As you should know, the CERT program consists of a random sample of Medicare claims selected each month which undergo an independent medical review process whereby the claims data are adjudicated against the medical records of the physician/provider. The results are analyzed and used to produce annualized estimates of the dollars paid incorrectly for each of the 15 Medicare Jurisdictions as well...
The President has signed the Department of Defense Appropriations Act of 2010, which provides for a zero percent (0%) update to the 2010 Medicare Physician Fee Schedule (MPFS) for a two month period, January 1, 2010, through February 28, 2010. CMS has instructed its contractors to hold claims for services paid under the MPFS for up to the first 10 business days of January (January 1 through...
Recently, WPS Medicare began seeing a dramatic increase in the number of providers experiencing claim denials when the provider submits claims past the timely filing limit for submitting claims. Although WPS Medicare recognizes that many providers must submit claims after Medicare's timely filing limit due to circumstances beyond their control, WPS Medicare must deny any claim submitted after the...
Decision Summary CMS has determined that the evidence is adequate to conclude that screening for HIV infection, which is recommended with a grade of A by the U.S. Preventive Services Task Force (USPSTF) for certain individuals, is reasonable and necessary for early detection of HIV and is appropriate for individuals entitled to benefits under Part A or enrolled under Part B. Therefore CMS will...
Effective January 1, 2010, consultation codes (99241-99245 and 99251-99255) are no longer recognized for Medicare Part B payment. Physicians shall code patient evaluation and management visit with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed. In the office or other outpatient setting where an evaluation is performed physicians and...
Are you wondering how to find the latest and greatest Medicare resources by subject? The REVISED Guided Pathways (November 2009) booklets incorporate existing Medicare Learning Network (MLN) products and other resources into well organized sections that can help Medicare Fee-for-Service (FFS) providers and suppliers find information to understand and navigate the Medicare Program. These booklets...
MODIFIED Column 1 and Column 2 Code Pairs - Expired 12/31/09 CODE 1 CODE 2 82307 84591 0145T 0144T 0145T 0146T 0145T 0147T 0146T 0144T 0146T 0150T 0147T 0144T 0147T 0146T 0147T 0150T 0148T 0144T 0148T 0145T 0148T 0146T 0148T 0147T 0148T 0150T 0149T 0144T 0149T...
As of July 1, 2010, Medicare contractors will consider, and providers must remember, that the appropriate DOS for the professional component is the actual calendar date that the interpretation was performed. The appropriate DOS for the professional component is the actual calendar date that the interpretation was performed. For example, if the test or technical component was performed on April...
Medicare has identified a recent increase in the number of CERT errors attributed to the lack of physician orders for diagnostic tests. A diagnostic test includes all diagnostic x-ray tests, all diagnostic laboratory tests, and other diagnostic tests furnished to a beneficiary! An “order” is a communication from the treating physician/practitioner requesting that a diagnostic test be performed...
In its Semiannual Report to Congress, the Department of HHS Office of Inspector General (OIG) today announced significant audit, investigation, and evaluation accomplishments for FY 2009. OIG reported savings and expected recoveries of $20.97 billion for all of FY 2009. The following areas pertaining to laboratories were identified in the report: End Stage Renal Disease: Separately Billed...
Effective for dates of service on or after February 1, 2010, the laboratory procedure codes listed below will no longer be split-billable using modifiers 26, TC and ZS. These modifiers will be end-dated effective January 31, 2010, for all laboratory procedure codes that have been defined as non-split-billable. CPT-4 Codes: 80047 – 80076, 80100 – 80103, 80150 – 80299, 80400 – 80440, 80500 – 80502...
Railroad Medicare has incorrectly denied claims for various procedures. The affected claims were processed between October 4 and December 14, 2009 and include CPT Codes 82000-84830; 80048-80076; 85002-85810 and 99840-99842. These codes were denied with the message text: 'M-76-These are non-covered services because this is not deemed a ‘medical necessity’ by the payer.' Railroad Medicare will...
CMS wants to notify affected providers that a Medicare payment provision Allowing Independent Laboratories to Bill for the Technical Component of Physician Pathology Services Furnished to Hospital Patients, will no longer be in effect when the provisions sunset as of December 31, 2009. CMS continues to work with Congress on significant legislation which affects the Medicare program. We believe...
This article was revised on December 11, 2009 to reflect an extension of phase 1 and a delay in implementing phase 2 of CR 6417. All other information remains the same. During Phase 1 (October 5, 2009-April 4, 2010): If the ordering/referring provider is on the claim, Medicare will verify that the ordering/referring provider is in PECOS and is eligible to order/refer in Medicare. If the ordering/...
This Special Open Door Forum will focus on a new reporting option, available for the 2010 PQRI and eRx Incentive Program, known as the Group Practice Reporting Option (GPRO). Group practices that are interested in participating in the GPRO for PQRI and/or the eRx Incentive Program must submit a self-nomination letter to CMS by no later than January 31, 2010. Once a group practice (Tax...
The Agency for Healthcare Research and Quality's (AHRQ) Technology Assessment Program will be posting a draft technology assessment for review on December 16, 2009. This draft is entitled "Update of Horizon Scan Reports of Genetic Tests Currently Available for Clinical Use." If you are interested in reviewing this document, please visit: http://www.ahrq.gov/clinic/ta/tareview.htm. The document...
The Medicaid Integrity Group (MIG) of CMS is required to review Medicaid provider actions, audit claims, and identify over payments. CMS has contracted with Health Integrity, LLC, to conduct audits of providers enrolled with the Nebraska Medical Assistance Program. Beginning in January of 2010, Health Integrity, LLC, will begin auditing providers. The review will include record requests, entrance...
The following updates for the Claim Adjustment Reason Codes (CARC) and Remittance Advice Remark Codes (RARC) take effect January 1, 2010. New Codes – CARC Code Current Narrative Effective Date Per WPC Posting 232 Institutional transfer amount. Note: Applies to Institutional claims only and explains the DRG amount differences when patients care crosses multiple institutions...
WPS Medicare has noted an increase in the number of Comprehensive Error Rate Testing (CERT) errors related to CPT codes 85025 and 85027. Based on review of documentation, either the test administered or the physician order did not support the service billed to Medicare. These codes are defined in CPT® 2009 as: 85025 - Complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and...
CMS is hosting a Listening Session on the 2011 Physician Quality Reporting Initiative (PQRI). The purpose of this listening session is to discuss and solicit feedback on the individual quality measures and measures groups being considered for possible inclusion in the proposed set of quality measures for use in the 2011 PQRI program and key components of the design of the PQRI program, such as...