HCPro.com - Medicare Update for Physician Services

Editor’s Note: Last issue of Medicare Update for Physician Services

Thu, 05 Jul 2012 04:00:00 GMT

This issue will be the final Medicare Update for Physician Services. Thank you for being a loyal subscriber. Various alternatives are available. Please consider subscribing to other free e-newsletters from HCPro, Inc., that address various Medicare billing and reimbursement topics. Click here to browse our entire catalogue of free e-newsletters.

Note from Peggy: Clarification of ABN Policy

Thu, 05 Jul 2012 04:00:00 GMT

This is my last note for the MUPS ezine as it is being discontinued after this issue. HCPro started this ezine July 5, 2007 as a biweekly publication. In February 2009, we dropped back to a monthly publication schedule. And now 5 years and 82 issues later, we are releasing our final issue. It’s been a good ride. This month I would like to talk about the ABN.

CMS released a transmittal and corresponding MLN Matters article clarifying the appropriate use of the Advanced Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131. ABNs are required to inform beneficiaries in the traditional fee-for-service Medicare program about possible non-covered charges when limitation of liability (LOL) applies.

The LOL protections apply only when a provider believes that a Medicare covered item or service may be denied in a particular instance because it is not medically necessary or because the item or service constitutes custodial care. In that event, the provider will be held liable for the service and cannot collect any money from either the Medicare contractor or the beneficiary unless the beneficiary receives advance note that the items or services will likely be denied. The ABN is the vehicle that shifts liability from the provider to the beneficiary should the beneficiary elect to receive the service after notice was provided.

Continue reading Peggy's note at the Medicare Mentor blog

Regulations: CMS posts IPPS proposed and final rules, relevant correction notices for FY 2013 and more

Thu, 05 Jul 2012 04:00:00 GMT

CMS posts IPPS proposed and final rules, relevant correction notices for FY 2013

On June 18, CMS issued on its IPPS website the changes to the hospital inpatient prospective payment systems and fiscal year 2012 rates; proposed, final, and relevant correction notices.

View the update.

CMS issues Medicare secondary payer and future medicals proposed rule

On June 15, CMS issued in the Federal Register a proposed rule that solicits comment on standardized options that CMS is considering making available to beneficiaries and their representatives to clarify how they can meet their obligations to protect Medicare’s interest with respect to Medicare Secondary Payer (MSP) claims involving automobile and liability insurance (including self-insurance), no fault insurance, and workers’ compensation when future medical care is claimed or the settlement, judgment, award, or other payment releases (or has the effect of releasing) claims for future medical care.

View the proposed rule.

CMS issues corrections to 2013 IPPS proposed rule

On June 11, CMS issued in the Federal Register technical and typographical corrections to the 2013 IPPS proposed rule.

View the corrections.

CMS issues correction to Medicare Advantage and prescription drug benefit final rule

On June 1, CMS issued a correction in the Federal Register to the Medicare Advantage and prescription drug benefit final rule.

View the correction.

Transmittals/MLN Matters articles: CMS issues transmittal on process for handling esMD and more

Thu, 05 Jul 2012 04:00:00 GMT

CMS issues transmittal on process for handling esMD

On June 15, CMS issued a transmittal that defines the steps esMD review contractors must use in situations where the provider has failed to submit a response to an ADR letter by the deadline.

Effective date: July 16, 2012

Implementation date: July 16, 2012

View transmittal R426PI.

CMS instructs on provider self audits

On June 15, CMS issued a transmittal which announces that it is updating the website references for the OIG Compliance Program guidelines and statistical sampling that providers follow when conducting a self audit.

Effective date: July 16, 2012

Implementation date: July 16, 2012

View transmittal R425PI.

CMS issues manual changes regarding the issuance of an ABN form

On June 1, CMS issued a transmittal which announces that editorial changes have been made to chapter 30, section 50 of the Claims Processing Manual regarding the issuance of the advanced beneficiary notice of noncoverage (ABN) form CMS-R-131.

Effective date: September 4, 2012

Implementation date: September 4, 2012

View transmittal R2480CP.

View MLN Matters article MM7821.

Quarterly updates: CMS issues July 2012 OPPS update and July update to the CY2012 Physician Fee Schedule Database

Thu, 05 Jul 2012 04:00:00 GMT

CMS issues July 2012 OPPS update

On June 8, CMS released two transmittals that describe changes to and billing instructions for various payment policies implemented in the July 2012 OPPS update.

Effective date: July 1, 2012

Implementation date: July 2, 2012

View the Claims Processing Manual transmittal.

View the Benefit Policy Manual transmittal.

CMS issues July update to the CY2012 Physician Fee Schedule Database

On June 1, CMS issued a transmittal containing a recurring update notification with the July 2012 update to the CY2012 MPFSDB.

Effective date: July 1, 2012, physician fee schedule; April 1, 2012, ASC measurement G-codes

Implementation date: July 2, 2012

View transmittal R2481CP.

View MLN Matters article MM7844.

Other developments: CMS issues July 2012 NCD Coding Policy Manual and Change Report and more

Thu, 05 Jul 2012 04:00:00 GMT

CMS issues July 2012 NCD Coding Policy Manual and Change Report

CMS released the July 2012 Medicare National Coverage Determinations (NCD) Coding and Policy Manual and Change Report for clinical diagnostic laboratory services.

View the report.

CMS issues certification letter on revised hospital conditions of participation

On June 15, CMS issued a certification letter on the recent changes to the hospital conditions of participation.

View the certification letter.

Events: None this week

Thu, 05 Jul 2012 04:00:00 GMT

There are no public events this week.

Note from Peggy: NPI vs. PTAN

Thu, 07 Jun 2012 04:00:00 GMT

Were you ever curious about the difference between the National Provider Identifier (NPI) versus the Provider Transaction Access Number (PTAN)? Of course the NPI is a national number that allows all payers and all practitioners and other providers who are considered covered entities to communicate in the same language, at least as far as what provider we’re talking about. It has a single translation that equates to an individual or a hospital or some other type of healthcare entity such as a physician group practice. The NPI is assigned by the National Plan and Provider Enumeration System (NPPES). Physicians thought that they were going to be able to get rid of that long list of provider numbers that were uniquely theirs and different for every payer. But for Medicare, every entity receiving an NPI will also have a PTAN. Unlike the NPI which can be translated by virtually everybody, the PTAN only makes sense to the Medicare Administrative Contractor (MAC) that assigns it.

Continue reading Peggy's note at the Medicare Mentor blog

Transmittals/MLN Matters: CMS issues manual updates and more

Thu, 07 Jun 2012 04:00:00 GMT

CMS replaces transmittal on screening for STIs and HIBC to prevent STIs (ICD-10)

On May 23, CMS replaced transmittal R2402CP, containing a notice which says that CMS will cover screening for chlamydia, gonorrhea, syphilis, and hepatitis B with the appropriate FDA-approved lab tests used consistent with FDA-approved labeling and in compliance with CLIA regulations when ordered by a primary care provider and performed by an eligible Medicare provider for these services.

View transmittal R2476CP.

CMS issues general update to chapter 15 of the PIM – Part VI

On May 18, CMS issued a transmittal that continues the process of updating chapter 15 of the Program Integrity Manual on enrollment of providers, including sections on Independent Diagnostic Testing Facilities (IDTFs) and Durable Medical Equipment (DME) suppliers, among others.

Effective date: June 19, 2012

Implementation date: June 19, 2012

View transmittal R421PI.

CMS updates part 1, chapter 9, Provider Reimbursement Manual

On April 20, CMS issued a transmittal that updates part 1, chapter 9 of the Provider Reimbursement Manual. The update applies to the inflation factors, which are applied on a calendar year basis.

View transmittal R451PR1.

CMS issues transmittal containing revisions of the financial limitation for outpatient therapy services and more

On April 27, CMS issued a transmittal that extends the therapy cap exceptions process through December 31, 2012 and adds therapy services provided in outpatient hospital settings to the therapy cap effective October 1, 2012.

Effective date: October 1, 2012

Implementation date: October 1, 2012

View transmittal R2457CP.

CMS issues new physician specialty code for sleep medicine and sports medicine

On April 27, CMS issued a transmittal that adds new specialty code C0 for sleep medicine.

Effective date: April 1, 2012

Implementation date: October 1, 2012

View the Claims Processing Manual transmittal.

View the Medicare Financial Management transmittal.

CMS issues transmittal on hospital dialysis services for patients with/without ESRD

On April 26, CMS issued a transmittal that provides guidance on billing for dialysis services for patients with and without ESRD.

Effective date: October 1, 2012

Implementation date: October 1, 2012

View transmittal R2455CP.

View MLN Matters article MM7762.

CMS issues transmittal on anesthesiologist services with modifier –GC in a Method II CAH

On April 26, CMS issued a transmittal that implements the payment methodology for anesthesiology claims submitted with a GC modifier for CAH Method II providers.

Effective date: January 1, 2010

Implementation date: October 1, 2012

View transmittal R2452CP.

View MLN Matters article MM7764.

Quarterly Updates

Thu, 07 Jun 2012 04:00:00 GMT

There are no quarterly updates in this issue.

Other developments: CMS issues minor edits to ABN instructions form and April 2012 Medicare NCD Coding Policy Manual and Change Report

Thu, 07 Jun 2012 04:00:00 GMT

CMS issues minor edits to ABN instructions form

On April 19, CMS issued an update stating that minor edits have been made in the ABN instructions to clarify that the provider/supplier is responsible for inserting wording in all of the blanks labeled “D” on the notice including the “D” blanks that are within the “Options” section. Please click the link in the list below to download the updated ABN instructions.

View the updated instructions.

CMS issues April 2012 Medicare NCD Coding Policy Manual and Change Report

On April 27, CMS issued the Medicare national coverage determinations (NCD) Coding Policy and Manual Change Report for clinical diagnostic laboratory services for April 2012.

View the report.

Events: June 5 Physicians, Nurses and Allied Health Professionals Open Door Forum transcript and audio

Thu, 07 Jun 2012 04:00:00 GMT

The transcript and audio of the Physician Nurses & Allied Health Open Door Forum (ODF) conference call held June 5 will be provided when it becomes available.

View the Open Door Forum archive.

Regulations: CMS issues final rule corrections and more

Wed, 06 Jun 2012 04:00:00 GMT

CMS issues correction to Affordable Insurance Exchanges final rule

On May 29, CMS issued a correction in the Federal Register to the final rule that implements the new Affordable Insurance Exchanges, consistent with the Affordable Care Act.

View the correction.

CMS issues final rule on provider and supplier enrollment, ordering and referring, and documentation requirements

On April 27, CMS issued in the Federal Register a final rule that finalizes several provisions of the Affordable Care Act, including the requirement of all providers of medical or other items or services and suppliers that qualify for a National Provider Identifier (NPI) to include their NPI on all applications to enroll in the Medicare and Medicaid programs and on all claims for payment submitted under the Medicare and Medicaid programs.

View the final rule.

CMS issues corrections to 2012 OPPS final rule

On April 24, CMS issued in the Federal Register technical corrections to the 2012 OPPS final rule.

View the corrections here.

Note from Peggy: Changes to CMS' website are not all good

Thu, 03 May 2012 04:00:00 GMT

CMS has done a lot of restructuring to their website recently. I can’t speak about all of the revisions they have made, but I can address the functionality of the Transmittals page. It is a change, to be sure, but I certainly would not call it an improvement. I read every transmittal that CMS releases, and trust me, there are a lot of them every year. I try to do this a couple times a month, but sometimes a whole month goes by before I can get to it. When that happens, I know it will take an entire day, or more, to read through the new list of transmittals.

Continue reading Peggy's note at the Medicare Mentor blog

Regulations: CMS proposes one-year delay of ICD-10-CM/PCS, issues final rule on provider and supplier enrollment, ordering and referring, and documentation requirements, issues corrections to 2012 OPPS rule, and more

Thu, 03 May 2012 04:00:00 GMT

CMS issues final rule on provider and supplier enrollment, ordering and referring, and documentation requirements

View the final rule.

CMS issues corrections to 2012 OPPS final rule

On April 24, CMS issued in the Federal Register technical corrections to the 2012 OPPS final rule.

View the corrections here.

CMS issues technical corrections to EHR Incentive Program—Stage 2 proposed rule

On April 18, CMS issued technical and typographical errors to the proposed rule entitled ‘‘Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 2’’ which appeared in the March 7, 2012.

View the corrections.

HHS issues administrative simplification proposed rule

On April 17, HHS issued a proposed rule in the Federal Register that would implement section 1104 of the Affordable Care Act by establishing new requirements for administrative transactions that would improve the utility of the existing HIPAA transactions and reduce administrative burdens and costs. This rule also proposes to change the official compliance date for ICD-10 from October 1, 2013 to October 1, 2014.

View the proposed rule.

View an HCPro article on the ICD-10 delay.

Submit a comment.

CMS proposes one-year delay of ICD-10-CM/PCS

On April 9, CMS released a proposed rule announcing a one-year delay of the implementation of ICD-10-CM/PCS. If finalized, ICD-10 would become effective October 1, 2014.

View the display copy of the proposed rule

View the HCPro article

View the associated fact sheet

View the associated press release

CMS makes changes to the Medicare Advantage and prescription drug benefit

On April 12, CMS issued a final rule that revises the Medicare Advantage program regulations and prescription drug benefit program regulations to implement new statutory requirements; strengthen beneficiary protections; exclude plan participants that perform poorly; improve program efficiencies; and clarify program requirements. It also responds to public comments regarding the long-term care facility conditions of participation pertaining to pharmacy services.

View the final rule

Transmittals/MLN Matters articles:

Thu, 03 May 2012 04:00:00 GMT

CMS revises "incident to" transmittal

On April 4, CMS rescinded Transmittal 2368 dated December 15, 2011, and replaced it with Transmittal 2437. The new transmittal corrects language in Chapter 17, section 20.1.3, paragraph three of the Medicare Claims Processing Manual, specifically it changes the effective date of the flu season from September 1 to August 1 and to changes “this file” to “payment allowance limits.” All other material remains the same.

Effective Date: January 1, 2013

Implementation Date: January 1, 2013

View the transmittal

CMS continues updates to Program Integrity Manual

CMS issued two transmittals this past week that continue its process of updating chapter 15 of the Program Integrity Manual.

View the April 6 transmittal

View the April 13 transmittal

CMS adds new test to list of CLIA waived tests

On April 6, CMS issued two transmittals that update the CLIA waived test list. CMS issued a second transmittal on the same date to add a test that was not included in the original transmittal (86386QW Nuclear Matrix Protein 22 (NMP22), qualitative).

Effective Date: January 1, 2012

Implementation Date: July 2, 2012

View the transmittal

CMS offers guidance for correct claims submission when secondary payers are involved

On April 11, CMS issued a special edition MLN Matters article that explains how providers should bill services for Medicare beneficiaries with secondary insurance.

View the special edition MLN Matters article

Quarterly updates: CMS updates Part B drug pricing files

Thu, 03 May 2012 04:00:00 GMT

CMS updates Part B drug pricing files

On April 6, CMS issued a transmittal to make its regular update to the average sales price (ASP) drug pricing files under Part B.

Effective Date: July1, 2012

Implementation Date: July2, 2012

View the transmittal

Other developments: OIG issues review of Medicare outpatient billing for selected drugs at Catskill Regional Medical Center, issues report on claim modifier ?KX, and more

Thu, 03 May 2012 04:00:00 GMT

OIG issues review of Medicare outpatient billing for selected drugs at Catskill Regional Medical Center

The OIG reviewed Medicare payments made to Catskill Regional Medical Center, located in Harris, NY, for line items for injections of selected drugs that the hospital billed to Medicare from January 1, 2008 through April 30, 2011. The OIG showed that Catskill received overpayments totaling $78,000 due to the following errors:

For five line items, Catskill billed the incorrect number of units of service
For two line items, Catskill used the incorrect HCPCS code
For one line item, Catskill billed for a drug that was not administered

View the report

OIG issues report on claim modifier –KX

On April 20, the OIG issued a report on the –KX modifier, which indicates that a claim meets Medicare coverage criteria and the supplier has the required documentation on file. The report found that the modifier is not effective in ensuring that suppliers of DMEPOS that submitted Medicare claims had the required supporting documentation on file and the OIG estimates that contractors paid approximately $316.4 million to suppliers that did not have the required documentation on file to support the DMEPOS items with 2007 dates of service.

View the OIG report.

CMS issues minor edits to ABN instructions form

View the updated instructions.

CMS issues April 2012 Medicare NCD Coding Policy Manual and Change Report

On April 27, CMS issued the Medicare national coverage determinations (NCD) Coding Policy and Manual Change Report for clinical diagnostic laboratory services for April 2012.

View the report.

Events: June 5 Physicians, Nurses and Allied Health Professionals Open Door Forum

Thu, 03 May 2012 04:00:00 GMT

The next Physician, Nurses and Allied Health Professionals Open Door Forum is scheduled for Tuesday, June 5, 2012 from 2 p.m. - 3 p.m. ET. To participate, dial 1-800-837-1935 conference ID 52260476.

Note from Peggy: March 2012 update to the Medicare Physician Fee Schedule

Thu, 05 Apr 2012 04:00:00 GMT

As expected, Congress finally passed legislation saving physicians from the drastic reduction in the Medicare Physician Fee Schedule conversion factor that was supposed to take place on January 1, 2012 and then postponed until March 1, 2012. Now that the Middle Class Tax Relief and Job Creation Act (MCTRJCA) of 2012 has been signed into law we can expect the conversion factor to remain at $34.0376 for the remainder of 2012.

Continue reading Peggy's note at the Medicare Mentor blog