Industry News

To help you stay up-to-date with the constant changes in medical billing, XIFIN compiles and publishes these articles, which cover the most important topics in the medical billing industry. Please check back as new articles are added each month.

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To help you stay up-to-date with the constant changes in medical billing, XIFIN compiles and publishes these articles, which cover the most important topics in the medical billing industry. Please check back as new articles are added each month.

For 2013, CMS used the gapfilling methodology to establish payment rates for the approximately 114 new Molecular Pathology CPT codes. The gapfilling process requires the Medicare Administrative Contractors (MACs) to set payment rates using a broad range of information. The MACs forwarded their interim carrier-specific payment amounts to CMS.

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Important Announcement on April 25, 2013: Temporary Delay in Implementing Ordering and Referring Denial Edits – Due to technical issues, the implementation of the Phase 2 denial edits is being delayed.

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CMS implemented date of service (DOS) medical unlikely edits (MUEs) for some Healthcare Common Procedure Coding System (HCPCS) and CPT codes effective April 1, 2013. CMS is converting some claim line MUEs to DOS MUEs.

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For transaction 835 (Health Care Claim Payment/Advice) and standard paper remittance advice, valid Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) must be used to report payment adjustments, appeal rights, and related information. The following are the new RARC codes.

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This National Provider Call will cover how to obtain an Individuals Authorized Access to the CMS Computer Services (IACS) account in order for (1) physician group practices to select their CY 2013 Physician Quality Reporting System (PQRS) Group Reporting Mechanism, and if applicable, elect quality tiering to calculate their CY 2015 Value-based P

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During 2011, Medicare incorrectly denied a group of claims as Medically Unlikely. These claims were denied with an indicator of either 51MUE or 52MUE, although most of the denials during this period of time with those indicators were properly processed.

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The CMS website offers resources for providers, payers, and vendors to help prepare for the transition to ICD-10. Resources provide tips and advice on how to plan and execute your transition to ICD-10, including timelines, checklists, and fact sheets.

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With the October 1, 2014, ICD-10 deadline approaching, you may be wondering how you will code a claim that you are submitting in October 2014 for a service that your practice provided in September 2014.

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Noridian is the new Medicare Administrative Contractor (MAC) for Jurisdiction E (JE) – formerly Jurisdiction 1; California, Hawaii, Nevada (transition date 9/16/2013). As they begin the process of implementing the JE workload, they want to inform you of important changes that may impact you.

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Effective May 13, 2013 Noridian Administrative Services (NAS) has officially changed its name to Noridian Healthcare Solutions (Noridian) to better reflect the scope of capabilities that have grown from their core business.

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CMS has awarded the J6 A/B MAC contract for the administration of the Part A and Part B Medicare fee-for-service claims in the states of Illinois, Minnesota, and Wisconsin to National Government Services, Inc. National Government Services Jurisdiction 6 MAC transition Web site has been launched.

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Independent laboratories (specialty 69) have received denials for diagnostic laboratory services provided in an ambulatory surgical center (ASC) (place of service 24), for claims processed on or before March 4, 2013.

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Because the MoPath Tier 2 CPT code descriptions do NOT identify the specific genes tested, laboratory providers that have not obtained a unique 5-digit ID through Palmetto GBA or McKesson Dex must provide additional information until an ID is obtained. As per the MolDx Program, claims submitted in J1 without a unique ID will be denied.

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CMS announced sequestration reductions to Medicare payments to physicians, facilities and other healthcare professionals. UnitedHealthcare intends to implement these reductions to physician, facility, ancillary provider and other health care professional payments from its Medicare Advantage plans.

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UnitedHealth is facing scores of complaints, including long backlogs for members to reach customer service and delays in providers obtaining referrals, since taking over a huge $20 billion contra

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The following changes will apply to professional (nonfacility) claims submitted for Humana commercial fully insured and select self-funded* members, as well as Medicare Advantage (MA) Health Maintenance Organization (HMO), Preferred Provider Organization (PPO) and Private Fee-for-Service (PFFS) members, as indicated below:

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You’ll find the latest information about procedure codes and Blue Cross Blue Shield of Michigan billing guidelines in the following chart. Procedures that have changed a billing guideline or added a new payable group will appear under Updates to Payable Procedures.

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Mississippi State Medical Association (MSMA) has learned that effective May 15, 2013, BCBS  Mississippi  will reduce provider payments by up to 25% for certain procedures, specifically radiology and pathology procedures. MSMA has repeatedly attempted to contact BCBS officials to request a meeting and to obtain additional informa

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A system error caused duplicate Medicare Supplement claim payments to be issued to providers who submitted corrected claims intended to replace previously processed claims.  Typically, BCBSNC just reverses and cancels out the first claim received, and reprocess the corrected claim for an additional payment or refund request.  However, when corre

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A reimbursement error caused coinsurance amounts to be reduced by 2 percent on a number of professional claims for beneficiaries enrolled in Anthem Medicare Supplemental plans (alpha prefix YTM).  The reimbursement error resulted in a shortage in payment for certain Medicare Supplemental claims with dates of service on or after April 1, 2013.

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Due to the increased demand of preliminary drug screens performed in the clinic setting, MO HealthNet has added coverage of procedure code G0434, “Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter”.

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  • Radiology: Diagnostic Radiology (Diagnostic Imaging): Spine and Pelvis

72040 Radiologic examination, spine, cervical; 2 or 3 views

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As the Oct. 1, 2014, implementation deadline for ICD-10 draws closer, legislation was introduced in the U.S. House of Representatives to bar the federal government from rolling out the new code set. The Cutting Costly Codes Act, introduced by Rep. Ted Poe, R-Texas, would prohibit the U.S.

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CMS expanded the MPPR by applying a reduction to professional component (PC) services. Full payment is made for each PC and technical component (TC) service with the highest payment under the MPFS. Payment is made at 75 percent for subsequent PC services furnished by the same physician to the same patient in the same session on the same day.

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Medicare believes that the evidence is adequate to conclude that MRIs improve health outcomes for Medicare beneficiaries with implanted Pacemakers (PMs) when the PMs are used according to the FDA-approved labeling for use in an MRI environment.

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The Legislature adopted a 10% Medi-Cal provider rate reduction that was to have taken effect on June 1, 2011 as part of the budget deal to close the then state budget deficit for 2011-12. Due to delays in CMS approval and a subsequent Federal  Court injunction that rate cut was never implemented for radiology services.

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A service-specific probe review was completed for CPT code 83036 glycated hemoglobin (A1C) for specialty 69 (Independent Clinical Lab). Major issues identified were documentation not received and services not medically reasonable or necessary. WPS Medicare must receive the documentation requested within 45 days or we will deny the service.

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Transmittal 2613, dated December 14, 2012, is being rescinded and replaced by Transmittal 2679, dated March 29, 2013, to indicate that clarification on the place of service for pathology and laboratory services will be provided through another Change Request.

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The Department of the Treasury has notified the Department of Health and Human Services that the private consumer rate has been changed to 10.125 percent effective April 17, 2013, for Medicare overpayments and underpayments.

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An updated Remittance Advice Remark Code (RARC) and Claim Adjustment Reason Code (CARC) “Codes.ini” file is now available to import into the current version of MREP (3.3).  A new version of the software is not being released at this time.  In order to download the most current “Codes.ini” file you must click on the following link

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