Medicare

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:

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.

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