollee years with the high-risk diagnosis codes for which HumanaChoice received higher payments for 2016 and 2017. We limited our review to the portions of the payments that were associated with these high-risk diagnosis codes, which totaled $744,438.” To read the full article, visit oig.hhs.gov
The following information appeared on oag.ca.gov The doctor will be required to pay $2.3 million in restitution and surrender his medical license, according to the Attorney General’s Office, which prosecuted the case. To read the full article, visit oag.ca.gov
The following information appeared on oig.hhs.gov Hospice of Palm Beach County, Inc. received Medicare reimbursement for hospice services that did not comply with Medicare requirements. To read the full article, visit oig.hhs.gov
The following information appeared on oig.hhs.gov For Medicaid managed care, States contract with private health insurance companies, or managed care plans, that have the primary responsibility for processing, paying, and monitoring the claims of providers in their networks. To read the full article, visit oig.hhs.gov
The following information appeared on cms.gov This is an interesting change in CMS policy. Effective for claims with dates of service on or after September 27, 2021, contractors shall be aware that the CMS MACs may determine reasonable and necessary coverage of oxygen therapy and oxygen equipment in the home for patients who are not…
The following information appeared on cms.gov Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers — follow requirements for standard written orders (SWOs). To read the full article, visit cms.gov
The following information appeared on cms.gov On July 26, 2022, the AMA issued three new CPT® codes to address the patient care needs of patients either exposed or at risk of Monkeypox. To read the full article, visit cms.gov
The following information appeared on justice.gov A physician and employee have been charged for their roles in a health care fraud scheme involving the submission of more than $3.5 million in claims to Medicare, announced U.S. Attorney Jennifer B. Lowery. To read the full article, visit justice.gov
The following information appeared on justice.gov Ventura County, the Ventura County MediCal Managed Care Commission and nonprofit health care providers Dignity Health and Clinicas del Camino Real have reached settlement agreements over allegations of violating the federal False Claims Act and the California False Claims Act, and will pay a total of $70.7 million to…
The following information appeared on cdc.gov Influenza circulated at historically low levels in the United States and globally during the 2020–21 influenza season. This was coincident with widespread implementation of nonpharmaceutical interventions (e.g., masking, social distancing, and suspension of in-person work and school) intended to prevent transmission of SARS-CoV-2 (the virus that causes COVID-19). To…
The following information appeared on congress.gov The original telehealth waivers were established in March 2020 and now have been extended to 151-day period beginning on the first day after the emergency period. The PHE has been extended into July and the Administration has promised that if it is not going to be renewed, there will…
The treating provider who performs the “substantiative portion” of a split/shared visit bills for the visit. All split/shared visits represent visits in a facility setting, including skilled nursing facilities, and emergency departments. Split/shared visits can be billed for initial and subsequent visits includ-ing critical care services. Split/shared visits can also be billed for prolonged services…
The following information appeared on, cms.gov A new update to the ASC payment system was released June 23, 2022. The Change Request reflects the major changes—the CR revision removed HCPCS codes A9601 and J0739 from Table 3 of the CR and reduced the number of new codes from 16 to 14 in Section 3a. To…
The following information appeared on, ASC X12. The RARCs and CARCs updated occur in publication 3 times per year—around March 1, July 1, and November 1. To read the full article, visit ASC X12.
The following information appeared on, cms.gov Since the beginning of the OPPS, CMS has maintained the Inpatient Only (IPO) list, which is a list of services that, due to their medical complexity, Medicare will only pay for when performed in the inpatient setting. In the CY 2021 OPPS/ASC final rule, CMS finalized a policy to…
The following information appeared on, cms.gov CMS created a new modifier—Modifier “FY” (X-ray taken using computed radiography technology/cassette-based imaging) to be reported on claims to identify those HCPCS codes that describe X-rays taken using CR technology. The payment reduction (7% for 2018) will be taken when this modifier is reported with the applicable HCPCS code(s)…
The following information appeared on, CNN Health. The Biden administration on Friday extended the Covid-19 public health emergency for another three months. US Department of Health and Human Services Secretary Xavier Becerra officially renewed the declaration, extending it through October 13, 2022. The emergency declaration has been in place since January 2020, and the latest…
The following information appeared on, Fierce Healthcare. The Biden administration is proposing a 2.7% increase to outpatient payment rates for hospitals for 2023 and an enhanced payment if a facility buys domestically manufactured N95 respirator masks. The Centers for Medicare & Medicaid Services (CMS) released Friday the Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical…
The following information appeared on, oig.hhs.gov During Fiscal Year (FY) 2021, the Federal Government won or negotiated more than $5.0 billion in health care fraud judgments and settlements,2 in addition to other health care administrative impositions. Because of these efforts, as well as those of preceding years, almost $1.9 billion was returned to the Federal…
The following information appeared on, cigna.com Effective 08/13/2022 Cigna will require the submission of documentation to support the use of modifier 25 when billed with E/M CPT codes 99212 – 99215 and a minor procedure. To read the full article, visit cigna.com
NCCI third quarter edit files are available on these Medicare NCCI webpages: PTP Coding Edits Medically Unlikely Edits Add-on Code Edits Each July, PCG updates to the ICD-10-CM diagnoses codes into the VE application databases. The effective date is October 1, 2022 for year 2023. There are over 1100 new diagnosis codes, 28 revised codes…
The following information appeared on, fda.gov On July 6, 2022, the U.S. Food and Drug Administration revised the Emergency Use Authorization (EUA) for Paxlovid (nirmatrelvir and ritonavir), to authorize state-licensed pharmacists to prescribe Paxlovid to eligible patients, with certain limitations to ensure appropriate patient assessment and prescribing of Paxlovid. To read the full article, visit…
The following information appeared on, medi-cal.gov Modifiers relevant to the NCCI edit method-ology are designated with the dagger symbol (†) in the following modifier list. See the Correct Coding Initiative: National section for instructions regarding the use of NCCI-associated modifiers. To read the full article, visit medi-cal.gov
The following information appeared on, medicaid.gov The Centers for Medicare & Medicaid Services (CMS) has released the quarterly National Correct Coding Initiative (NCCI) payment policy updates. These mandatory national edits have been incorporated into the Medi-Cal claims processing system and are effective for claims received on or after July 1, 2022. To read the full…
The following information appeared on, Healthcare Finance News “A plaintiff who filed a lawsuit against Meta, the parent company of Facebook and Insta-gram, is seeking class-action status for his case, which alleges that the company used a tracker called Pixel to illegally siphon information about a person’s health from patient portals of more than 660…
The following information appeared on, oig.hhs.gov In the semi-annual reports to Congress, the OIG provides not only an overview of the work being done in the HHS programs, but the reports on their valuable work. In this reporting period (October 1, 2021 through March 31, 2022), there are expected recov-eries of nearly $3 billion as…
The following information appeared on, go.usa.gov Scammers are impersonating HHS-OIG employees in an attempt to obtain your member’s personal, medical, or financial information. The Consumer Alert page lists current scams. Seniors are frequently targeted and the scammers are really good at presenting themselves as government employees or medical device representatives. Please take any calls to…
The following information appeared on, cms.gov Before COVID-19, subsequent hospital care services (inpatient and nursing facility visits) were limited to one telehealth visit every three days for hospital inpatients and one visit every 30 days for patients in a nursing facility. CMS temporarily removed these frequency limitations for the duration of the COVID-19 PHE. To…
The following information appeared on, justice.gov On June 17, 2022, the Department of Justice announced the arrest of Lazaro Hernandez for the distribution of adulterated HIV medications. To read the full article, visit justice.gov
The following information appeared on, cms.gov Effective July 1, 2022, CMS added J1551 JB (Injection, immune globulin (cutaquig), 100mg) to payment category 2 (PDF). CMS assigns home infusion drugs to 3 pay-ment categories, as determined by the HCPCS J-Code. Payment Category 1 includes certain intravenous antifungals and antivirals, uninterrupted long-term infusions, pain management, inotropic, chelation…
The following information appeared on, ama.assn.org The inpatient E/M descriptors are being changed for 2023 and the documentation requirements will be focused on MDM and time in many instances. The new inpatient guidelines look very similar to the E/M guide-lines for office visits. To read the full article, visit ama.assn.org
The following information appeared on, cms.gov Use HCPCS Level II code M0201 for the additional payment for administering the COVID-19 vaccine to certain Medicare patients in their homes. The $35.50 fee for the M0201 is geographical adjusted and the actual value for your member should be validated on the MAC’s website. To read the full…
The following information appeared on, ama.assn.org The Current Procedural Terminology (CPT®) Editorial Panel (the Panel) has approved a new vaccine administration code (0083A) for the third dose of the Pfizer vaccine product to address severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease 2019 [COVID-19]) in pediatric patents aged 6 months through 4 years. This…
The following information appeared on, johnshopkinssolutions.com Add new revenue code 0161 (R&B/HOSPITAL AT HOME) to the valid revenue codes list. Subcategory Definition: Room & Board – Hospital at Home. Revenue code 0161 will be used to report the accommodation charges of the at-home care room and board. Revenue Code 0161 is billable for 11X claims,…
The following information appeared on, cms.gov There are approximately 1,176 new diagnoses codes for FY 2023. Most of these are external cause codes, however there have been some significant changes and updates in most sections. To read the full article, visit cms.gov
The following information appeared on, cms.gov Both the ICD-10-PCS update for 2023 and the new guidelines have been released. Please review the new guidelines. To read the full article, visit cms.gov
The following information appeared on, cms.gov This document summarizes the mandates and prohibitions for HIPAA Covered Entities set forth in 45 Code of Federal Regulations (CFR) Subchapter C Part 162 related to administrative transactions, code sets, unique identifiers and operating rules./ To read the full article, visit cms.gov
The following information appeared on, phe.gov Federal health officials will extend the COVID-19 public health emergency past mid July, which will continue the pandemic-era policies as coronavirus cases increase again. HHS has renewed the COVID-19 public health emergency through October 13, 2022. The PHE provides Americans with free COVID-19 vaccines, therapeutics and test-ing, it provides…
The following information appeared on, oig.hhs.gov In 2010, OIG reported the first national incidence rate of patient harm events in hospitals—27 percent of hospitalized Medi-care patients experienced harm in October 2008. During that month, hospital care associated with these events cost Medicare and patients an estimated $324 million in reimbursement, coinsurance, and deductible payments. Nearly…
The following information appeared on, hhs.gov The U.S. Health and Human Services Department’s Health Resources and Services Administration (HRSA) announced the launch of the Maternal Mental Health Hotline, a new, confidential, toll-free hotline for expecting and new moms experiencing mental health challenges. With an initial $3 million investment, the hotline launched on Mother’s Day, May…
The following information appeared on, CMS.gov This CMS booklet reviews Medicare-covered behavioral health services, typically referred to as mental health and substance use services. These services affect a patient’s overall well-being. It’s important to under-stand these Medicare-covered services and the updates identified and summarized on page 1. To read the full article, visit CMS.gov
The following information appeared on, justice.gov Over a dozen defendants across eight federal districts have been charged in connection with the illegal prescription and distribution of 5.1 million opioid pills, the Justice Department announced Wednesday. The 14 individuals that were charged have not only ruined patient lives, but their distribution also led to death. The…
The following information appeared on, CMS.gov The update to the Medicare Benefit Policy Manual, Chapter 15 is in Section 60. This section covers services and supplies provided incident to a physician’s or a non-physician practitioner’s professional service. To read the full article, visit CMS.gov
The following information appeared on, CMS.gov Chemotherapy administration codes 96401-96549 apply to parenteral administration of non-radionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of noncancer diagnoses (e.g., cyclophosphamide for auto-immune conditions) or to substances such as certain monoclonal antibody agents, and other bio-logic response modifiers. The billing and coding requirements for the…
The following information appeared on, oig.hhs.gov Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care is the title of a new OIG Report that was delivered to HHS and other concerned government departments in April 2022. To read the full article, visit oig.hhs.gov
The following information appeared on, cms.gov Lung cancer is one of the most common cancers and the leading cause of cancer-related deaths in both men and women in the U.S. This particular screening – LDCT- is aimed at early detection of non-small cell lung cancer. To read the full article, visit cms.gov
The following information appeared on, cms.gov CMS has updated the listing of the medication on the exclusion list with an effective date of June 6, 2022. Each Medicare Administrative Contractor updates the list based on their claims experience. The website resource is from the CMS Medicare Coverage Database. To read the full article visit, cms.gov
The following information appeared on, oig.hhs.gov “The Centers for Medicare & Medicaid Services (CMS) has long taken the position that services provided to a hospice beneficiary that are unrelated to the beneficiary’s terminal illness and related conditions should be exceptional, unusual, and rare given the comprehensive nature of the services covered under the Medicare hospice…
The following information appeared on, cms.gov On December 23, 2001, the FDA authorized the emergency use of Pfizer’s Paxlovid, for the treatment of mild-to-moderate COVID-19 in adults and children (12 years of age and older weighing at lease 88 pounds (40kg) with a positive test for COVID and at risk for progression to severe COVID…
The following information appeared on, aspr.hhs.gov The U.S. Department of Health and Human Services (HHS) must extend the federal pub-lic health emergency (PHE) related to COVID-19 every 90 days to maintain certain health care flexibilities and waivers. The PHE has been in place since January 27, 2020, and has been renewed several times during the…
The following information appeared on, med.noridianmedicare.com VEKLURY™ (remdesivir) is FDA approved for the treatment of COVID-19 in hospitalized patients. The FDA label states that VEKLURY should only be administered in a hospital or in a healthcare setting capable of providing acute care comparable to inpatient hospital care. There are various U.S. guideline recommendations on the…
The following information appeared on, wpsgha.com The instructions for Modifier FT, which indicate critical care services during an unrelated procedure’s global surgical period, have not been either detailed or specific in the guidance from CMS. To read the full article, visit wpsgha.com
The following information appeared on, cms.gov Effective for claims processed with Dates of Service (DOS) on or after January 11, 2022, Hepatitis B vaccine (HepB), 3-antigen (S, Pre-S1, Pre-S2), 10 mcg dosage, 3-dose schedule for intramuscular use, for claims processed with DOS on or after January 11, 2022 is payable by Medicare. To read the…
MM12676 – Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
The following information appeared on, cms.gov In January 2022, an update to the signature requirements by the ordering or prescribing physician or Non-Physician Practitioner (NPP) was released. To read the full article, visit cms.gov
The following information appeared on, cms.gov CMS added these new DMEPOS codes to the HCPCS file, effective April 1, 2022. To read the full article, visit cms.gov
The following information appeared on, oig.hhs.gov The OIG has been very busy during the period between April 1, 2021 and September 30, 2021. The agency released 87 audit reports and 26 evaluation reports. To read the full article, visit oig.hhs.gov
The following information appeared on, cchpca.org The Center for Connected Health Policy is a nonprofit, nonpartisan organization working to maximize telehealth’s ability to improve health outcomes, care delivery, and cost effectiveness. To read the full article, visit cchpca.org
The following information appeared on, oig.hhs.gov The OIG has added inpatient claims with mechanical ventilation to the OIG Work Plan. As COVID-19 respiratory and sepsis diagno-ses have been on the rise, so also has the number of claims for ventilator support. To read the full article, visit oig.hhs.gov
The following information appeared on, justice.gov This is not an unusual case as it happened to me when my daughter was taken by ambulance to the nearest hospital for a fall at camp. The billing was for an ALS level of care and we also received a billing from the fire department. To read the…
The following information appeared on, novitas-solutions.com Physicians and non-physician practitioners who perform procedure codes, CPT 15271-15278 (application of skin substitute) may also bill separately for the skin substitute codes A2001-A2010. To read the full article, visit novitas-solutions.com
The HCPCS coding decisions from the 4th quarter 2021 are included in the April 2022 HCPCS Quarterly Update:https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update
The following information appeared on, oig.hhs.gov “So far from what I understand in the evidence and data, it shows that we spend more per Medicare recipient through MA than through fee-for-service,” Secretary Becerra said. “We have seen some evidence that in certain areas there seems to be charges that go beyond what would be necessary.”…
The following information appeared on, oig.hss.gov In 2021, the state and federal partners in MFCUs convicted 1105 individuals and recovered $1.7 billion. To read the full article, visit oig.hss.gov
The following information appeared on, cms.gov This is an interesting reminder that was sent out to Medicare Fee-for-Service providers. Only bill Medicare for the clinical lab tests performed in your lab. Do not submit charges to Medicare if you purchase the lab service from the clinical lab. The outside clinical lab must bill Medicare when…
The following information appeared on, cms.gov The NCCI Version 28 for physicians has a small set of additions, deletions, and revisions. To read the full article, visit cms.gov
The following information appeared on, Beckers Hospital Review. Twelve physicians in Michigan and Ohio were among 16 defendants sentenced to prison for a healthcare fraud scheme that involved submitting $250 million in false billings to insurers, the Justice Department said March 9. To read the full article, visit Beckers Hospital Review.
The following information appeared on, cms.gov CMS has provided an up-to-date FAQ list on COVID-19 billing as of 2-28-22. This doc-ument has 180 pages of information and an index. Please review the many changes. To read the full article, visit cms.gov
The following information appeared on, justice.gov March 8, 2022, authorities arrested a physician and a marketer on federal charges stemming from a scheme that bilked Medi-care out of more than $30 million for medically unnecessary hospice services provided to patients who were obtained through illegal kickbacks. To read the full article, visit justice.gov
The following information appeared on, cms.gov The Transitional Drug Add-on Payment Adjustment (TDAPA) is a payment adjust-ment under the ESRD PPS for certain new renal dialysis drugs and biological products. To read the full article, visit cms.gov
The following information appeared on, med.noriianmedicare.com A new March 1, 2022, policy from Noridian is unique among the Medicare Administrative Contractors. To read the full article, visit med.noriianmedicare.com
The following information appeared on, cms.gov On February 24, the FDA revised the emergency use authorization for tixagevimab co-packaged with cilgavimab (EVUSHELD™) to change the initial dose for the authorized use as preexposure prophylaxis of COVID-19 in certain adults and pediatric patients. To read the full article, visit cms.gov
The following information appeared on, webpricer.cms.gov CMS released the Hospice Prospective Pay-ment System Web Pricer for fiscal years 2020–2022. For the best experience, access the Web Pricer through Google Chrome. You may also use Microsoft Edge or Mozilla Firefox but not Microsoft Internet Explorer. PCG was also able to use Safari with good results. To…
The following information appeared on, justice.gov Nathan LaParl, 34, of Boca Raton, Fla., was sentenced by U.S. District Court Senior Judge George A. O’Toole, Jr. to three years of probation, the first year to be served subject to a curfew and forfeiture in the amount of $220,671. On Jan. 21, 2021, LaParl pleaded guilty to…
The following information appeared on, ag.nv.gov On February 16, 2022, Attorney General Aaron D. Ford announced that Shonna Nicole Marshall, 52, of Las Vegas, was sentenced in a Medicaid fraud and money laundering case involving falsely billing for Medicaid services allegedly provided to Medicaid recipients. To read the full article, visit ag.nv.gov
The following information appeared on, cms.gov Pneumococcal conjugate vaccine code 90677 (Pneumococcal conjugate vaccine, 20 valent (PCV20), for intramuscular use) and 90671 (Pneumococcal conjugate vaccine, 15 valent (PCV15), for intramuscular use) were released and effective July 1, 2021 and July 16, 2021. To download the resource, visit cms.gov
The following information appeared on, med.noridianmedicare.com The U.S. Food and Drug Administration approved a second COVID-19 vaccine. The vaccine has been known as the Moderna COVID-19 Vaccine; the approved vaccine will be marketed as Spikevax for the prevention of COVID-19 in individuals 18 years of age and older. To read the full article, visit med.noridianmedicare.com
The following information appeared on, qualitynet.cms.gov To track inpatient claims submitted for the Acute Hospital Care at Home program, the National Uniform Billing Committee approved the fol-lowing codes for claims received on or after July 1, 2022. Revenue Code 0161: Hospital at Home, R&B / Hospital at Home Occurrence Span Code 82: Hospital at Home…
The following information appeared on, cms.gov From the CMS Medicare Learning Network: MM12519 Released 12-2-2021. For CY 2022, CMS is not adding any new Category 1 HCPCS codes to the list of Medi-care telehealth services. CMS is also not adding any new Category 2 HCPCS codes to the list of telehealth services. Codes that are…
The following information appeared on, ama-assn.org Synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located away at a distant site from the physician or other qualified health care professional. To read the full article, visit ama-assn.org
The following information appeared on, cms.gov For the time being, only patients without insurance or self-pay are expected to receive a Good Faith Estimate (GFE) although there is an expectation that the rules may be extended to other patients by the end of 2022. The GFE does not apply to individuals insured under Medicare, Medicaid,…
The following information appeared on, novitas-solutions.com Because there have been so many changes in the billing requirements and new codes, there have been some interesting requests for information regarding the vaccines and mAb administration. To read the full article, visit novitas-solutions.com
The following information appeared on, fiscal.treasury.gov The prompt payment interest rate for January through June 2022 is 1.625%. To read the full article, visit fiscal.treasury.gov
The following information appeared on, cms.gov A new Opioid Treatment Program MLN Book-let was released in November 2021. To read the full article, visit cms.gov
The following information appeared on, cms.gov CMS is adding 5 CPT© codes and long descriptors as “sometimes therapy” codes effective for dates of service on or after January 1, 2022. To read the full article, visit cms.gov
The following information appeared on, ama-assn.org Modifier FQ (The service was furnished using audio-only communication technology) was designed to identify mental health tele-health services that are provided to a member in the home using audio-only com-munication such as a phone. To read the full article, visit ama-assn.org
The following information appeared on, justice.gov Anita Louise Jackson (“Jackson”) was a licensed North Carolina physician who operated an Ear, Nose, and Throat (ENT) practice in Rockingham, Lumberton, and other locations within the Eastern District of North Carolina. To read the full article, visit justice.gov
The following information appeared on, cms.gov The full description and use of Modifier FT is (Unrelated evaluation and management [E/M] visit during a postoperative period, or on the same day as a procedure or another E/M visit. The modifier is reported when an E/M visit is furnished within the global period but is unrelated, or…
The following information appeared on, govinfo.gov New CMS revisions to the Split or Shared E/M visits make many changes to the billing and payment for these services. To read the full article, visit govinfo.gov
The following information appeared on, cms.gov Effective January 1, 2022, CMS program payment for Physician Assistant services is 85% of the physician fee under MFPS. To read the full article, visit cms.gov
The following information appeared on, cms.gov Medicare covers primary or secondary surgical dressings when used to protect or treat a wound and when needed after wound debridement. To read the full article, visit cms.gov
Modifier 93 was released to the AMA web-site on December 30, 2021, and did not make it into Appendix A. The effective date is January 1, 2022 and will be included in the 2023 CPT code Manual.
The following information appeared on, cms.gov CMS announced a new COVID-19 HCPCS Code for Convalescent Plasma in outpatient setting on December 28, 2021. To read the full article, visit cms.gov
The following information appeared on, cms.gov Effective January 3, 2022, 86328 with a modifier QW is payable as a CLIA waived test. While the MACs will not search the claims data base for previously denied claims, any claims brought to the attention of the MAC will be adjusted. To read the full article, visit cms.gov
The following information appeared on, medicare.fcso.com Effective immediately, for claims with dates of service on or after 1/7/2022, the Centers for Medicare & Medicaid Services (CMS) is removing current procedural terminology code 67911 (correction of lid retraction) from the list of codes that require prior authoriza-tion as a condition of payment. This service is not…
The following information appeared on, go.usa.gov The rapid #COVID19 test was the top diagnostic lab test, based on spending, that Medicare Part B paid for in 2020. Over $1 billion was paid for 10 million+ uses of it. To read the full article, visit go.usa.gov
The following information appeared on congress.gov Many of the Medicare Physician Fee Schedule cuts that were planned for 2022 have be pushed out to 2023 by current legis-lation named Protecting Medicare and American Farmers. To read the full article, visit congress.gov
The following information appeared on, cms.gov The final rule reinstates patient safety criteria for adding a procedure to the ASC Covered Procedures List (ASC CPL) that were in place in CY 2020 and removes from the ASC CPL 255 of the 267 procedures added in CY 2021. To read the full article, visit cms.gov
The following information appeared on, aetna.com Aetna announced an update on a previous announcement regarding the change of benefit coverage for office consults. To read the full article, visit aetna.com
The following information appeared on, reuters.com On January 11, 2022, CMS announced that it will limit coverage of Biogen’s costly Alzheimer’s disease drug, Aduhelm, to patients enrolled in approved randomized clinical trials. “While there may be the potential for promise with this treatment, there’s also the potential for serious harm to patients,” CMS Chief Medical…
The following information appeared on, aapc.com CMS is reversing course on the elimination of the IPO list, explaining that more time is required to evaluate the implications for each service, particularly on patient safety. In the OPPS final rule, the agency finalizes, with modification. To read the full article, visit aapc.com
The following information appeared on, Fierce Healthcare. From Fierce Healthcare, “a Nevada jury has awarded TeamHealth $60 million in punitive damages as part of an ongoing legal spat between the physician staffing firm and health insurance giant UnitedHealthcare.” To read the full article, visit Fierce Healthcare.
The following information appeared on, cms.gov There are 3 new ICD-10-CM diagnosis codes and 7 new ICD-10-PCS procedure codes for inpatient care. These codes describe introducing or infusing therapeutics, including vaccines for Covid-19 treatment. The new diagnosis codes go into effect on April 1, 2022. To read the full article, visit cms.gov
The following information appeared on, cms.gov CMS has updated the current POS code set by revising the description of existing POS code 02 and adding new POS code 10. The POS code set provides setting infor-mation necessary to pay claims correctly. At times, the health care industry has a greater need for specificity than Medicare.…
The following information appeared on, oig.hhs.gov A new HHS-OIG audit recommends Medi-care Advantage organization, @upmchealth-plan, (University of Pittsburgh Medical Center) refund to the federal government the $6.4 million of estimated net over-payments for the high-risk diagnoses codes in 2015 and 2016. Read more: https://go.usa.gov/xej2J. To read the full article, visit oig.hhs.gov
The following information appeared on, justice.gov Tampa, Florida – U.S. District Judge Virginia M. Hernandez Covington has sentenced Michael Nolan (48, Tampa) and Richard Epstein (29, Aurora, CO) for their roles in a conspiracy to defraud federal health benefit programs, Medicare and the Civilian Health and Medical Program of the Department of Veterans Affairs (“CHAMPVA”)…
The following information appeared on, justice.gov A Nevada-based clinical laboratory, MD Spine Solutions LLC, d/b/a MD Labs Inc., and two of its owners and co-founders have agreed to resolve allegations that MD Labs submitted false claims for payment to Medicare, Medicaid, and other federal health care programs. To read the full article, visit justice.gov
The following information appeared on, CMS.gov Beginning Jan. 1, 2022, a 15% payment reduction for therapy services provided at least in part by a therapy assistant goes into effect. Modifiers CO for occupational therapy assistants (OTA) and CQ for physical therapy assistants (PTA) are used to trigger the payment reduction. To read the full article,…
The following information appeared on, CMS.gov The DMEPOS fee schedule file contains fee schedule amounts for non-rural and rural areas. Also, the Parenteral and Enteral Nutrition (PEN) fee schedule file has state fee schedule amounts for enteral nutrition items and national fee schedule amounts for parenteral nutrition items. To read the full article, visit CMS.gov
The 2022 Annual AMA Symposium is virtual again. The Conference dates are November 17, 18 and 19th. There are 240 new CPT codes for January 1st, and many, many changes and deletions. See the AMA site for details: https://www.ama-assn.org/practice-management/cpt/outpatient-cdi-workshop-cpt-and-rbrvs-annual-symposium
Beginning January 1, 2022, an RHC or FQHC can bill and get payment under the RHC All-Inclusive Rate (AIR) or FQHC Pro-spective Payment System (PPS), respectively, when their employed and designated attending physician provides services during a patient’s hospice election. To get the RHC AIR or payment under the FQHC PPS: RHCs must report the…
The following information appeared on, CMS.gov Some Durable Medical Equipment, Pros-thetics, Orthotics, & Supplies (DMEPOS) suppliers bill Medicare for items provided to patients while they are in a facility. These are improper DMEPOS claims because Medi-care pays the facility to provide DMEPOS. Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). To read the full article,…
The following information appeared on, CMS.gov Beginning January 1, 2021, CMS expanded the TPNIES policy to include home dialysis machines when used in the home for a single patient. Beginning January 1, 2022, we’ll pay ESRD facilities the CRA adjustment for TPNIES. To read the full article, visit CMS.gov
The following information appeared on, Dol.gov United Behavioral Health and United Healthcare Insurance Co. will pay $13.6 million to affected participants and beneficiaries; pay $2,084,249 in penalties; and take other corrective actions following investigations and litigation by the U.S. Department of Labor and the New York State Attorney General. To read the full article, visit…
The following information appeared on, Pac.training The Centers for Medicare & Medicaid Services (CMS) is offering a web-based training that provides an overview of the assessment and coding of K0200. Height and Weight and K0510, Nutritional Approaches. The course should take approximately 20 minutes to complete, and topics included are listed below. While it is…
The following information appeared on, CMS.gov The full Excel spreadsheet and associated files are available for download at:https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update
The following information appeared on, Medicaid.gov If you are providing services to Medicaid pro-gram members, please remember to review the Medicaid NCCI Policy Manual. Many state programs reference this manual or have added it to their own provider documentation. To read the full article, visit Medicaid.gov
The following information appeared on, Justice.gov The Department of Justice on Friday announced criminal charges against 42 doctors and nurses and nearly 100 other medical professionals for alleged healthcare fraud schemes that cost $1.4 billion in losses. To read the full article, visit Justice.gov
The following information appeared on, CMS.gov CMS MLN Matters Number: MM12354 The law governing payment for hospice care requires annual updates to the hospice pay-ment rates. Payment rates are updated annually according to section 1814(i)(1)(C)(ii)(VII) of the Social Security Act (“the Act”), which requires CMS to use the inpatient hospital market basket, adjusted for multi-factor…
The following information appeared on, CMS.gov The new update to the ICD-10-CM codes is available including the ICD-10-CM Official Guidelines for Coding and Reporting. While the 115 pages of the document seem long, there is valuable information that should be reviewed. Visit the 2022 ICD-10-CM webpage for Fiscal Year (FY) 2022 diagnosis code information: To…
The following information appeared on, CMS.gov With an effective date of 10/01/2021, CMS has approved the following new tests as waived under CLIA. The CPT codes for the following new tests must have the modifier QW to be recognized as a waived test. To read the full article, visit CMS.gov
The following information appeared on, Healthcare Law Brief. In a September 3, 2021, Health Care Law Brief authors, Elizabeth (Betsy) Rosen Siegel & Edward S. Kornreich reviewed the impact of the delays of the certain provisions of the No Surprises Act. These particular provisions are delayed now until 2023. To read the full article, visit…
The following information appeared on, Justice.gov Sutter Health, headquartered in Sacramento, contracted to provide health care services to California beneficiaries enrolled in certain plans. In exchange, Sutter Health received a portion of the payments for treating the beneficiaries under its care. To read the full article, visit Justice.gov
The following information appeared on, Justice.gov When Erma Lee, Compliance Director, for JPS Hospital brought the audit report of improper usage of Modifiers 59, 25, and XU to the attention of management, she expected a change in practice and close monitoring of the billing errors. Not only was the action plan rejected and CMS not…
The following information appeared on, CMS.gov In an August CMS release, Medicare benefi-ciaries who have difficulty leaving their homes or are otherwise hard-to-reach, can receive the COVID-19 vaccination. Healthcare providers can now receive additional payments for administering vaccines to multiple residents in one home setting or communal setting of a home. Medicare will pay the…
The following information appeared on, Noridian Medicare. Noridian has a very helpful Anesthesia and Pain Management guide that was released April 2021. Of interest to all, is the multiple procedure reduction instructions in the guide under MULTIPLE PROCEDURES: “A physician bills for the anesthesia services associated with multiple bilateral surgeries by reporting the anesthesia procedure…
The following information appeared on, CMS.gov Effective for claims with dates of service on and after April 13, 2021, CMS will nationally cover autologous PRP for the treatment of chronic non-healing diabetic wounds under Section 1862(a)(1)(A) of the Social Security Act (the Act) for a duration of 20 weeks. This applies when using devices whose…
The following information appeared on, jdsupra.com The Office of the Inspector General (OIG) of the US Department of Justice (DOJ) recently announced that it had won or negotiated more than $1.8 billion in healthcare fraud settlements over the past fiscal year. The DOJ opened 1148 criminal healthcare fraud investigations and 1079 civil healthcare fraud investigations…
The following information appeared on, justice.gov While CMS and private insurers along with many physician practices are pushing for additional telehealth services, there is major increase in telehealth fraud. Right now, the federal government estimates that there were $4.5 billion worth of telehealth-related fraud losses in fiscal year 2020, the largest of any category and…
The following information appeared on, justice.gov San Mateo County Medical Center and San Mateo County (collectively SMMC), located in California, have agreed to pay approximately $11.4 million to resolve alleged violations of the False Claims Act for submitting or causing the submission of claims to Medicare for non-covered inpatient admissions. To read the full article,…
The following information appeared on, kff.org The Kaiser Family Foundation prepared an excellent review of the rising costs of the MA Plans. “Over the last decade, the role of Medicare Advantage, the private plan alter-native to traditional Medicare, has grown. In 2021, more than 26 million people are enrolled in a Medicare Advantage plan, accounting…
The following information appeared on, CMS.gov The delay of the implementation of the AUC is over. Beginning January 1, 2022, providers who order an advanced diagnostic imaging service for a Medicare beneficiary will be required to consult a Clinical Decision Support Mechanism (CDSM) to gauge adherence to evidence-based criteria and report the consultation information to…
The following information appeared on, Justice.gov Department of Justice Press Release—Friday, July 30, 2021 “The United States has intervened in six complaints alleging that members of the Kaiser Permanente consortium violated the False Claims Act by submitting inaccurate diagnosis codes for its Medicare Advantage Plan enrollees in order to receive higher reimbursements.” The Kaiser Permanente…
The following information appeared on, Justice.gov In the July 15, 2021, DOJ press release, the Denver Grand Jury has indicted both DaVita, Inc. and the former CEO, Kent Thiry. The charges are related to a conspiracy to deprive workers of “free-market opportunities”. The indictment describes an anti-poaching agreement with Surgical Care Affiliates LLC from 2012…
The following information appeared on, CMS.gov On December 2, 2020, the Centers for Medi-care & Medicaid Services (CMS) finalized policies that are consistent with the directives in President Trump’s Executive Order, entitled “Protecting and Improving Medicare for Our Nation’s Seniors,” that aim to increase choice, lower patients’ out-of-pocket costs, empower patients, and protect taxpayer dollars.…
The KU modifier is used to receive the unadjusted fee schedule amount and was implemented for a variety of wheelchair accessories and seat back cushions used with complex rehabilitative manual wheel-chairs and certain manual wheelchairs. The use of the KU modifier started for claims submitted on July 6, 2020 and is effective for dates of…
The following information appeared on, CMS.gov HHS has renewed the PHE waivers and flexibilities for another 90 days from July 21, 2021 through October 2021. The full update with the changes in red and cross out of terminated policies in red with the termination date are found at: https://www.cms.gov/files/document/Covid-19-emergency-declaration-waivers.pdf
The following information appeared on, IRS.gov From the IRS press release of July 8, 2021, a McKinney man has been sentenced to prison for federal violations in the Eastern District of Texas, announced Acting U.S. Attorney Nicholas J. Ganjei today. Demetrius Cervantes pleaded guilty on December 4, 2020, to conspiracy to obtain information from a…
The following information appeared on, Reuters.com In a recent July 12, 2021, Rueters article by Trisha Roy and Caroline Humer, the cost and coverage of a new Alzheimer’s medication is brought to light. The U.S. government on Monday started a review process for national Medicare cover-age of Biogen Inc’s (BIBB.O) Alzheimer’s drug, Aduhelm, that was…
The following information appeared on CMS.gov On July 13, 2021, the Centers for Medicare & Medicaid Services (CMS) issued a pro-posed rule that announces and solicits public comments on proposed policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues, on or after January 1, 2022.
The following information appeared on, CMS.gov The American Medical Association (AMA) releases CPT Category III codes twice per year: in January, for implementation beginning the following July, and in July, for implementation beginning the following January. To read the full article visit, CMS.gov
The following information appeared on, CMS.gov The CMS Mandate governing the new Clinical Decision Support Mechanism (CDSM) and the Appropriate Use Criteria (AUC) Pro-gram takes effect on January 1, 2022. Tasked with improving diagnostic accuracy for physicians when ordering advanced imaging, this new CMS Mandate is part of the “Protecting Access to Medicare Act” (PAMA)…
The following information appeared on, CMS.gov The consolidated billing (CB) requirement confers on the SNF the billing responsibility for the entire package of care that residents receive during a covered Part A SNF stay and physical, occupational, and speech therapy services received during a non-covered stay. Exception: There are a limited number of services specifically…
The following information appeared on, Delbene.house.gov A new House bill was introduced and is moving forward under the current name of Improving Seniors’ Timely Access to Care Act of 2021. If passed, Medicare Advantage Plans would be required to establish “electronic prior authorization programs.” To read the full article visit, Delbene.house.gov
The following information appeared on, JAMA A 2017 study at the University of California San Francisco Medical Center of over 23,000 patient progress notes for one partic-ular software showed that only 15% of the text was entered manually. The rest was either cut and pasted or “imported.” The hospital system has since changed its policy…
The following information appeared on, Beckers Hospital Review. Morgan Haefner’s piece on the UHC delay of their retro review policy of emergency services is an important issue as the policy was in conflict with the prudent layperson standard of presenting symptoms and final diagnosis. To read the full article visit, Beckers Hospital Review.
The following information appeared on, CMS.gov Two-thirds of all bankruptcies filed in the United States are tied to medical expenses. Researchers estimate that 1 of every 6 emergency room visits and inpatient hospital stays involve care from at least one out-of-network provider, resulting in surprise medi-cal bills. Studies have shown that in the period from…
Notice was posted that the Federal Prompt Pay Interest Penalty Rate has been changed to 1.125% effective July 1, 2021 through December 31, 2021. Previously it had been .875% from January 1, 2021 through June 30, 2021.
The following information appeared on, AMA-ASSN.org The AMA has released an errata update that is effective dating back to January 1, 2021. It is a key focus update to the VE and VA knowledge bases. Please take the time to evaluate how the changes will affect both claims determination and payment. To read the full…
The following information appeared on, Justice.gov Acting U.S. Attorney Bridget M. Brennan announced that a federal grand jury returned a 24 count indictment charging Thomas Mox, 53, of Grove City, Ohio; Ryan Casady, 49, of Uniontown, Ohio; Elizabeth Baljak, 35, of Pataskala, Ohio and Megan Ilg, 53, of Grafton, Ohio for their roles in health…
The following information appeared on, FDA.gov The antibody drug, Sotrovimab, is not authorized for patients who are hospitalized due to COVID-19 or require oxygen therapy, the health regulator said on May 26, 2021. Sotrovimab (VIR-7831), also known as GSK4182136, is a monoclonal antibody with the ability to neutralize the SARS-CoV-2 virus. On May 26, 2021…
The following information appeared on, CMS.gov One of the items in the CMS signature update information has been brought forward to the Fact Sheet on Medicare Signature Requirements. This addition addresses the changes to the requirements when partici-pating in Graduate Medical Education as an attending physician or NPP. “If you rely on the medical student’s…
The following information appeared on, CMS.gov CMS is increasing the Medicare payment rate for administering monoclonal anti-bodies to treat patients with COVID-19. Effective May 6, the national payment rate will be $450 for most healthcare settings, up from the previous rate of $310. CMS also said its national payment rate will increase to $750 when…
The following information appeared on, OIG.HHS.gov A new OIG Report on the billing of E/M services on the same day as a minor surgery by dermatologists is an eye open-ing read. “In 2019, about 56 percent of dermatologists’ claims with an E/M service also included minor surgical procedures (such as lesion removals, destructions, and biopsies)…
The following information appeared on, CMS.gov Effective July 1, 2021, CMS made the addition of the QW modifier to HCPCS code 87636 [Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique]. The full change…
The following information appeared on OCR. The Office for Civil Rights (OCR) at the U.S. Department of Health and Human Services announces its eighteenth settlement of an enforcement action in its HIPAA Right of Access Initiative. OCR announced this initiative to support individuals’ right to timely access of their health records at a reasonable cost…
The following information appeared on, FDA.gov The U.S. Food and Drug Administration issued an Emergency Use Authorization (EUA) for the investigational monoclonal antibody therapy, bamlanivimab and etesevimab, administered together, for the treatment of mild- to-moderate COVID-19 in adults and pediatric patients with positive COVID-19 test results who are at high risk for progressing to severe…
The following information appeared on CMS.gov While most of the 2021 ESRD PPS remains unchanged, there are updates that are effective back to January 1, 2021 with an implementation date of April 5, 2021. This includes new rates for Acute Kidney Injury (AKI). The full MLN Matters can be reviewed at: https://www.cms.gov/files/document/mm12188.pdf
The following information appeared on CMS.gov New billing and coding guidance has been issued on Hemophilia Factor with the Revision effective date of April 8, 2021. The LCD has both examples of individual factors and monthly supplies with coding for both. The $99,000.00 monthly threshold billing split is very helpful.There are listings of the correct…
The following information appeared on NGS Medicare. For COVID-19 vaccine administration billing purposes, CMS is allowing specialty 73 (Mass Immunization Roster Billers) to use the code set assigned to specialty A5 (pharmacy/suppliers) or specialty 58 (medical supply company w/registered pharmacist). This will ensure that the claims processing system selects the correct Medicare PTAN for your…
On April 14, 2021, the House passed the legislation that pauses the 2% Sequestration through December 31, 2021. It is expected the President will sign the new legislation shortly. The past year has been a financial struggle for many health care organizations and the 2% does make a difference. Now we will see if the…
The following information appeared on Justice.gov “Ivan Andre Scott, 36, of Kissimmee, was convicted by a federal jury on Jan. 8, 2021, of one count of conspiracy to commit health care fraud, three counts of health care fraud, one count of conspiracy to pay and receive unlawful health care kickbacks, and three counts of receiving…
The following information appeared on, CMS.gov On April 13, 2021, the Sequestration Suspension was continued through December 31, 2021. An Act to Prevent Across-the-Board Direct Spending Cuts, and for Other Purposes, was signed into law on April 14, 2021, and it extends the suspension period to December 31, 2021. To read the full article visit,…
The folllowing information appeared on CMS.gov The list of Telehealth services has grown with the pandemic. While new codes are being added, there are four that have been removed. The removed codes include— initial hospital care codes 99221, 99222, and 99223 along with 96121 for neurobehavioral status exam. The removal of these codes is retroactive…
The following information appeared on CMS.gov For subsequent nursing facility care services, Medicare had limited the patient’s admitting physician or non-physician practi-tioner to one telehealth visit every 30 days. CMS is changing this limitation to once every 14 days. Also, you may not furnish or report subsequent nursing facility care ser-vices for a Federally-mandated periodic…
The following information appeared on Noridian.com If you are looking for information to share with your provider network, the MACs have Education menus available that are updated due to their findings from review of billing issues. Updates to the Surgery Modifiers on demand tutorial is helpful. To learn more visit, Noridian.com
The following information appeared on CMS.gov Section 5012(d) of the 21st Century Cures Act (Pub. L. 144-255) amended Sections 1861(s)(2) and 1861(iii) of the Social Security Act (the Act), requiring the Secretary of HHS to establish a new Medicare HIT services benefit. To read the full article, visit CMS.gov
The following information appeared on Office Inspector General. There has been an exponential increase in health care fraud related to COVID-19. There is some excellent material being developed by the OIG, HHS, and CMS. Reporting suspect healthcare fraud is essential to protect members and providers. Identity theft is a key focus of criminals. To see…
The following information appeared on Justice.gov On March 18, 2021, Acting United States Attorney W. Anders Folk announced charges against 13 defendants in a multi-million dollar health care fraud conspiracy. The defendants made their initial appearances yesterday before Magistrate Judge David T. Schultz in U.S. District Court. To read the full article, visit Justice.gov
The following information appeared on Justice.gov In a March 19, 2021, Department of Justice Press Release, the Acting U.S. Attorney Prerak Shah announced “Fourteen defend-ants convicted in the Forest Park Medical Center bribery scam have been sentenced to a combined 74+ years in federal prison and ordered to pay a total of $82.9 million in…
Several CPT® codes used for therapy modalities, procedures, and tests and measurements specify that direct (one-on-one) time spent with the patient is 15 minutes. Services provided for a single timed CPT® code that is less than 8 minutes should not be billed. The CPT code is reported for the time actually spent in the delivery…
The following information appeared on NGS Medicare. In an effort to reduce the Part B CERT error rate, the NGS Medical Review Department is conducting a service specific post payment review of CPT code 74177 (Computed Tomography, Abdomen and Pelvis; with Contrast Materials). The NGS site not only lists the areas of primary focus for…
The following information appeared on CMS.gov The Medicare Claims Processing Manual Chapter 32, Section 411, was updated on March 15, 2021 to include new billing requirements set out in Change Request 12108. Effective for claims with a Date of Service on or after January 1, 2021, CWF shall create a new reject claim when a…
LCDs are now found in the Virtual AuthTech® Application and you will be able to access the pertinent LCD as you adjudi-cate claims information. The following will be displayed: PROFESSIONAL RESULTS For Locality: (54) BAKERSFIELD, CA 2021 priced @100% of CMS SOS pricing is calculated using 2021 Non-Facility RVUs. K0553 DMEPOS pays: $223.22 (Primary Procedure)…
The following information appeared on, CMS.gov Medicare Administrative Contractors are reprocessing Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) claims with HCPCS code G2025 (payment for a telehealth distant site service furnished by a RHC or FQHC only): Update the national rate to $99.45 Dates of service on or after January 1 To…
The following information appeared on tempus.gov The Tempus Next Generation Sequencing Panel must be submitted with CPT code 81479. Tempus Labs, Inc, has introduced Tempus, a genome sequencing panel that analyzes genes related to diagnosis, progno-sis, and therapeutic targeting of cancer. Among other things, the panel looks for single-nucleotide variants, small insertions and deletions, amplifications…
The following information appeared on OIG.HHS.gov. If you are not reviewing for this area of fraud, please review the OIG article referenced below. This topic has had numerous appearances in both the OIG outreach materials and from the MACs. It is a serious problem and at least would validate a review of claims data. To…
The following information appeared on JAMA Network. In a recent JAMA Psychiatry article of February 3, 2021, the Findings are illustra-tive of the increased needs for mental health care during the PHE. “Findings This cross-sectional study of almost 190 million ED visits found that visit rates for mental health conditions, suicide attempts, all drug and…
The following information appeared on, justice.gov Department of Justice Office of Public Affairs Friday, January 15, 2021 A Mississippi businessman was sentenced today for his role in a multimillion-dollar scheme to defraud TRICARE, the health care benefit program serving U.S. military, veterans, and their respective family members, as well as private health care benefit programs.…
The following information appeared on, CMS.gov For prolonged Preventative Services, the 2018 policy has not changed and to continue to report G0513 and G0514 as an add-on(s). To read the full article visit, CMS.gov
The following information appeared on, CMS.gov In response to an Office of Inspector General (OIG) May 2020 report, Medicare Made $11.7 Million in Overpayments for Nonphysician Outpatient Services Provided Shortly Before or During Inpatient Stays. While much of the information in this FAQ sheet is not new, there are new emphasis that needs to be…
The following information appeared on, govinfo.gov Starting on January 1, 2021, each hospital operating in the United States is required to provide clear, accessible pricing information online about the items and services they provide in 2 ways: Comprehensive machine-readable file with all items and services Display of shoppable services in a consumer-friendly format Visit the…
The following information appeared on, CDC.gov Effective January 1, 2021 the CDC (Centers for Disease Control) Prevention’s National Center for Health Statistics (CDC/NCHS) has added new codes into the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for reporting. To read the full article visit, CDC.gov
The following information appeared on, CMS.gov On November 2, CMS issued a final rule that updates payment policies and rates under the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for renal dialysis services furnished to beneficiaries enrolled in Original Medicare on or after January 1, 2021. This rule also updates the Acute Kidney Injury…
The following information appeared on, novitas-solutions.com The Portable X-Ray Transportation fees are changing as the result of the cost analysis of survey data. The 2021 fees will become effective after a 45-day notice period on February 23, 2021, for dates of service on or after January 1, 2021. Each CMS region has a different fee…
The following information appeared on, CMS.gov On December 27, the Consolidated Appropriations Act, 2021 modified the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS): Provided a 3.75% increase in MPFS payments for CY 2021 26,084 RVU changes to PE, work and Malpractice. 70% of RVU increases were for facility PE Suspended the 2% payment…
