Medicare

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:

New Bipartisian Budget Act of 2018 Provisions

On February 9, 2018, the Bipartisan Budget Act of 2018 was signed into law. There were some changes which will affect Medicare payments. The following is a brief summary, for a more comprehensive summary see the References.

Whenever there is a high-cost item, CMS has historically evaluated usage to determine appropriateness of billing and this is another example. A Decision Memo was released on February 15, 2018 which included the following changes:

Intensive Outpatient Treatment (IOP)

Intensive Outpatient Programs (IOPs) are considered to be an intermediate level of care which is commonly considered after the patient has been discharged from inpatient care. For some patients and/or conditions they can also provide an effective level of care when hospitalization is not clinically indicated or preferred. The following ...

Psychiatric Partial Hospitalization Programs

BACKGROUND

Health Risk Assessment

Risk Adjustment models are used to calculate risk scores used in predicting average beneficiaries healthcare expenditures. Currently Medicare Advantage and Prescription Drug programs include a risk adjustment as a component of the bidding and payment process to standardize bids, compare bids, and adjust plan payments. If you are not familiar of risk adjustment or HCC codes, it is time to get on board.

60 Day Final Rule

Effective March 14, 2016, the CMS Final Rule regarding the reporting of overpayments took effect. This ruling clarifies the standards that have been unclear for years since the the PPACA created what is called the "60-day rule." The problem has been the unclear standards on what it means to "identify" an overpayment and when the 60 day clock begins running.

Now, the 60-day rule requires anyone who has received an overpayment from either Medicare or Medicaid to report and return the overpayment within the latter of:

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