Medicare

CMS Proposes Changes to Evaluation & Management Requirements

It is no secret that providers have long argued that E/M coding is burdensome and does not truly reflect the services provided. This fact is acknowledged by CMS with the following statement "Prior attempts to revise the E/M guidelines were unsuccessful or resulted in additional complexity due to lack of ...

Dual Medicare-Medicaid Billing Problems

It is important to keep in mind that Medicaid is run at a state level so there can be some differences when it comes to coverage. However, the rules regarding balance billing of covered services is set at the federal level. The law states (emphasis added):

Small Practices are Affected by MIPS Increased Thresholds

We recently heard about a small practice that had been faithfully submitting all the required “G” codes for the Quality Payment Program (QPP) only to discover that for 2018 they are excluded from MIPS because the low volume threshold increased from $30,000 in Part B allowed charges or 100 Part B beneficiaries to $90,000 in Part B allowed charges or 200 Part B beneficiaries. They were unsure about what they needed to do at this point and how it would impact their practice.

We recently heard about a small practice that had been faithfully submitting all the required “G” codes for the Quality Payment Program (QPP) only to discover that for 2018 they are excluded from MIPS because the low volume threshold increased from $30,000 in Part B allowed charges or 100 Part B beneficiaries to $90,000 in Part B allowed charges or 200 Part B beneficiaries. They were unsure about what they needed to do at this point and how it would impact their practice.

How Does the Physician Compare Website Affect You?

The physician compare website may not be working quite the way you think it is. Not all providers will have rankings showing up for them. Physician compare lists basic information, but quality measure information was not added until this year (2018) and not all quality measures are included in the Star Rating system. Additionally, patient surveys are also sent out and those are an additional rating.

Inappropriate Use of Units Costs Practice Over $800,000

A recent OIG enforcement action emphasizes the need to understand the proper use of units. A healthcare provider in Connecticut submitted multiple units for urine drug screening tests. The press release stated that "Urine drug screening tests use a single sample of a patient’s urine to test for multiple classes of drugs. Although the test screens a patient’s urine for multiple classes of drugs, Medicare considers it a single test that should be billed only once per patient encounter."

PSAVE Pilot Program - What Does it Mean to You?

Noridian, the Jurisdiction F Medicare Administrative Contractor (MAC), recently announced that they will be extending their pilot program: Provider Self-Audit with Validation and Extrapolation (PSAVE). Whenever a program is extended, that means that it has been successful for the payer, which likely means that they are saving money. It doesn’t state precisely HOW they are saving money. Historically, when a pilot program is proven to be successful, it isn’t too long before other MACs follow. Before signing up to participate, providers need to carefully evaluate the program.

MLN released information stating they have eliminated the requirement to use modifier GT on Telehealth services.

As a result of eliminating the need for the GT modifier Medicare now requires the use of a POS Code 02 to describe services furnished via telehealth.

Preventive Medicine: Coding and Billing Information

This is an educational tool, not meant to be viewed as coding or billing guidelines.
Preventive Medicine Coding and Billing Info
Telehealth applicable codes will be indicated with a phone icon. 
(Click on a topic to view the information or scroll down to view all topics)

Documentation for Home Health Services (Part A non DRG)

The Medical Learning Network provides coverage guidance, which should be documented, for home health services.

Regarding inadequate physician certification/re-certification

Physicians or Medicare allowed NPPs must certify that:

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