In 2009, the Centers for Medicare and Medicaid Services (CMS) added a new PQRI measure titled Preventive Care and Screening: Unhealthy Alcohol Use – Screening. It was developed by the Physician Consortium for Performance Improvement. The criterion for the measure requires providers to assess a patient’s use of alcohol using a systematic method of screening on an annual basis. 

Are you struggling to research coding, payment, medical necessity and compliance rules related to the myriad reviews and issues from your Recovery Audit Contractor (RAC) or other investigators?  This article is designed to show you how to get to the most often-requested information as it relates to MS-DRG Validation and Medical Necessity Reviews.  Instructions apply to the Regulation & Reimbursement Suite or Audit & Revenue Resource Center unless otherwise noted.

10/01/2011 is coming up fast, and we've got you covered on the Regulation & Reimbursement Suite and Coding Suite.  The Inpatient Final Rule in E-Book format is ready to use, and the 2011 ICD-9-CM and 2011 MS-DRG Pre-released codebooks are available.  Also, you can get a head start on understanding ICD-10-CM and ICD-10-PCS with a comprehensive book available now.  Watch your daily e-mail alert, or visit the Inpatient, Coding, or Coding Guidance libraries for access to these resources.

What is a Regulatory E-BOOK?

On August 5, 2010, four major insurers announced meaningful use incentives.  Aetna, Highmark, UnitedHealth Group and WellPoint, at minimum, will align their pay-for-performance programs with federal meaningful use criteria.  In a joint statement, National Coordinator for Health Information Technology David Blumenthal, M.D., and Centers for Medicare and Medicaid Services' Principal Deputy Administrator Marilyn Tavenner, stated:

Having trouble using the most recent Part B Utilization data file from CMS? You’re not alone. Lots of people are upset about the non-friendly .pdf version of the file this year. The gurus at Wolters-Kluwer heard your concerns and converted the file to the Excel format for easier use.

Hospitals have been struggling since the inception of the Outpatient Prospective Payment System (OPPS) back in 2000 with CMS’s instructions for hospitals to develop internal hospital guidelines to determine what level of visit to report for each patient. General guidelines have been provided over the course of the last 10 years such as:

As part of the Patient Protection and Affordable Care Act, Medicare Part B coverage for preventive exams will change. Starting on January 1, 2011, Medicare will cover an annual preventive examination. The Initial Preventive Physical Examination service will remain and be available as a service those beneficiaries within the first 12 months of coverage under Part B. The coinsurance/deductible will not apply to the new preventive services. 

The AHA reports that CMS' New Issue Review Board approved the first "medical necessity review" audits last week.  The  audits include eighteen types of inpatient hospital claims and one type of DME claim. Remember that the RAC's must post the issues on their websites before issuing Additional Documentation Requests.  CMS expects the RACs to post the new audits and begin issuing ADR's within the next two weeks.  So, watch the RAC websites.  For your convenience, the issue pages on the RAC websites are:

The Medicare Electronic Health Record (EHR) Incentive Program is only available to “eligible” professionals and hospitals. The final rule will soon be published and CMS is planning to use the Provider Enrollment, Chain and Ownership System (PECOS) to verify Medicare enrollment. While this may seem like a no-brainer, you may or may not have an enrollment record in PECOS. Use the checklist below to avoid a last minute scramble that could impact your incentive payment.

Summary of Changes to Questions Sets - Second Quarter 2010

We would like to notify you of changes that have been made to the ComplyTrack Risk Assessment questions in the Comprehensive Library for the Provider Baseline. As part of the Quarterly Review Process, the following Risk Assessments were reviewed this quarter: