Medicare / modifier 76 / modifier 77 / modifier GD / Provider News

Medicare Medically Unlikely Edits MythBuster Stops Practice Pay Losses

Medically unlikely edits ignorance could be causing you medical coding claim  denials.

Ensure you’re not letting medically unlikely edits (MUEs) wreak havoc on your urology practice’s coding and reimbursement by uncovering the truth about four aspects of these edits.

Myth 1: MUE Edits Don’t Affect Your Practice

Some practices feel that they don’t need to worry about MUEs.

Reality: “They limit the frequency a CPT code can be used,” says Chandra L. Hines, business office manager at Capital Urological Associates in Raleigh, N.C. “With our specialty of urology, we need to become aware of the denials and not let every denial go because the insurance company said it was an MUE. We should all be aware of MUEs as they occur, and we cannot always control whether or not we will receive payment.”

The MUE list includes specific CPT or HCPCS codes, followed by the number of units that CMS will pay. CMS developed the MUEs to reduce paid claims error rates in the Medicare Program. The first edits were implemented in January 2007, although some of the edits themselves became public in October 2008.

Some MUEs deal with anatomical impossibilities while others edit automatically the number of units of service you can bill for a service in any 24-hour period. Still others limit codes according to CMS policy. For example, excision of a hydrocele, bilateral (55041) has a bilateral indicator of “2,” so you should never bill two or more units of this code. Additional edits focus on the nature of the equipment for testing, the study or procedure, or pathology specimen.

Anatomical example: The MUEs edit out and deny an erroneously coded claim for a circumcision (54161, Circumcision, surgical excision other than clamp, device or dorsal slit; older than 28 days of age) for a patient...

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October 15, 2010
CMS / Provider News

CPT 99406, 99407 Coverage Extended to All Smokers

CMS announcement is triumph for physicians who haven’t collected in the past. If you’ve been writing off tobacco cessation counseling as non-payable, it’s time to change your tune. In the past, CMS only covered 99406-99407 (Smoking and tobacco us...

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August 31, 2010
CMS / Provider News

Medical Record Retention: How Long Should You Keep Patient Charts?

CMS says keep patient medical records for 6 years. Medical practices often hear conflicting advice regarding how long they must hang on to a patient’s medical records, but CMS intends to clear up any misinformation with new MLN Matters article SE1022...

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August 25, 2010
CMS / Hot Coding Topics / ICD-10

Watch for Denials If You Take Shortcuts on Form 5010

Say goodbye to form 4010A1 for ICD codes as well, starting in 2012.

Dig into your claim forms now to ensure that the beneficiary’s information is accurate to the letter, or you’ll face scores of denied claims on the new HIPAA 5010 forms.

Why it matters: CMS will deny claims on which the beneficiary’s name doesn’t perfectly match how it’s listed on his Medicare I.D. card when you begin using HIPAA 5010 form — the new Medicare universal claim form starting in 2012.

Include Jr. or Sr. Suffixes

“Whenever there is a name suffix, such as ‘Jr.’ or ‘Sr.’ abbreviations, etc., it must be included with the last name,” said Veronica Harshman of CMS’s Division of Medicare Billing Procedures during an April 28 Open Door Forum regarding the eligibility component of the HIPAA 5010 form.

You can include the suffix either with the patient’s last name or in the suffix field, specified CMS’s Chris Stahlecker during the call.

“The date of birth must also match exactly to what the Social Security Administration has on file,” Harshman said. CMS will use several new error codes on claims once the 5010 form goes into effect. “If you communicate with CMS through a third-party vendor (clearinghouse), it is strongly recommended that you discuss with them how these errors will be communicated to you and how these changes will impact you and your business,” Harshman advised.

Look for Production Systems Next Year

According to the HIPAA 5010 Final Rule, CMS will have a production 5010 system available as of Jan. 1, 2011, Harshman said.

The last day CMS will accept a 4010A1 form will be Dec. 31, 2011. As of Jan. 1, 2012, if you aren’t using the 5010 form, you’ll “lose the ability to receive eligibility data from Medicare,” Harshman said. In...

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August 12, 2010
CMS / Provider News

Proposed 2011 Fee Schedule Offers Vast Benefits for Primary Care Practices

CMS adds Obama recs into next year’s fee schedule.

The President signed the Patient Protection and Affordable Care Act (PPACA) into law on March 23, but many practices haven’t yet noticed significant impacts from the legislation. In 2011, however, you could see huge boosts from it, because CMS has proposed incorporating many of the law’s features into next year’s Physician Fee Schedule.

On June 25, CMS released its proposed Physician Fee Schedule for 2011. The 1,250-page document, which will be published in the July 13 Federal Register, offers several advantages to medical practices, including bonuses for primary care physicians. “Improving access to preventive services and primary care is a top priority for HHS,” said HHS Secretary Kathleen Sebelius in a June 25 statement. “The proposed rule is just one part of a broader effort we are making to improve the health status of Medicare beneficiaries.”

According to the proposal, primary care practitioners will benefit from a 10 percent bonus starting on January 1, as prescribed in the PPACA.

Practitioners who qualify will be doctors, nurse practitioners, clinical nurse specialists, or physician assistants with the primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatrics.

To qualify for the 10 percent bonus, the law stipulates that the primary care practitioners will have to bill at least 60 percent of their allowed charges as ‘primary care services,’ which are defined by E/M codes 99201-99215, nursing facility or rest home care codes 99304-99340, or home services codes 99341-99350.

“The rule we are proposing today is just one part of the Administration’s efforts to improve the health status of Medicare beneficiaries by expanding access to preventive services, and promoting early detection and prompt treatment of medical conditions,” said Jonathan Blum, deputy administrator and director of CMS’s Center for Medicare, in a...

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August 10, 2010
CMS / Hot Coding Topics / ICD-10

Heads Up Coders: 2013 ICD-10 Implementation Date Is Firm

Plus: CMS has proposed freezing the ICD-9 codeset after next year.

If you were hoping that the Oct. 1, 2013 ICD-10 implementation date wasn’t set in stone, you are out of luck. That’s the word from CMS during a June 15 CMS Open Door Forum entitled “ICD-10 Implementation in a 5010 Environment.”

“There will be no delays on this implementation period, and no grace period,” said Pat Brooks, RHIA, with CMS’s Hospital and Ambulatory Policy Group, during the call. “A number of you have contacted us about rumors you’ve heard about postponement of that date or changes to that date, but I can assure you that that is a firm implementation date,” she stressed.

Brooks indicated that the rumor about a potential delay in the implementation date continues to persist throughout the physician community, and recommended that practice managers alert their physicians to the fact that that the rumor is untrue.

The Oct. 1, 2013 date will be in effect for both inpatient and outpatient services. Keep in mind that the ICD-10 implementation will have no impact on CPT and HCPCS coding, Brooks said. You will still continue to bill your CPT and HCPCS procedure codes as before.

You’ll Find Nearly 55,000 Additional Codes

Currently, CMS publishes about 14,000 ICD-9 codes, but there are over 69,000 ICD-10 codes. The additional codes will allow you to provide greater detail in describing diagnoses and procedures, Brooks said.

If you’re wondering which specific codes ICD-10 includes for your specialty, you can check out the entire 2010 ICD-10 codeset, which CMS has posted on its Web site. “Later this year, we’ll be posting the 2011 update,” Brooks said during the call.

@ For more details on CMS’ upcoming plans, subscribe to Part B Insider (Editor: Torrey Kim, CPC).

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June 18, 2010
Medicare / Toolkit

Chiropractic Coding: Avoid This Common Documentation Mistake

Treatment plans are a must, experts say.

You’ve treated your chiropractic patient, you’ve selected the correct codes, and you’ve submitted your claim. All set, right? Not quite. Check out this common mistake that chiropractors make.

“Many chiropractors do not create written chiropractic treatment plans for every new patient,” says Marty Kotlar, DC, CHCC, CBCS, president of Target Coding, a chiropractic coding and billing consulting firm. Use this checklist to ensure you send Medicare the information CMS most wants to see included “with every new patient plan of care,” Kotlar says:

__ The history
__ Present illness
__ Family history
__ The past health history
__ The physical examination
__ The diagnosis
__ The plan — This should include:

  • Therapeutic modalities to effect cure or relief (patient education and exercise training)
  • The level of care that is recommended (the duration and frequency of visits)
  • Specific goals that are to be achieved with treatment
  • The objective measures that will be used to evaluate the effectiveness of treatment
  • Date of initial treatment.

__ Signature/initials to authenticate the records.

@ Part B Insider (Editor: Torrey Kim, CPC).

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June 8, 2010
Cardiology / CMS / MAC / Provider News

MACs Differ on Response to CMS’s Cardiology Payment Adjustments

Don’t look for a raise just yet, in most cases.

CMS may talk, but MACs don’t always listen — at least not quickly.

As we told you in last week’s Insider, CMS recently corrected several “technical errors” published in the 2010 Fee Schedule, and thanks to these corrections, Medicare will increase payment for several cardiology-related testing codes, including codes 75571-75574 (Heart CT) and 78451-78454 (Heart muscle SPECT imaging).

Although many practices are eager to see the payment boosts in their next Medicare payments, that may be an overly ambitious goal at this point.

“I inquired with a few MAC carriers such as Trailblazer, Noridian, and Palmetto, and was told different things by different Medicare payers,” says Terry Fletcher, BS, CPC, CCS-P, CCS, CMSCS, CCC, CEMS, CMS, CEO of Terry Fletcher Consulting Inc.

“One did not even know there was a change,” she says. “Next, Noridian said that they will be making the adjustments when they get the directive from CMS. And Palmetto said they would need the provider to contact them and then batch retroactive to January the myocardial perfusion imaging claims and send a letter to request the increase,” she says.

Bottom line: Until CMS provides a clear answer to the MACs regarding when they must implement the changes, you may not see your pay increases, but keep an eye on your carrier’s Web site for information on when it intends to reprocess claims using the new rates.

@ Part B Insider. Editor: Torrey Kim, CPC

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May 27, 2010
CCI / Medicare / NCCI / Provider News

2 Reasons to Think Twice Before Reporting 78070 With 78803

Sometimes CCI compliance requires looking beyond the edit pairs.

Correct Coding Initiative (CCI) edits don’t bundle SPECT (78803) and planar (78070) parathyroid imaging codes, but coding experts often tell you not to code the two together for SPECT and planar parathyroid imaging on the same date.

Add some method to this madness by looking at the information offered by two coding resources, the Society of Nuclear Medicine (SNM) and the NCCI Policy Manual for Medicare Services (CCI Manual).

1. SNM Singles Out 78803

SNM’s online Practice Management Coding Corner features a Q&A that recommends reporting 78070 (Parathyroid imaging) for planar imaging alone, but 78803 (Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent[s]; tomographic) for parathyroid SPECT imaging with or without planar, says Jackie Miller, RHIA, CCS-P, CPC, vice president of product development for Coding Metrix Inc. in Powder Springs, Ga.

Support: “Choose the single code that describes the protocol and procedure performed,” states the Q&A, located at http://interactive.snm.org/index.cfm?PageID=2442&RPID=1995. SNM “would NOT recommend coding both CPT codes,” the article notes.

2. CCI Makes the Case for SPECT Code

Although there is notyou won’t find any a specific edit bundling 78070 and 78803, CCI does address the SPECT/planar issue in the CCI Manual, says Miller.

CCI Manual, Chapter 9, Section E.2, explains that you may not report a SPECT study and planar study of the same limited area because “Single photon emission computed tomography (SPECT) studies represent an enhanced methodology over standard planar nuclear imaging. When a limited anatomic area is studied, there is no additional information procured by obtaining both planar and SPECT studies.”

Bonus tip: The manual indicates you may report both planar and SPECT codes only when the size of the scanned area makes both sets necessary, such as with whole body bone scans with...

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May 25, 2010
Hot Coding Topics / Medicare

Examine These FAQ to Sort Your Medicare Cancer Screen Codes

Remember frequency rules differ for average, high risk.

Getting Medicare to pony up for colorectal cancer screenings is not difficult provided you follow its frequency guidelines and eligibility requirements to the letter. A coding slip up on one of these items will knock you out of the saddle, and Medicare won’t accept the claim at all.

Rope in all the coding info you’ll need via this Medicare colorectal cancer screening FAQ.

Who’s Eligible for Average-Risk Test?

If the Medicare patient is 50-plus years old, he is eligible for a covered Medicare screening, confirms Dena Rumisek, CPC, biller at Michigan’s Grand River Gastroenterology PC.

However: These patients are considered average risk, and can have a colorectal cancer screening only once every 10 years, says Cheryl Ray, CCS, CPMA, of Atlantic Gastroenterology in Greenville, N.C. Ignore Medicare’s frequency guidelines at your peril, experts warn.

“Medicare is very stringent on the date … it has to be 10 years or longer — it can’t be 9 years and 360 days,” between covered screening colonoscopies, assures Rumisek.

Example: A 68-year-old established Medicare patient reports for a screening colonoscopy on Dec. 5, 2009. The patient’s records indicate that he last had a covered screening on Sept. 15, 1998. On the claim, you should report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).

What ICD-9 Codes Are In Play for G0121?

Just one, provided there is no need for any therapeutic intervention during the colonoscopy. Medicare requires V76.51 (Special screening for malignant neoplasms; colon) on all G0121 claims. You might list other identified conditions secondarily, including diverticulosis (562.10) or hemorrhoids (455.0).

Always list the V code first for an average-risk screening, however.

What if the Patient Had a Recent Flexible Sig?

The frequency rules differ depending on whether other related...

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May 25, 2010
Audit / CMS / Oig / RAC / Toolkit

Recovery Audit Contractors: Know These RAC Fast Facts

RACs are just another tool in the government’s arsenal to collect improper payments.

You’ve got so many compliance acronyms flying at you every day that you may not be able to differentiate your RAC from the OIG. Know these quick facts about RACs to stay better informed.

  • Recovery audit contractors (RACs) detect and correct past improper payments so CMS and the MACs can prevent such problems in the future
  • RACs are hired as contractors by the government, and they can can collect “contingency fees,” which means that they get a percentage of the amount that they recover from providers who were paid inappropriately The maximum RAC lookback period is three years, and they cannot review claims paid prior to Oct. 1, 2007
  • Between 2005 and 2008, RACs involved in the original demonstration project recovered over $1.03 billion in Medicare improper payments, but referred only two cases of potential fraud to CMS, according to a February OIG report on the topic, which noted that “because RACs do not receive their contingency fees for cases they refer that are determined to be fraud, there may be a disincentive for RACs to refer potential cases of fraud.”
  • Unlike RACs, the OIG is a government entity. Although the OIG also performs reviews and audits and seeks improper payments, the OIG does not collect contingency fees.

For more on the RAC program, visit www.cms.gov/rac.

@ Part B Insider. Editor: Torrey Kim, CPC

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May 24, 2010
Medicare / Oig / Provider News

Cost of Freezing Conversion Factor is Over $6 Billion — Just for 2010

Plus: The OIG recovered over $1.5 billion in fiscal year 2009, and is on the lookout to collect more.

With less than two weeks to go before Medicare payments once again threaten to decrease by 21 percent, a new report sheds light on the financial outcome of Congressional actions.

Although the 2010 Physician Fee Schedule originally included a conversion factor that would have been 21 percent lower than the 2009 level, practices haven’t felt that cut yet this year,because legislators have voted several times to freeze payments, which now use the conversion factor of $36.0791. That freeze will expire on May 31, after which your Medicare payments will drop considerably unless Congress steps in once more.

However, one government entity’s calculations show that the freeze is costly. According to a May 7 Congressional Budget Office report, freezing payments at the current levels for the rest of 2010 would cost the government… … $6.5 billion. The AMA has turned up the heat on Congress to replace the current payment method, releasing a print ad aimed at Congress to demonstrate that “more delays of permanent reform now increase the cost for taxpayers,” and that the association “calls on Congress to fix the flawed Medicare physician payment formula now.”

Congress has not yet introduced a bill to extend the payment freeze past May 31. Keep an eye on the Insider for more information as this story develops.

To read the Congressional Budget Office’s calculation sheet,visit www.cbo.gov/budget/factsheets/2010b/SGR-menu.pdf.

@ Part B Insider. Editor: Torrey Kim, CPC

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May 24, 2010
Medicare / Toolkit

Recognize a Write-Off in 6 Steps

Save this option for when other collection methods have failed.

You’ve offered discounts, payment plans, and more,but you still haven’t received payment from a patient. You may be forced to do a write-off at this point, says Steve Verno, CMMC,...

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May 9, 2010