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XIFIN Billing Newsletter

To help you stay up-to-date with the constant changes in medical billing and reimbursement, XIFIN compiles information and articles that cover important billing-related topics. These proctored articles are an excellent digest of key updates and issues, and are generally published monthly. Information is power. Subscribe to the XIFIN newsletter and get the information and visibility you need, delivered to you every month.

Billing News

  • The Medical Group Management Association (MGMA) recently called on CMS Administrator Seema Verma to immediately release Merit-Based Incentive Payment System (MIPS) eligibility notifications as well as approved vendor lists and hospital or patient-facing status. MACRA’s Quality Payment Program... More
  • When Medicare has determined that an overpayment has occurred, a Demand Letter is issued. Providers are given 30 days from the date of the Demand Letter to pay the requested overpayment amount. Timely payment is needed to avoid interest from accruing. The Demand Letter includes detailed information... More
  • The College of American Pathologists (CAP) selected FIGmd, the leading provider of clinical data registries to specialty societies, to develop the first pathologist-specific clinical data registry, Pathologists Quality Registry. Designed specifically for the practice of pathology, this registry... More
  • Effective February 27, 2017, Novitas Solutions will consider a corrected claim reopening notification satisfied with a corrected Remittance Advice (RA). A Clerical Error Reopening (CER) decision letter will no longer be issued when the reopening determination results in one of the following:... More
  • A new interim rule released Monday delays the expansion and implementation of major bundled payment initiatives and calls into question whether the new White House administration is committed to the programs. In the interim rule (PDF), posted to Monday’s Federal Register, the Centers for Medicare... More
  • The American Clinical Laboratory Association has asked CMS to delay implementation of a new market-based payment system by another year. CMS is aware that labs have encountered technical challenges in reporting the data the agency needs to publish a fee schedule based on private payor rates and... More
  • The Comprehensive Error Rate Testing Program discovered an increase in denials for urine drug testing (UDT) related to substance monitoring and drug abuse testing. The reasons for denials include: insufficient or no documentation to support intent to order the test and/or medical necessity for the... More
  • It has come to the attention of CMS that due to existing logic in the Multi-Carrier System (MCS), claims submitted by providers that are only certified to perform film mammograms with dates of service on or after January 1, 2017 are being rejected when billing for HCPCS code G0202, G0204, or G0206... More
  • The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, requires CMS to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019. A new Medicare Beneficiary Identifier (MBI) will replace the SSN-based Health Insurance Claim Number (HICN) on the new Medicare cards... More
  • This article is to notify providers that WPS GHA is defining what is considered a timely submission of documentation for the corrective action determination. Beginning with any post pay probe that is open on or after March 15, 2017, the provider has 45 days to submit documentation for review (... More
  • Effective for dates of service on or after October 1, 2016, HCPCS code C9744 (ultrasound, abdominal, with contrast) is a new Medi-Cal benefit. Code C9744 is reimbursable with an approved Treatment Authorization Request (TAR) and may be billed in conjunction with modifiers U7 (Medicaid level of care... More
  • CMS has issued two separate MLN Matters articles regarding new CPT code 80305 which became effective on January 1, 2017. CMS MLN Matters MM9946  states claims with dates of service January 1, 2017 are subject to CLIA Edits and only those providers with a CLIA certificate type code of 9, 1, or... More
  • Effective April 1, 2017, the rate for HCPCS code S3620 (newborn metabolic screening panel, includes test kit, postage and the following tests: hemoglobin; electrophoresis; hydroxyprogesterone; 17-D; phenalanine [PKU]; and thyroxine, total) is retroactively updated for two periods of service. The... More
  • The Affordable Care Act established a requirement for all enrolled providers/suppliers to revalidate their Medicare enrollment information under new enrollment screening criteria. CMS has completed its initial round of revalidations and will be resuming regular revalidation cycles. In an effort to... More
  • Effective April 1, 2017, all HUSKY Health medical policies currently in use by Community Health Network of Connecticut, Inc. (CHNCT) to review requests for genetic testing services will be retired. McKesson’s InterQual Molecular Diagnostics Criteria will instead be used, in conjunction with the... More
  • Physicians and non-physician practitioners must use the revised CMS-855O application (Eligible ordering, certifying, and prescribing physicians and other eligible professionals) beginning January 1, 2018. The revised application will be posted on the CMS forms list by early summer. Medicare... More
  • The Indiana Health Coverage Programs (IHCP) has identified a claim processing issue affecting claims with detail line items that require manual pricing processed on or after February 13, 2017. Claim details denied incorrectly for explanation of benefits (EOB) 6000 – The payment has been calculated... More
  • On October 14, HHS finalized its policy implementing the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM) incentive payment provisions in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), collectively referred to as the Quality Payment... More
  • The Indiana Health Coverage Programs (IHCP) currently covers cervical cancer screening services including cytology (Pap smear) and human papillomavirus (HPV) testing, as well as medically necessary services such as the collection of samples, screening by a cytotechnologist, and a physician’s... More
  • The Senate confirmed President Donald Trump's pick to lead the Centers for Medicare and Medicaid Services, the health care agency whose programs Republicans are targeting for overhaul. Seema Verma a health consultant from Indiana who helped design a Medicaid expansion program when Vice President... More
  • The Indiana Health Coverage Programs (IHCP) has identified a claim processing system issue affecting claims for HCPCS codes G0477, G0478, and G0479. These codes were deleted by CMS effective December 31, 2016, but, in error, were not end-dated in CoreMMIS. This error was corrected January 20, 2017... More
  • When a Supplemental Medical Review Contractor (SMRC) or Recovery Audit (RA) contractor identifies improper payments, they notify the provider via a determination letter (also referred to as a review results letter).  They also notify CGS to initiate the overpayment process.  Once CGS is... More
  • Genetic testing for breast cancer aims to help breast cancer patients and their physicians determine whether adjuvant chemotherapy would be beneficial. The BRCA Genetic Mutation Testing for Breast & Ovarian Cancer Susceptibility: Authorization Criteria defines coverage criteria. MHCP allows... More
  • Performant, Region 1 (which includes MI, IN, KY, OH, VT, NH, ME, MA, RI, CT and NY) has received approval from (CMS to begin recovery audit activity. Please visit the Performant website Provider Portal to view the CMS approved issues list or access additional information such as FAQs or Forms and... More
  • Effective immediately, rendering providers are no longer required to list the addresses of all their service locations under their individual provider records in NCTracks. Providers complied with this requirement by submitting a Managed Change Request (MCR) to NCTracks. No further action needs to... More
  • Effective March 1, 2017, First Coast Service Options Inc. (First Coast) no longer issues Part B fully favorable redetermination decision letters. Providers will continue to receive a revised remittance advice that will reflect the change(s) made as a result of the redetermination request that was... More
  • The proposed amendment to the State Plan will allow members to access genetic counseling after genetic testing has found that a member displays clinical features of a suspected genetic condition, is at direct risk of inheriting the genetic condition in question, or has been diagnosed with a... More
  • Effective March 1, 2017, hospitals submitting claims (5010A1-837I) for molecular tests must first register in the Diagnostics Exchange. Once registered, hospital laboratories must enter the molecular tests they perform (See Molecular Diagnostic Program (MolDX) (M00106)) for applicable CPT codes (... More
  • Molecular pathology services, including genetic testing, are rapidly becoming the standard of care in diagnostic medicine and other related areas. OHCA is committed to ongoing evaluation of the clinical evidence supporting the use of these services to ensure that medically necessary tests and... More
  • National Government Services has seen an increase in claims incorrectly coded with individual codes for molecular biomarkers when five or more gene tests are completed for lung cancer. Correct coding requires that when a panel code applies it should be billed rather than the individual test... More
  • Effective March 1, 2017, outpatient claims for UCare’s State Public Programs (PMAP, MSC+, MinnesotaCare and Special Needs BasicCare (SNBC) or UCare Connect), modifier 59 must be appended instead of L1 to the laboratory service to indicate these are the only services submitted on the claim and are... More
  • CMS calculates the Medicare Fee-for-Service (FFS) improper payment rate through the Comprehensive Error Rate Testing (CERT) program. Each year, CERT evaluates a statistically valid random sample of claims to determine if they were paid properly under Medicare coverage, coding, and billing rules.The... More
  • UCare will implement a formal provider appeal process effective April 1, 2017. When a provider is requesting an adjustment, recoupment or appeal on a claim, the new, universal Claim Reconsideration Request Form must be thoroughly completed and submitted to UCare along with additional documentation... More
  • A plan for regulating laboratory-developed tests that a group of diagnostic manufacturers and labs had penned two years ago has resurfaced in the US House of Representatives with backing from a Republican and Democratic legislator. Representative Larry Bucshon (R-IN) and Diana DeGette (D-CO)... More
  • CMS has given approval for Cotiviti to begin audit activity for recovery audit contractor (RAC) regions 2 and 3, which includes Illinois, Minnesota, Wisconsin, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont, Connecticut and New York. Visit the Cotiviti website to view the CMS Approved... More
  • Claims billed with modifier FX to indicate X-ray imaging services were provided using film reduces will be subject to a 20% reduction. The reduction applies to the technical component (TC) (including the TC portion of a global service). This reduction will be effective January 1, 2017 for Medicare... More
  • Effective for services furnished beginning Jan. 1, 2017, BCBSGa will follow the Centers for Medicare & Medicaid Services’ requirement for providers to bill modifier FX when billing for X-rays using film. A payment reduction of 20 percent will apply to the technical component (and the... More
  • Evidence Street, the Blue Cross Blue Shield Association's web-based evidence review platform for medical products that's been operational for around 15 months, is continuing to grow its influence within the diagnostics sector and among payors. Several molecular diagnostics companies, which... More
  • A provision of the Affordable Care Act that requires providers to revalidate or recertify their Medicaid reimbursement eligibility has caused 65,000 providers to be stripped from the federal program, according to a Modern Healthcare analysis. Providers that enrolled in Medicaid before March 25,... More
  • Despite a preliminary injunction and an unwilling partner standing in the way, Anthem is still clinging to the possibility of closing its $54 billion merger with Cigna by settling with a new Justice Department under the Trump-led administration that it hopes will cut it some slack and greenlight... More
  • In a move that defies Anthem’s push to fight for their deal, Cigna has terminated its merger agreement with Anthem and filed suit against the larger insurer. Earlier this month, a federal judge ruled against the two insurers’ planned merger, saying it would violate antitrust law by... More
  • Anthem will appeal a federal judge's decision preventing a merger with Cigna, the insurer announced. A federal judge blocked the proposed $48 billion merger of Anthem and Cigna, two of the nation's largest health insurers. Anthem, which is based in Indianapolis, said it plans to "... More
  • A federal judge blocked the proposed $54 billion tie-up between national insurers Anthem and Cigna, saying the combination would harm competition in the national employer market. In a 12-page order, U.S. District Judge Amy Berman Jackson said the merger would eliminate the firms' head-to-head... More
  • Aetna and Humana have decided to end their merger agreement rather than appeal a judge’s decision to block the deal on antitrust grounds. “While we continue to believe that a combined company would create greater value for healthcare consumers through improved affordability and quality... More
  • New laboratory-developed tests (LDTs) used to diagnose and assess various conditions have been added to the list of LDTs covered under TRICARE’s LDT Demonstration. The LDTs covered under this demonstration have not yet been approved by the U.S. Food and Drug Administration (FDA). Examples of... More
  • Coming soon, is a faster option that will be available to submit supporting documentation Cigna has requested to process and pay a pended claim. Instead of mailing or faxing the information, you’ll be able to upload it and send it through a new enhancement on the Cigna for Health Care... More
  • When patients with Cigna-administered coverage need a referral, they usually expect that their physician will refer them to a provider that participates in the Cigna network to minimize their costs. Whenever the physician refers the patient to non-participating providers, including freestanding... More
  • UCare's Provider Manual has been updated to reflect current business practices. It is important that providers reference it regularly for up-to-date content. The Provider Manual has been updated to reflect current business practices. A new section was added regarding Claim Appeals Process, the... More
  • Providers might be seeing claims denied for Rendering Provider NPI. This is due to the rendering provider NPI not being listed on BCBSND provider file as being affiliated with the billing provider NPI, tax ID and/or the 9-digit practicing location ZIP code for the date of service submitted. You can... More
  • Changes to our Laboratory Management Program clinical guidelines took effect Feb. 6, 2017. The current edition of the Laboratory Management Clinical Guidelines is available for your reference. Details about these changes that were made Feb. 6 are available in this Executive Summary.


XIFIN is a healthcare information technology company that leverages diagnostic information to improve the quality and economics of healthcare. Our health economics optimization platform is a connected health solution that facilitates connectivity and workflow automation for accessing and sharing clinical and financial diagnostic data, linking healthcare stakeholders in the delivery and reimbursement of care.