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ICD-10 PCS and Diagnosis CodeBook

Rayellen.Gilles — Mon, 15 Mar 2010 10:41:16 -0500

The 2010 ICD-10 Codebook is available in all Regulatory and Coding Suite products. This is a breakdown of over 2000 pages of coding, mapping, and guidance information reformatted into an easy to search and browse book. As always, the 2009 archive version has been saved in the Archives libraries - available with other codebook archives in the Audit & Revenue Resource Center an Regulation & Reimbursement Suite. If you create bookmarks in the 2009 book, they should now autom

AHA Says the "Meaningful Use" Bar Proposed by CMS Is Too High

admin — Tue, 09 Mar 2010 09:21:08 -0600

On March 8, 2010, the American Hospital Association (AHA) submitted comments to CMS on its proposed "meaningful use" rule.

Reporting “Uncertain Tax Positions" by Albert Y. Lin, LLM, CPA

admin — Tue, 09 Mar 2010 08:53:42 -0600

Continuing a trend towards increasing detailed taxpayer disclosures (which tax-exempt healthcare providers have seen through the recently re-vamped Form 990), the Internal Revenue Service (IRS), in Announcement 2010-9, 2010-7 (Jan.

What is the Problem with CBCs?

Coding Advisory Board — Fri, 05 Mar 2010 14:02:24 -0600

“Billing for services while operating in an environment of audit” has become my favorite catch phrase for 2010. It has been just over 7 years since the AMA updated the CPT descriptions for hematology procedures adapting the codes to current reporting practice of the clinical laboratory. Still in 2010, one of the most frequently billed outpatient tests continues to be incorrectly or inappropriately reported for reimbursement.

Diabetes Self Management Training

Coding Advisory Board — Fri, 05 Mar 2010 13:48:14 -0600

Medicare covers diabetes outpatient self-management training when furnished by a certified provider who meets certain quality standards. A diabetes outpatient self-management training (DSMT) program includes education about self-monitoring of blood glucose, diet/ exercise, an insulin treatment plan developed specifically for the patient who is insulin-dependent, and motivation for patients to use the skills for self-management. The following is a guide explaining Medicare coverage requirements.

MediRegs Customer Appreciation Event: April 19, 2010!

Lauren.vanderKeyl — Fri, 26 Feb 2010 11:43:56 -0600

“Experience Texas” at the MediRegs Customer Appreciation Event!

Physician Quality Reporting Specifications Manual

Rayellen.Gilles — Wed, 10 Feb 2010 09:15:06 -0600

Are you participating in this important program? We've updated Code Explorer in Coding & Revenue Resource Center and Audit & Revenue Resource Center to make flagging PQRI codes a breeze. The 2010 Specifications Manual contains details for each specific measure - simply click the GUIDANCE link from Code Explorer to see which measures any particular code falls into and tunnel in for details. Access the 2010 PQRI&nbsp

CMS Changes E-Prescribing Codes for 2010

Coding Advisory Board — Mon, 08 Feb 2010 09:22:34 -0600

The Centers for Medicare and Medicaid Services made it easier this year to collect a bonus for Electronic Prescribing. For certain ambulatory services, CMS now requires only one “G” measure code to be submitted on a claim. The measure is required to be reported on only 25 claims for the reporting period to be eligible for the 2% bonus. This is much easier than last year, when CMS required that one of three measure codes be submitted on 50% of eligible claims.

How to make more Microbiology money!

Coding Advisory Board — Wed, 03 Feb 2010 12:37:29 -0600

The micro lab has numerous “add on” procedures that are routinely performed to complete the culture report. Frequently, add on charges are never captured. There are several reasons for this – some process driven (such as bill drop dates coming too soon for the completion of all testing) and human errors (not submitting charges in a timely manner). One BIG reason is simply because bacteria do not grow at the whim of human time lines.

OIG: Disclosure of Adverse Events Limited

Darci.Friedman — Wed, 27 Jan 2010 08:10:40 -0600

The Office of Inspector General (OIG) found that public disclosure of information about adverse events was limited, according to its review of 17 state adverse event report systems, eight Patient Safety Organizations overseen by the Agency for Healthcare Research and Quality (AHRQ), and the Centers for Medicare and Medicaid Services (CMS).

Immediate Jeopardy Finding Fails Due To Lack Of Fact-Finding Specific Analysis

Darci.Friedman — Wed, 27 Jan 2010 08:03:13 -0600

A Department Appeals Board (DAB) order upholding the finding of an immediate jeopardy level violation and the imposition of $3,500 per day civil money penalty (CMP) against a skilled nursing facility (SNF) was vacated by the Eighth Circuit Court of Appeals because the DAB's finding was based on pure

Help Identifying Changes in the Physician Fee Schedule RVU Files

Coding Advisory Board — Wed, 20 Jan 2010 09:04:18 -0600

CMS issues its changes to the Physician Fee Schedule quarterly, but how often do you have the chance to analyze it and review it? With over 15000 lines filling a spreadsheet, comparing each quarter’s changes can be a daunting and time consuming task. Are you aware that MediRegs does this for you? They issue a difference report every quarter that highlights the changes between the current version and the last quarter’s version. Look for the file called “Difference Report” and “MediRegs created.”

Inpatient vs. Observation-Condition code 44

Coding Advisory Board — Tue, 29 Dec 2009 14:14:56 -0600

A conversation was recently had with a CMS representative regarding their policy and billing instructions associated with observation hours and services in situations when a patient is admitted as an inpatient but is subsequently found to be only eligible for observation; thus billed as an outpatient on the UB-04 reporting the Condition code 44.

How to Query Providers to Achieve Complete Documentation

Coding Advisory Board — Tue, 29 Dec 2009 14:04:50 -0600

Coding professionals face increasing challenges to code claims accurately. Facilities can help ensure documentation integrity and coding accuracy by establishing and managing an effective query process. The importance of complete documentation in the patient’s health record cannot be overstated; without such documentation accurate coding cannot be assigned.

Physician Supervision in the Hospital Outpatient Setting - Final 2010 OPPS Rule

Coding Advisory Board — Tue, 29 Dec 2009 13:50:42 -0600

CMS has revised or better defined several current policies for the supervision of outpatient services. The goal, per CMS, is “to ensure that hospital outpatient services are appropriately supervised by qualified practitioners while not impeding beneficiary access to these services, and in response to concerns raised by the hospital community.” In 2010, CMS will allow certain non-physician practitioners (NPP) (specifically physician assistants, nurse practitioners, clinical nurse specialists, certified nurse midwives, and licensed social workers) to provide direct super

MediRegs' ComplyTrack Suite Named Finalist in Prestigious Software & Information Industry Association Awards

Darci.Friedman — Mon, 14 Dec 2009 09:07:29 -0600

MediRegs, a part of Wolters Kluwer Law & Business (mediregs.com), is pleased to announce that MediRegs ComplyTrack® Suite has been selected as a finalist in the 25 th annual Software & Information Industry Association CODiE Awards. The awards recognize excellence and innovation in information and software products and applications.

Hot off the press! Eliminating consult code payments for 2010: Symposium Briefing

Coding Advisory Board — Sun, 15 Nov 2009 17:26:05 -0600

While attending the AMA Symposium this week there was a HUGE uproar about eliminating payments for consults. I thought one physician was going to take the head off of the guy from CMS! Whoa baby, talk about hot! Then you have the coders who are gunning for bear. The AMA left the CPT consult codes in for 2010 but CMS says they won’t pay! In light of this, the attending physicians are going to have to bill the initial hospital care day with a modifier. Then the consultants come along and they have to use the

2010 Electronic Procedure Codebook is ready

Rayellen.Gilles — Tue, 10 Nov 2009 11:46:21 -0600

The Coding Suite team is pleased to announce that the 2010 HCPCS and CPT Codebook is available in pre-release format. Customers with access to the Coder's Resource Center, Coding & Revenue Resource Center, or Audit and Revenue Resource Center will find the link to the codebook on the Welcome tab (RRS customers, click on the Codebooks link on the left-hand navigation pane. Also, watch your Daily E-Mail Alert for the updates and changes report, a simple way to quickly see which codes have been added, deleted and modified. More tips for 2010 changes:

Analysis of the 2010 CPT Code Changes

Coding Advisory Board — Fri, 06 Nov 2009 10:41:25 -0600

Fall is here, and along with the change in the weather comes the annual change to CPT codes.

Evaluation and Management: The E/M Guidelines at the beginning of the Evaluation and Management chapter were updated to expand the definition of Concurrent Care to include "Transfer of Care." The new definition reminds users to not use consultation codes when a transfer of care occurs, unless such transfer happens after the initial consultation evaluation.

Drugs of abuse analysis: Proposed changes for 2010

Coding Advisory Board — Fri, 06 Nov 2009 10:27:52 -0600

Within the listing of 2010 HCPCS posted by CMS on November 2nd laboratorians will see two new G-codes that redefine coding of qualitative drug analysis billed to Medicare.

Modifiers: It’s all about the money! – Part 2

Coding Advisory Board — Fri, 06 Nov 2009 09:33:09 -0600

In part 1 of this modifier series we identified and discussed the largest category—Global Package Modifiers, and the following modifier categories: GP, BUN, E/M only, #, Anes, Lab, and OTH. In part 2, we will explore the other categories of modifiers starting with the “BUN” grouping.

The following are the modifiers that relate to the bundling of CPT codes or related CCI edits:

Seeing the "Gray" in E/M Coding, Part 2 - Review of Systems and Past Family Social History

Coding Advisory Board — Fri, 06 Nov 2009 08:57:22 -0600

In a previous blog I wrote, "Seeing the “Gray” in Evaluation and Management Coding – Chief Complaint and History of Present Illness," I had started a dialogue related to Chief Complaint (CC) and History of Present Illness (HPI) gray areas. In this edition I hope to continue the conversation as it relates to review of systems (ROS) and past family social history (PFSH).

Timely Claim Filing Rules: Impact on Re-Billing Inpatient Ancillary Services

Coding Advisory Board — Wed, 04 Nov 2009 08:58:03 -0600

One of the more difficult issues facing hospitals today is related to the timely claim filing rules associated with re-billing ancillary charges for denied inpatient stays.

Under the RAC demonstration project, CMS allowed hospitals to re-bill their RAC denied inpatient short stay hospitalization cases as outpatient claims. The UB-04 claim type used to submit these claims for benefits was the traditional 13x; and Medicare Part B hospital benefit policies dictated coverage of services and payments.

January 2010 Code Set Updates: HCPCS, APC, Phys Fee

Jennifer.Ridell — Wed, 04 Nov 2009 08:33:55 -0600

The 2010 HCPCS Level II update is now available in CCH Coding Comply. The updated data files became available on CMS’ website late Monday Night. It is anticipated that this update will be released in the HCPCS and CPT electronic code book in the Coding Suite and RRS sometime next week. When complete, a link will be provided in the “Hot Topics” box on the Welcome page of the Coding Suite.

FTC Red Flags Rule Enforcement Delayed Until June 1, 2010

Lauren.vanderKeyl — Tue, 03 Nov 2009 08:51:46 -0600

The Federal Trade Commission has extended enforcement of the Red Flags Rule until June 1, 2010. Enforcement of the rule has been delayed previously as the FTC sought to adequately educate affected corporations and institutions. The Red Flags Rule impacts financial institutions and creditors subject to FTC jurisdiction. According to the Rule, created under the Fair and Accurate Credit Transactions Act, covered entities must develop and implement written policies that aid in identity theft prevention.

Bloggity Blog - The New IT Standards Blog!

Darci.Friedman — Mon, 02 Nov 2009 15:44:00 -0600

The HIT Standards Committee met on October 29, 2009 and formed an "Implementation Workgroup" which is charged with bringing forward “real-world” implementation experience to the HIT Standards Committee recommendations. The Implementation Workgroup will have a special emphasis on strategies to accelerate the adoption of proposed standards, or mitigate barriers, if any. In addition to public meetings designed to uncover new strategies, the Committee also launched a blog. Industry groups, including the AHA, are encouraging hospital leader's to partic

Home Health and DME hit the “most wanted” list in the Senate Finance Committee Bill

Maria.Bounos — Fri, 30 Oct 2009 22:25:16 -0500

Home Health and Durable Medical Equipment (“DME”) can’t seem to get out of the spotlight and who can blame the government for scrutiny. Back in the day when Home Health charged on a “per visit” basis, we saw independent Home Health agencies in abundance across the United States, company CEOs using Medicare dollars to purchase airplanes and living in mansions as they reaped the benefits of what was found to be Home Health fraud and abuse. In the late 90’s an “interim payment system” was implemented pri

Still confused as to whether a visit is a consult or a referral?

Coding Advisory Board — Fri, 30 Oct 2009 14:24:28 -0500

Let’s take a look at the definition of a consultation. A consultation is a type of service provided by a physician or qualified provider whose opinion or advice regarding the evaluation and/or management of a specific problem is requested by another physician or provider. Another way of defining a consultation is a rendering of advice of your professional opinion, followed by a report of your findings to the referring physician.

Hospital Services – A different mindset for documentation

Coding Advisory Board — Fri, 30 Oct 2009 10:00:16 -0500

As we have moved into a new era of CMS compliance measures, the importance of solid hospital coding and documentation is a must to avoid unnecessary audits. With the onslaught of RAC’s aggressively beginning to focus on hospital services around the country, training internal coding staff and physicians will be the key to survival. Criteria for hospital admission services (99221-99223) are frequently under documented by physicians. Further, the use of time (counseling & coordination

Expanded Code Search Functionality

Rayellen.Gilles — Wed, 28 Oct 2009 06:33:16 -0500

Senate Finance Committee Requests Answers From 3M Regarding Software Complaints

Nicole.Stone — Tue, 27 Oct 2009 12:22:10 -0500

In response to compliants from medical practitioners, patients, and technology engineers that Health Information Technology (HIT) and Computer Physician Order Entry Systems (CPOE) software programs are often faulty and that the manufacturers' shift blame to the medical facility when errors are found, Senator Grassley, on behalf of the Senate Finance Committee, sent a letter on October 16, 2009, to the CEO of 3M Company requesting information and documentation about 3M's software policies and programs.

Secondary Infusion Coding: 96367 & 96368 Clarified

Coding Advisory Board — Fri, 02 Oct 2009 21:13:28 -0500

Since 2006 your facility has most likely provided numerous in-services and documentation reviews that focus on the need for clear and concise documentation of infusion services. The end result being the reduction of failed claims and enhanced compliance with CCI coding policies for selection of primary or “initial” procedure CPT. But what practices has your facility implemented to identify inaccurate code selection for sequential and concurrent IV infusions?

Why do Providers Need to Know Coding Basics?

Coding Advisory Board — Fri, 02 Oct 2009 21:02:38 -0500

A comment I often hear by many physicians is “all I want to do is treat my patients.” The truth is that despite their tendency to avoid the topic, providers must take the responsibility for coding seriously. With the constant changes of our medical system, who other than the person treating the patient is best qualified to determine the correct code to use when submitting claims for reimbursement?

E-Prescribing Incentive Program Changes

Coding Advisory Board — Fri, 02 Oct 2009 20:41:50 -0500

In July, the Centers for Medicare & Medicaid Services released proposed changes to the e-prescribing incentive program. The goal of the program is to incent prescribers to voluntarily adopt e-prescribing in the early years of the program and later in the program, penalize those who don’t adopt e-prescribing.

Proposed 2010 E-Prescribing Incentive Program Changes

Coding Advisory Board — Fri, 02 Oct 2009 20:40:17 -0500

Seeing the “Gray” in Evaluation and Management Coding – Chief Complaint and History of Present Illness

Coding Advisory Board — Fri, 02 Oct 2009 20:16:15 -0500

Being able to see and audit the "gray" areas of E/M coding is what separates coding professionals from other coders. It’s human nature to want absolute truth in all we do. But the savvy coder knows that especially when it comes to coding E/M services, there are few absolutes.

CPT 2010 Update is Ready in CCH Coding Comply

Jennifer.Ridell — Fri, 02 Oct 2009 18:48:00 -0500

The 2010 CPT update will be available for export in CCH Coding Comply on October 3. The annual update includes more than 150 new codes. Some of the new codes cover complex cystometrogram (51727-51729), injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic (64490-64492), and computed tomographic (CT) colonography, screening, including image postprocessing (74261-74263). Additionally, over 170 codes were modified for 2010.

CPT 2010 is Coming!

Jennifer.Ridell — Wed, 30 Sep 2009 19:30:37 -0500

We recently received the 2010 update files for CPT and are working hard to bring the information to you. Keep checking the MediBlog and CCH and MediRegs What's New publications for information regarding the availability of the 2010 update in our products. Aside from the standard CPT update data, the American Medical Association (AMA) released additional information this year pertaining to H1N1 codes and data structure.

OIG Reports on Pandemic Flu and Medical Surge

Darci.Friedman — Wed, 23 Sep 2009 09:00:16 -0500

Are we ready for the impending flu season? What about an influenza pandemic? The OIG recently released a duo of reports addressing preparedness for an influenza pandemic. In one of the reports, the OIG examined the extent to which states and localities have prepared for a medical surge in response to an influenza pandemic and whether they have conducted and documented exercises that test their medical surge

What are your EMTALA obligations during a pandemic?

Darci.Friedman — Tue, 08 Sep 2009 10:42:23 -0500

Flu season is coming and concerns over an H1N1 resurgence are rising. To make sure hospitals understand their obligations under EMTALA during a disaster or a pandemic, CMS issued, on August 14, 2009, a Survey and Certification Letter. See CMS S&C-09-52. The letter has an attached Fact Sheet, which addresses planning for a surge in ED services and waiver rules.

Picking the right code—is it as easy as it appears?

Maria.Bounos — Fri, 04 Sep 2009 13:40:13 -0500

Coders learn early on “to assign procedural codes based on the documentation noted in the medical record.” Sound easy?

Modifiers: It’s all about the money! - Part 1

Coding Advisory Board — Tue, 01 Sep 2009 09:07:07 -0500

Knowing what modifiers are available and when to use them can be quite confusing. Most modifiers have some effect on reimbursement so rather than review modifiers in numerical order it is helpful to consider them in groups related to their function and how they increase or decrease payment.

Modifiers do just that – they modify the code description without changing the core meaning. They are a way to provide additional information regarding a service and are integral to the CPT and HCPCS coding systems.

When Does Observation Time Begin and End?

Coding Advisory Board — Mon, 31 Aug 2009 13:35:49 -0500

We all know that the term observation has many meanings and associated reporting guidelines depending upon the payer. One of the most significant questions is “when does observation time begin and end?” This sounds simple, but it is anything but that.

ADM Users - Custom Fields

Carla Engle — Fri, 21 Aug 2009 14:10:48 -0500

Join MediRegs on LinkedIn or Twitter

Darci.Friedman — Thu, 20 Aug 2009 10:54:58 -0500

Did you know that MediRegs has a User Group on LinkedIn? Did you know that you can follow MediRegs on Twitter? Check these great resources out and join us today!

Bone Biopsy vs. Aspiration Explained

Coding Advisory Board — Thu, 20 Aug 2009 07:56:30 -0500

A biopsy is a minimally invasive procedure; a means of percutaneously sampling potentially abnormal tissue and provide diagnostic information. Cells or a small amount of tissue is removed by placing a sterile needle into the area.

E&M Coding Grids: Are You Aware of Recent Changes?

Coding Advisory Board — Wed, 19 Aug 2009 09:40:21 -0500

Many health care professionals use E&M coding grids to assist with the application of E&M codes. In it’s Evaluation and Management Services Guide, CMS indicates that for determining the complexity of medical decision making, “The number of possible diagnoses and/or the number of management options that must be considered is based on:

2010 Medicare Physician Fee Schedule Proposed Rule Published

Coding Advisory Board — Sat, 15 Aug 2009 09:52:40 -0500

On July 1, the CMS released the proposed changes to the Medicare Physician Fee Schedule (MPFS). CMS updates the MPFS annually to set payment rates for physician and non-physician practitioner services. The press release is found on the Medical Release Database section within CMS: http://tinyurl.com/kqsdym.

2010 Outpatient PPS Proposed Rule Published

Coding Advisory Board — Sat, 15 Aug 2009 09:44:41 -0500

On July 1, the CMS released the proposed policy changes for services provided in hospital outpatient departments and ambulatory surgical centers (ASC) for 2010, under the outpatient Prospective Payment System (OPPS). The press release is found on the Medical Release Database section within CMS: http://tinyurl.com/nmx88h.

OIG Report on Qualifications of Nonphysicians Performing "Incident To" Services

Darci.Friedman — Thu, 13 Aug 2009 09:59:50 -0500

In a report issued on August 5, 2009, the OIG examined days that Medicare allows more than 24 hours of services billed by a single physician and sought to identify the services physicians bill to Medicare but do not perform personally and the qualifications of nonphysicians performing "Incident To" services. The OIG found that:

Coding and Reporting Updates for the PQRI and E-Prescribing Programs

Nicole.Stone — Fri, 07 Aug 2009 10:58:49 -0500

A recent CMS Manual Transmittal provides a high-level overview of claims-based reporting for the 2009 physician quality reporting initiative (PQRI) and the E-Prescribing Incentive Program.

Payment for Necessary and Reasonable Maintenance of Oxygen Equipment

Nicole.Stone — Fri, 07 Aug 2009 10:02:32 -0500

CMS has released clarification on payment for maintenance and servicing of certain oxygen equipment as a result of the Medicare Improvements for Patients and Privacy Act (MIPPA) of 2008. MIPPA established payment rules and supplier responsibilities related to the maintenance and servicing of oxygen concentrators and transfilling equipment.

Advance Beneficiary Notice of Non-coverage (ABN)

Coding Advisory Board — Fri, 07 Aug 2009 09:36:42 -0500

The Centers for Medicare and Medicaid (CMS) require a provider to notify Medicare beneficiaries when a service may not be covered under the Medicare program. The new Advance Beneficiary Notice of Non-coverage (ABN), which became effective March 1, 2009, must be completed by the provider, or his/her representative, and signed by the patient, before a service is rendered.

New Remittance Advice Remark and Claim Adjustment Reason Codes Now Available

Coding Advisory Board — Thu, 06 Aug 2009 11:59:14 -0500

Kathy Lindstrom, a professional coder at Provation and a CCH & MediRegs Coding Advisory Board member, has compiled a list below of the best resources your staff can use to implement the latest changes to the Remittance Advice Remark Codes (RARCs) and Claim Adjustment Reason Codes (CARCs) that became effective July 1, 2009.

Sebelius Delegates HIPAA Security Authority to the OCR

Darci.Friedman — Tue, 04 Aug 2009 09:11:19 -0500

In a notice published in the Federal Register on August 4, 2009, Kathleen Sebelius, Secretary of the Department of Health and Human Services delegated authority to the Director of the Office of Civil Rights over the HIPAA Security rules. With this delegation, the OCR is responsible for interpreting and enforcing both the HIPAA Privacy and Security rules. The OCR can now impose civil money penalties, issue subpoenas, and make exception determinations. The delegation is effective immediately. See 74 FR 38630.

ICD to CPT Procedure Crosswalking

Rayellen.Gilles — Thu, 30 Jul 2009 09:47:45 -0500

We recognize how important it is to be able to "translate" ICD to CPT(R), and are troubled by the lack of a National official crosswalk.

The Coding Suite allows you to map codes - here are instructions and a more in-depth discussion of the issues surrounding code-to-code mapping.

FTC Red Flags Rule Enforcement Delayed Until 11/1/2009

Lauren.vanderKeyl — Thu, 30 Jul 2009 09:27:56 -0500

In an effort to extend their Red Flags education campaign, the FTC has announced that enforcement on the Red Flags Rule will be delayed until November 1, 2009. This education campaign seeks to educate businesses on whether they are covered by the Rule, and if so, which steps to take in order to be compliant. Small businesses, in particular, had fumbled to grasp whether their risk-based programs were harmonious with the Red Flags Rule.

Obama presents legislation for new Medicare rate-setting agency

Paul.Clark — Fri, 17 Jul 2009 15:50:05 -0500

President Obama on July 17 sent a draft of legislation to Congress that would establish an Independent Medicare Advisory Council (IMAC), which would have the authority to make recommendations to the President on annual Medicare payment rates as well as other reforms.

Senate, House committees approve reform legislation

Paul.Clark — Fri, 17 Jul 2009 14:02:51 -0500

Comprehensive health care reform legislation passed a significant milestone last week as Senate and House committees approved different legislative packages. At the same time, comments from the head of the Congressional Budget Office (CBO) put a damper on the potential further progress of the legislation.

State Privacy Regulation and EMR's

Darci.Friedman — Wed, 15 Jul 2009 12:26:02 -0500

The July issue of Management Science contains a study that "quantifies the effect of state privacy regulation on the diffusion of electronic medical records." The study, by Amalia Miller, Department of Economics, University of Virginia and Catherine Tucker, MIT Sloan School of Management, Massachusetts Institute of Technology, found that "state privacy regulation restricting hospital release of health information reduces aggregate EMR adoption by hospitals by more than 24%." To see the abstract, click

Electronic Health Records Incentives under the Recovery Act

Rayellen.Gilles — Fri, 26 Jun 2009 06:38:08 -0500

Medicare has created a new FAQ Category for E-Health; Elecronic Health Records and has provided simple answers to common questions related to the Recovery Act financial incentives to encourage "meaningful use" of certified Electronic Health Records (EHR) among Medicare and Medicaid providers. They've included an estimated EHR timeline (with a rule expected late in 2009), their intention to provide "supportive programs" to assist providers with taking advanteage of the incentive program, and eligibility information.

House Democrats Unveil Draft of Health Care Reform Legislation

Paul.Clark — Tue, 23 Jun 2009 07:51:29 -0500

House Democratic leaders unveiled a comprehensive health care reform plan on June 19, calling for the establishment of a public health insurance program that would compete with private insurers to lower costs. The proposal would create a Health Insurance Exchange to provide a functional marketplace for individuals and small employers to comparison shop among private and public insurers.

Few details of how the plan would be paid for were announced, and lawmakers said they were awaiting estimates from the Congressional Budget Office.

Interesting Trend in NCCI Edits

Rayellen.Gilles — Thu, 18 Jun 2009 13:56:13 -0500

The number of active NCCI edits increased significantly this year.

We saw a near doubling of physician edits last quarter, with hospital CCI edits quickly converging to match the physician version.

If you have updateable NCCI tools, that means you are going to see many more codes involved in edits. If you rely solely on paper-based updates published yearly, the content that hit the presses last fall will be remarkably inaccurate for the 2nd half of 2009.

Crowding In Hospital Emergency Departments Continues To Occur

Darci.Friedman — Tue, 16 Jun 2009 12:21:54 -0500

Emergency department crowding continues to occur in hospital emergency departments, and some patients wait longer than the recommended time frames, according to a recent study by the Government Accountability Office (GAO).

ICD-9-CM 2010 Update Now Available

Jennifer.Ridell — Wed, 10 Jun 2009 18:50:14 -0500

The October 1, 2009, updates to the ICD-9-CM volume 1 and volume 3 code sets have been released via the ICD-9-CM Tabular Addenda and the FY 2010 Final Addenda. An ICD-9-CM code is required for all professional claims and for all institutional claims; however, an ICD-9-CM code is not required for ambulance supplier claims. New procedure codes include: 17.51, 33.73 and 46.87 and new diagnosis codes include: 209.70, 453.50, and V15.52.

House, Senate release health care reform drafts

Paul.Clark — Tue, 09 Jun 2009 14:52:28 -0500

Members of both the House and the Senate have released draft summaries or draft legislative language for comprehensive health care reform legislation. Staff members of three House committees -- Ways and Means, Energy and Commerce, and Education and Labor – released a three-page summary of a possible health care reform bill that includes a public insurance option, insurance market reforms, and insurance premium support for families up to 400 percent of the federal poverty level.

Inappropriate Part D Payments for Part A SNF Beneficiaries

Darci.Friedman — Mon, 08 Jun 2009 09:40:39 -0500

The OIG recently released a report entitled "Medicare Part D Payments For Beneficiaries In Part A Skilled Nursing Facility Stays In 2006." The purpose of the review was to determine the extent to which Medicare Part D paid for drugs for beneficiaries in Part A SNF stays in 2006. The OIG found that Part D payments were widespread among SNFs and ph

Obama may use MedPAC to fast-track Medicare changes

Paul.Clark — Wed, 03 Jun 2009 14:39:35 -0500

President Obama is looking at making the recommendations made by the Medicare Payment Advisory Commission (MedPAC) each year easier to put into effect. In a letter to Sens. Edward Kennedy (D.-Mass.) and Max Baucus (D.-Mont.) sent June 2, Obama outlined several proposals to cut health care spending over the next 10 years, particularly in the Medicare program.

DHHS and DOJ Turn on the HEAT

Darci.Friedman — Tue, 02 Jun 2009 12:19:21 -0500

On May 20, 2009, Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius announced the creation of a new interagency effort, the Health Care Fraud Prevention and Enforcement Action Team (HEAT), to combat Medicare fraud. Holder and Sebelius also announced the expansion of Strike Force team operations to Detroit and Houston. Medicare Fraud Strike Forces, currently in operation in South Florida and Los Angeles, fight Medicare fraud on a targeted local level.

OIG Advisory Opinion on Compensating On-Call Physicians

Darci.Friedman — Wed, 27 May 2009 08:30:00 -0500

On May 21, 2009, the OIG posted an advisory opinion regarding a proposal to compensate physicians for on-call services performed on behalf of it’s uninsured patients. Although the OIG acknowledged the legitimate reasons for such arrangements, they also stated there is a substantial risk that improperly structured payments for on-call coverage could be used to disguise unlawful remuneration. However, the key inquiry is whether the compensation is: (i) fair market value in an arm’s-length transaction for actual and necessary items

Surgery for diabetes

Jennifer.Ridell — Thu, 21 May 2009 16:14:05 -0500

CMS has determined that open and laparoscopic Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and open and laparoscopic biliopancreatic diversion with duodenal switch in Medicare beneficiaries who have type 2 diabetes mellitus (T2DM) and a body mass index (BMI) less than 35 is no longer considered reasonable and necessary. It has been determined that these same procedures do improve health in patients with T2DM with a BMI greater than 35 so they are still considered reasonable and necessary in those situations.

Healthcare reform may draw on Massachusetts model

Paul.Clark — Thu, 21 May 2009 08:24:30 -0500

As Congress and the Obama administration consider reform of the healthcare system, they may consider the experience

Type of Service Data

Rayellen.Gilles — Wed, 20 May 2009 10:34:56 -0500

A smart client asked "What is the BETOS Data? Can you give me a hint of what it is and how is it used?"

I'd like to answer that question, but also ask YOU a question in response!

My QUESTION is: How can we improve the existing tools in the Coding Suite to make it easier for you to view information by specialty/type of service? We already offer bookmarking and personal stored searches, and each tool lets you enter lots of codes at once, but what are we missing? Comment or contact me directly if you are interested in helping us improve!

Routine Cost of Clinical Trials

Jennifer.Ridell — Tue, 19 May 2009 17:50:50 -0500

CMS has decided there is no longer a need to distinguish between diagnostic and therapeutic clinical trial services. This decision by CMS goes into effect July 10, 2009 and applies to all claims submitted with dates of service on or after January 1, 2008. The ICD-9 diagnosis code of V70.7 is still required to be reported on all claims that were submitted with either the QV or Q1 modifier.

Product Enhancement - Find the Codes that are Current TODAY

Jennifer.Ridell — Tue, 05 May 2009 16:36:39 -0500

Wolters Kluwer Law & Business is excited to announce recent enhancements to the CCH Coding Comply product that is available via the CCH Internet Research Network and the CCH and MediRegs Coding and Revenue Resource Center and Audit and Revenue Resource Center.

Hospitals face practically zero update in 2010

Paul.Clark — Mon, 04 May 2009 11:01:05 -0500

Acute care hospitals will receive a net 0.2 percent increase in payments for inpatient hospitals services in fiscal year (FY) 2010 under the proposed rule for the inpatient hospital prospective payment system (IPPS). Hospitals face a net decrease in payments in FY 2011 and 2012 under the proposed rule.

Red Flag Rule Delayed until August 1, 2009

Joanna.Maher — Fri, 01 May 2009 09:41:56 -0500

FTC announced on April 30, 2009 that the enforcement of the Red Flag Rule will be delayed until August 1, 2009. This will allow time for creditors and financial institutions to create and fine tune their identity theft prevention programs. A template has also been developed and will be available soon which will aid companies with a low risk of identity theft.

More information is available from here: http://www.ftc.gov/opa/2009/04/redflagsrule.shtm

NCCI, MUEs and OCE

Rayellen.Gilles — Wed, 29 Apr 2009 16:23:17 -0500

We've noticed that the NCCI code pairs in the physician version for 04/01/2009 have nearly doubled this quarter! For this and other customer requests, we held a webinar today on NCCI and MUE. Check the What's New in the product for the Study Aid in the MediNotes collection. There you will also find a copy of the presentation slides. Comment to this posting if you have any follow up questions, want to make comments, or wish to start a deeper dialogue about NCCI Issues!

Bariatric Surgery for Diabetes

Jennifer.Ridell — Thu, 23 Apr 2009 14:39:01 -0500

HHS Guidance on Protecting Health Information

Darci.Friedman — Tue, 21 Apr 2009 07:57:33 -0500

On April 17, 2009, HHS issued guidance specifying the technologies and methodologies that render protected health information unusable, unreadable, or indecipherable to unauthorized individuals, as required by the Health Information Technology for Economic and Clinical Health (HITECH) Act passed as part of the American Recovery and Reinvestment Act of 2009. The guidance was developed through a joint effort by OCR, the Office of the National Coordinator for Health Information Technology, and CMS.

Increasing Cashflow and Strengthening the Bottom Line

Rayellen.Gilles — Fri, 17 Apr 2009 15:51:15 -0500

I want to extend a special thank-you to Vickie Fry from Prospective Payment Specialists (http://www.ppscompliance.com/) for her great presentation 04/16. The Study Guide is now available, and we invite your comments. If you attended and would like to provide feedback please click on the COMMENT link associated with this article.

Article provides clues on views of new HIT coordinator

Paul.Clark — Fri, 17 Apr 2009 14:29:08 -0500

In late March the Obama administration named David Blementhal, physician and director of the Institute for Health Policy at the Massachusetts General Hospital/Partners Healthcare System as the national coordinator for health information technology (HIT). This new post was included in the recently enacted American Recovery and Reinvestment Act of 2009 (ARRA).

In his new role, Blumenthal will be responsible for determing how almost $20 billion in new funding will be disbursed over the next few years.

Changes to DMEPOS competitive bidding program in effect April 18

Paul.Clark — Fri, 17 Apr 2009 13:35:13 -0500

The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), enacted on July 15, 2008, made limited changes to the competitive bidding program for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS), including a requirement that the Secretary conduct a second competition to select suppliers for Round 1 in 2009.

Red Flags Rule: Fighting Identity Theft

Lauren.vanderKeyl — Mon, 06 Apr 2009 09:15:03 -0500

On January 1, 2008, the newly-released Red Flags Rule stipulated that certain businesses are required to "spot and heed" the red flags for identity theft. Health care providers, in particular, should be vigilant in monitoring any suspicious activity that may indicate identity thieves have accessed stolen information including social security numbers, birth dates, account numbers, etc. in order to acquire accounts or services. Compliance to the Red Flags rule will be enforced starting on May 1, 2009. Is your organization covered?

CMS to host RAC teleconference

Paul.Clark — Thu, 02 Apr 2009 15:53:21 -0500

CMS is hosting a Special Open Door Forum teleconference for Part A provider Recovery Audit Contractors (RACs) on April 8, 2009, from 2:00 to 3:30 EST. The purpose of the forum is to introduce providers to the new RACs and provide more information about the RAC program.

CMS notes that capacity is limited; participants may may begin dialing into this forum as early as 1:45 PM EST. Dial: 1-800-837-1935 and reference Conference ID 92490299.

Twenty percent of Medicare inpatients rehospitalized within 30 days

Paul.Clark — Thu, 02 Apr 2009 14:18:26 -0500

Unplanned rehospitalizations of Medicare beneficiaries within 30 days leaving the hospital cost the program $17.4 billion in 2004, according to a study published April 2 on the web site of the New England Journal of Medicine. This equals about 17 percent of all hospital payments from Medicare in 2004. Almost one-fifth (19.6 percent) of beneficiaries discharged from a hospital that year were rehospitalized within 30 days. Only about 10 percent of these rehospitalizations were planned.

Physician Groups Press FTC For Exemption From Red Flag Rules

Darci.Friedman — Wed, 25 Mar 2009 05:32:46 -0500

With a May 1st deadline for compliance looming, the American Medical Association (AMA) has asked the Federal Trade Commission (FTC) to suspend the application of the Red Flag Rules to physicians and publish a new rule so that physicians have an opportunity to provide comments. In a March 9 letter to the FTC, AMA Executive Vice President Michael D. Maves wrote that the AMA “strongly believes that the FTC did not provide physicians with an opportunity to review and comment on this Rule.”

Use Risk-Remediation Process; Focus on Areas in Broad Categories

Darci.Friedman — Mon, 23 Mar 2009 04:26:16 -0500

Recently, MediRegs' own GM Steve Lefar and William Moran (of Strategic Management Services), a former regional HHS Inspector General, were interviewed by Atlantic Information Services on a method of approaching risk assessment and remediation. "While you want to be able to deal with all of your risks, you have to make some choices. You don’t have enough staff to look at everything all the time," Moran says. Moran and Lefar identified the ten most pressing risks within some general risk categories. To see the entire article click here.

OIG Report on Hospital Compliance with Postacute Care Transfer Policy

Darci.Friedman — Mon, 16 Mar 2009 03:35:57 -0500

Medicare's postacute care transfer policy pays full DRG payments to hospitals for patients discharged to home. Medicare pays hospitals that transfer patients to postacute care settings (e.g., skilled nursing, home health care) a per diem rate. In a recent audit report, the OIG found that of 150 claims sampled, 92 of them were improperly coded as discharges to home rather than transfers to postacute care settings. The OIG noted that multiple prior reports have found that hospitals are not complying with the postacute transfer policy. Perhaps it is time for your hospital to audit its compliance with the policy? See OIG Report A-04-07-03035 (February 2009).

ICD-10 Final Rule is Moving Again

Jennifer.Ridell — Thu, 05 Mar 2009 09:23:18 -0600

The final rule to implement the ICD-10 code set, which was released on January 16, 2009 and them promptly put on hold by the Obama Administration on January 21, 2009 for further review, has been officially released. It has been determined that the effective date will not be extended and the comment period will not be re-opened.

Electronic Health Records, Friend or Enemy?

Jennifer.Ridell — Thu, 05 Mar 2009 09:01:41 -0600

I'm all for saving money and making things easier, at least when it doesn't publicize my Dr's finding from my latest physical.

M. Eric Johnson who is the director of the Center for Digital Strategies at Dartmouth College discovered a number of medical records available for public view during a two week study he completed in January for the Department of Homeland Security. Amazingly these files were available for the taking on peer-to-peer file sharing networks you and I would visit to download our favorite song.

May 1st Is Fast Approaching - Are You Red Flag Ready??

Darci.Friedman — Thu, 26 Feb 2009 08:01:44 -0600

On May 1, 2009, the FTC's six month suspension of the enforcement of the Red Flag Rules will be lifted. Is your organization's Identity Theft Prevention Program in place? If not, review the requirements at 16 CFR 681 on the MediRegs research portal. If your organization has implemented a program - be sure it passes compliance muster by conducting the Red Flag Rules risk assessments developed by MediRegs for ComplyTrack. Question sets include:

Ingenix at Root of another Reimbursement Fraud Case

Nicole.Stone — Wed, 25 Feb 2009 04:33:58 -0600

On February 17, 2009, WellPoint Inc. agreed to stop using the Ingenix database of reimbursement rates that New York Attorney General Andrew Cuomo called “defective and manipulated.”

HIPAA and the Stimulus Bill

Joanna.Maher — Tue, 24 Feb 2009 07:13:31 -0600

By now you've probably heard the rumblings surrounding HIPAA and the new Stimulus Bill signed by President Obama on February 17, 2009. If not, the effect the bill is going to have on business associates and covered entities is extensive. Numerous changes will be made to their current policies and procedures.

Stimulus law provides funds for "comparative effectiveness research"

Paul.Clark — Wed, 18 Feb 2009 11:25:23 -0600

One of the provisions of the "American Recovery and Reinvestment Act of 2009'," signed into law by President Obama on Feb. 17, 2009, that has received a lot of often negative attention in some parts of the media relates to "comparative effectiveness research."

Two Self-Referral Exceptions Recommended by Hospital Groups

Darci.Friedman — Wed, 18 Feb 2009 05:37:00 -0600

On February 17, 2009, the American Hospital Association, Association of American Medical Colleges and Federation of American Hospitals submitted a comment letter to CMS recommending two new exceptions to the physician self-referral law - exceptions for incentive payment and shared-savings programs. At the same time, the hospital groups also submitted a letter to the OIG asking for formal withdrawal of the 1999 Special Bulletin regarding gainsharing arrangements. The letters address CMS final rule with comment

IRS Report on Nonprofit Hospitals

Darci.Friedman — Fri, 13 Feb 2009 04:11:44 -0600

Recently, the IRS released a final report on its 2006 nonprofit hospital study, which analyzes community benefit and compensation reporting by almost 500 hospitals. The IRS found that the average and median percentages of total revenues reported as spent on aggregate community benefit expenditures were 9% and 6%, respectively, for the overall group. AHA President and CEO Rich Umbdenstock said, “Today’s IRS report reaffirms that hospitals of all types are providing a healthy mix of care and services to the communities they serve.

Medicare, Medicaid and health IT provisions key part of final stimulus bill

Paul.Clark — Wed, 11 Feb 2009 13:00:48 -0600

Late on Wednesday, Feb. 11, the House and Senate reached agreement on final language for the American Recovery and Reinvestment Act. President Obama is expected to sign the bill into law as soon as it reaches his desk. An unofficial summary of the conference agreement includes the following health-related provisions --

Senate, House include similar health provisions in stimulus bills

Paul.Clark — Tue, 10 Feb 2009 12:39:37 -0600

Both the Senate and House have passed different versions of an economic stimulus bill. In addition to tax cuts and new government spending provisions, both bills include many provisions that affect healthcare providers. A conference committee will meet this week in an attempt to iron out the differences.

According to a fact sheet from the Senate Finance Committee, here are some of the key differences in the two bills, relating to healthcare.

Permanent RAC program roll-out resumes

Paul.Clark — Tue, 10 Feb 2009 05:29:37 -0600

CMS announced on Feb. 4, 2009, that all parties involved in the protest of the award of the Recovery Audit Contractor (RAC) contracts settled their protests. The settlement means that the stop work order has been lifted and CMS will now continue with the implementation of the RAC program.

Stimulus to Include Regulations on Charity Care and Not-For-Profit Hospitals?

Darci.Friedman — Mon, 09 Feb 2009 03:56:47 -0600

Sens. Chuck Grassley (R-Iowa) and Jeff Bingaman (D-NM) propose amendments to the economic stimulus bill "intended to ratchet up the scrutiny on charity care and not-for-profit hospitals" says ModernHealthcare.com. The Wall Street Journal Health Blog reports that "[o]ne Grassley-sponsored amendment would require the Treasury department (which includes the IRS) to compare the amount of uncompensated care and executive compensation provided at nonprofit versus for-profit hospitals.

HIPAA and Privacy of PHI

Darci.Friedman — Fri, 06 Feb 2009 03:34:19 -0600

A recent article in HealthDay discusses an Institute of Medicine report on personal health information. "The privacy of Americans' personal health information isn't adequately protected by existing federal government regulation, according to an Institute of Medicine report. The Health Insurance Portability and Accountability Act (HIPAA) privacy rule also hinders important health research, the report's authors said.

CMS, Congress To Ramp Up Quality Enforcement In 2009

Darci.Friedman — Thu, 05 Feb 2009 03:34:26 -0600

CMS and Congress will be focusing more on regulatory compliance matters in 2009 than they have in years, according to Brian Flood, managing director at KPMG. "You have a lot of activity going on in the next six months," he said during a recent American Bar Association teleconference.

President Obama puts ICD-10 Final rule on hold

Jennifer.Ridell — Fri, 23 Jan 2009 09:51:08 -0600

On Wednesday, January 21st, the Obama Administration put the ICD-10 final rule, along with others that are pending, on hold while further review is conducted. Don’t start cheering yet!

Obama administration review may delay pending regulations

Paul.Clark — Thu, 22 Jan 2009 08:18:54 -0600

One of the first actions of the new Obama administration was to issue an order to undertake a legal and policy review of all regulations issued by the executive that have not yet gone into effect. The review may push back the effective dates of several regulation issued by CMS and HHS, or lead to their repeal. The Bush administration issued a similar directive when it first took office, suspending the effective dates for several final rules issued in the last days of the Clinton administration.

OIG Approves Wisconsin FCA, Rejects New Jersey Statute

Darci.Friedman — Thu, 22 Jan 2009 08:07:06 -0600

As officials in Wisconsin received a letter from the Office of Inspector General indicating that the state's false claims act meets the requirements of the Deficit Reduction Act of 2005, New Jersey officials learned that their false claims statute will have to be amended for the state to become eligible for an increase in its share of Medicaid false claim recoveries. OIG determined that New Jersey's false claims statute is not as effective in rewarding and facilitating qui tam actions as the federal False Claims Act.

New APC Grouping Logic for 2009

Rayellen.Gilles — Tue, 20 Jan 2009 04:06:52 -0600

Important Notice: Addendum A & B were posted 01/02/2009 by CMS. CMS issued a notice to FI/MACs to hold Outpatient claims until 1/15/2009.

Senate Finance panel approves SCHIP extension, expansion

Paul.Clark — Mon, 19 Jan 2009 07:47:00 -0600

The Senate Finance Committee on January 15 approved legislation to renew and expand the State Children’s Health Insurance Program (SCHIP) by a vote of 12 to 7. The $31.5 billion measure funds investment in the SCHIP program with a 61 cent increase in Federal tax on cigarettes, with proportional increases for other tobacco products, raising approximately $65 million over 10 years. The House passed a similar measure (HR 2) on January 14 by a vote of 289-13. The full Senate is expected to take-up its version during the week beginning January 19.

ICD-10 - Is it finally ready?

Jennifer.Ridell — Fri, 16 Jan 2009 12:07:45 -0600

It looks like there finally is an official plan to implement the ICD-10 code set in the United States.

House offers stimulus package with more Medicaid spending

Paul.Clark — Thu, 15 Jan 2009 07:40:59 -0600

The House Appropriations Committee on Jan. 15 issued the outline for an $825 billion stimulus package which includes several provisions relating to Medicare and Medicaid.

The proposal (for which actual legislative text is still being written) would provide $8.6 bilion to provide 100 percent federal funding to states through 2010 for optional state Medicaid coverage of individuals and their dependents who are involunitarily unemployed and whose income is no higher than 200 percent of the federal poverty level.

House passes SCHIP reauthorization bill

Paul.Clark — Wed, 14 Jan 2009 11:05:50 -0600

The House of Representatives on Jan. 14 passed, by a 289 to 139 vote, HR 2, the State Children's Health Insurance Program (SCHIP) Reauthorization bill. The legislation is intended to expand the number of children covered by health insurance under SCHIP or Medicaid from 7 million to 11 million.

Ingenix at Root of Reimbursement Rate Fraud?

Nicole.Stone — Wed, 14 Jan 2009 06:24:51 -0600

On January 13, 2009, Attorney General Andrew M. Cuomo announced that Ingenix was at root of fraud scheme and that as a result a historic reform of the nationwide health care reimbursement system is needed that will end conflicts of interest and generate fair reimbursement rates for working families nationwide.

Congress will not act on Medicare "trigger" in 2009-2010

Paul.Clark — Fri, 09 Jan 2009 09:22:23 -0600

The 111th Congress, which will meet in 2009 and 2010, will not consider anylegislation that would enact reductions in Medicare financing from the Treasury'sgeneral revenues.

Court Prohibits Balance Billing in CA

Darci.Friedman — Fri, 09 Jan 2009 02:58:25 -0600

"California's high court ruled that emergency-room patients can no longer be billed by doctors and hospitals for care that isn't fully paid by their health plans. The court on Thursday struck down a practice known as 'balance billing,' in which doctors and hospitals seek to collect from patients any amounts that their managed-care plans refuse to pay.

Revised Disclosure of Financial Relationships Report Form Submitted to OMB

Darci.Friedman — Wed, 07 Jan 2009 09:53:19 -0600

On December 12, 2008, CMS published notice in the Federal Register that it had submitted a revised Disclosure of Financial Relationships Report ("DFRR") audit form to the Office of Management and Budget for review ("OMB"). The DFRR form will be used by CMS to identify arrangements that potentially may not be in compliance with the physician self-referral statute/regulations and to identify examples and areas of noncompliance that may assist CMS in f

Providers successfully appeal 7.6 percent of RAC overpayment determinations

Paul.Clark — Wed, 07 Jan 2009 05:39:37 -0600

Healthcare providers involved in CMS's three-year recovery audit contractor (RAC) demonstration program successfully appealed 7.6 percent of overpayment determinations. The demonstration program ended in March 2008. From the inception of the RAC demonstration through August 31, 2008, providers chose to appeal 22.5 percent (118,051) of the RAC determinations.

NCCI Edits for Anesthesiology, Evaluation & Management, and Mental Health Services

Rayellen.Gilles — Thu, 25 Dec 2008 03:24:52 -0600

In the past, the Outpatient Code Editor (OCE) has not applied the NCCI edits for the following categories of services: anesthesiology, evaluation and management, and mental health services. Effective 1/1/09, these categorical exclusions will be removed and there will be a large number of new institutional (hospital) NCCI edits applied to claims.

Medical Coding - It Still Needs a Human Touch

Jennifer.Ridell — Thu, 18 Dec 2008 00:00:00 -0600

Automate! Automate! Automate! That seems to be the call across most industries these days. How can we automate job x, y, and z?

APC and Clinical Lab - Wondering about the January 1 updates?

Jennifer.Ridell — Thu, 18 Dec 2008 00:00:00 -0600

We were wondering ourselves last week when the APC and Clinical Lab code set updates would be realeased. Our curiosity got the better of us so I reached out to a couple contacts at CMS and got information on these elusive January 1 updates. According to CMS they were still waiting on ASP data before they could finalize their APC file for 1/1/2009. The ASP data was released this week so we can expect the release of the APC data soon.

Medicare, Social Security to hit 18 percent of GDP without changes

Paul.Clark — Wed, 17 Dec 2008 09:09:11 -0600

The Treasury Department and the Office of Management and Budget released on December 15, 2008 the Fiscal Year 2008 Financial Report of the United States Government, projecting that over the next two decades, Social Security and Medicare expenditures will increase from 8 percent of GDP to about 11 percent. Without reform, the cost of these programs is projected to approach 18 percent of GDP by 2080. Medicare, Medicaid, and Social Security accounted for 16 percent of total government expenditures 40 years ago.

2009 Physician Quality Reporting Initiative Measures

Rayellen.Gilles — Wed, 17 Dec 2008 07:22:25 -0600

CMS has issued the 2009 PQRI Specifications Manual for Claims and Registry (v 3.0). This identifies the 153 measures for 2009. The complete manual is available for download in the CMS PQRI collection which can be found in the CMS - Coding Guidance library.

CMS proposes new NCDs on preventable surgical errors

Paul.Clark — Thu, 04 Dec 2008 09:08:45 -0600

CMS on Dec. 2, 2008, proposed three national coverage determinations (NCDs) to establish uniform national policies that will prevent Medicare from paying for certain serious, preventable errors in medical care. The errors, also referred to as “never events,” include:

-- wrong surgical or other invasive procedures performed on a patient;

-- surgical or other invasive procedures performed on the wrong body part; and

-- surgical or other invasive procedures performed on the wrong patient.

HIPAA Violation, Not Age Bias, Caused Hospital Employees’ Discharges

Darci.Friedman — Wed, 03 Dec 2008 16:11:33 -0600

Two employees over the age of 40 who were fired for violating a hospital’s confidentiality policy failed to show they were discharged because of their age under the ADEA or Kentucky law or that the hospital’s cost-cutting measures targeting higher-paid workers with seniority had a disparate impact on older employees, held the Sixth Circuit Court of Appeals. (Allen v. Highlands Hosp. Corp., 6th Circuit)

FTC Official Explains Identity Theft Red Flag Rule

Darci.Friedman — Mon, 24 Nov 2008 12:01:34 -0600

The “Identity Theft Red Flag Rules” (Rules) impose mandatory compliance with the regulations that require financial institutions or creditors to establish (1) protocols on discrepancies between an address requested in a consumer report and the address in the consumer reporting agency's file, and (2) policies and procedures to assess the validity of a change of address.

The Physician Fee Schedule Code Set 2009 Update Has Been Released!

Nicole.Stone — Fri, 21 Nov 2008 14:29:43 -0600

CMS recently released the Physician Fee Schedule code set update in conjunction with the Physician Fee Schedule Final rule, which was published in the Federal Register on November 19, 2008. This code set update becomes effective January 1, 2009.

This code set update includes several new surgical laparoscopy procedures (49652-49657) and stereotactic radiosurgery procedures (61796-61800) and modified skin debridement and benign lesion excision procedures with updated payment rates and RVU values (11004-11012 and 11404, 11406, 11420-11426, respectively).

Updated: New features coming to MediRegs search results

Joy.Woller — Fri, 21 Nov 2008 10:09:10 -0600

MediRegs is excited to release an improved search results screen for our research products Wednesday, Nov. 26th. Here's a quick tour:

Excerpts of the text surrounding your search terms appear below each document link.
You can control the number and size of excerpts displayed with each search result using the "Search Settings" control, or opt to hide them altogether.
The location of the document within a particular collection is displayed in an easy-to-read format.
Don't see exactly what you're looking for in the results? You can opt to browse the collection using the link above the results.

These changes are the first of many planned improvements to the Rex platform that lives under our many great research products. Most feature and design changes we make to our products come directly from user feedback. What else would you like to see?

OIG Reviews a Pair of State False Claims Acts

Darci.Friedman — Mon, 17 Nov 2008 09:30:30 -0600

Wisconsin FCA Passes Muster With OIG

The OIG, on November 4, 2008, found that the Wisconsin False Claims Act meets the requirements of the Deficit Reduction Act, thus entitling Wisconsin to an increase of 10 percentage points in the State medical assistance percentage with respect to any amounts recovered under a State action brought under such a law.

OIG Permits Prescription Drug Proposal

Darci.Friedman — Thu, 13 Nov 2008 09:12:27 -0600

The Office of Inspector General (OIG) would not impose sanctions related to a proposed arrangement that would allow a charitable organization to provide financial assistance to cover cost-sharing obligations associated with outpatient drug treatment for financially needy Medicare or Medicaid patients and was reliant upon donor funds, because it was designed with sufficient safeguards.

Alabama sues CMS over alleged illegal administrative regulation

Paul.Clark — Tue, 11 Nov 2008 08:43:50 -0600

The state of Alabama on Nov. 3, 2008, sued CMS for what it called “illegal rulemaking” concerning a letter the agency sent to all states on October 28 setting guidelines for states to reimburse the federal government for amounts states gained from suits filed under a state Medicaid False Claims Act. In the suit, Alabama claims the requirements outlined in the letter (1) constitute illegal rulemaking in violation of the Administrative Procedure Act; (2) are in excess of CMS’ statutory authority; and (3) would violate state sovereignty.

2009 HCPCS Level II Coding Update Has Been Released!

Nicole.Stone — Fri, 07 Nov 2008 09:36:23 -0600

The 2009 HCPCS level II annual update has been released! This update includes approximately 140 new codes, 178 modified codes and 73 deleted codes.

Six Financial Arrangements Successfully Pass OIG Scrutiny

Darci.Friedman — Wed, 05 Nov 2008 10:06:37 -0600

In six recently released advisory opinions, the Office of Inspector General (OIG) gave clearance to several programs and financial arrangements, finding that sufficient safeguards had been put in place to prevent violations of the Social Security Act and the anti-kickback statute. The OIG announced that the following arrangements would not be subject to civil monetary penalties or sanctions:

Technical Support: Making a product page one of your browser "Favorites"

Rayellen.Gilles — Fri, 31 Oct 2008 11:45:26 -0500

You can add a page within one of the Rex products like RRS to your internet browser favorites for instant access. To do this:

1) Sign In to the product

2) On the "You have access to the following products" screen, click on a product button.

3) Navigate to the tab or link on the leftnav that is your favorite.

4) Use your browser features to set this as a favorite. (Notice how the address bar shows where you are, including the "view" and other details.)

Additional tips...

Retired LCDs Pose a New Problem for Clinical Laboratories

Nicole.Stone — Wed, 29 Oct 2008 11:32:22 -0500

The retirement of a LCD is considered by many to be a blessing rather than a problem because while a LCD is active, claims denials are automatic if the requirements of the LCD are not met. This forces the provider to obtain an advance beneficiary notice (ABN). Further, laboratories must maintain a database of LCD edits and update them when LCDs change or new ones are issued. Many think this all goes away when a LCD is retired. Think again!

Medical Associations Challenge FTC's Interpretation Of "Red Flag" Rules

Darci.Friedman — Wed, 29 Oct 2008 10:20:46 -0500

American Medical News Article on FTC Red Flag Rules

Amy Sorrel of AMNews wrote a recent article discussing the Red Flag Rules and the delayed enforcement: "New Federal Trade Commission regulations to combat identity theft have taken physicians and the health care industry by surprise and prompted the agency to delay enforcement from Nov. 1 to May 1, 2009."

False Statement Within Claim Does Not Result In Liability Under FCA

Darci.Friedman — Tue, 28 Oct 2008 12:44:31 -0500

Effect of Untrue Certification of Compliance in Annual Cost Report

A provider's certification of compliance with Medicare statutes and regulations as stated in an annual cost report does not render all claims submitted for reimbursement by that provider false under the False Claims Act (FCA) if that statement is not true.

The 2009 CPT Update Has Been Released!

Nicole.Stone — Thu, 23 Oct 2008 16:08:44 -0500

The January 1, 2009, CPT annual update has been released by the AMA. To avoid denied claims for improper coding beginning January 1st, all providers must implement this annual update over the next two months - not an easy thing to accomplish for any staff! To help, we've compiled the following summary to give you a sample of the larger procedural services that are changing.

Necessary Documentation for E/M Codes

Jennifer.Ridell — Thu, 23 Oct 2008 15:21:33 -0500

The Health Care Compliance Association recently hosted a webinar related to coding evaluation and management (E/M) services provided in an outpatient facility.

Can you define "child" for coding purposes?

Jennifer.Ridell — Thu, 23 Oct 2008 15:08:58 -0500

Recently a customer asked us what the definition of “child” is for coding purposes. Our own research on this topic has proven inconclusive so we wanted to put this out there to others in the field for consideration and feedback.

Let’s start by considering a general definition for child. When you think of the word "child" as a general term what is the true definition? Next, is there a specific catch-all definition for child or does it truly differ for a specific code or payment system?

FTC Delays Identity Theft Prevention Program Compliance Deadline

Darci.Friedman — Wed, 22 Oct 2008 18:44:22 -0500

New Red Flag Compliance Deadline - May 1, 2009!

Just this afternoon, the FTC announced that it would delay the deadline to comply with the new Red Flag Rules from November 1, 2008 to May 1, 2009. The delay is to due to the confusion and uncertainty created in certain industries over whether the rules apply to them. "Many entities also noted that because they generally are not required to comply with FTC rules in other contexts, they had not followed or even been aware of the rulemaking, and therefore learned of the requirements of

Profit/Nonprofit Hospitals Provide Similar Charity Care

Darci.Friedman — Wed, 15 Oct 2008 09:50:02 -0500

IRS Authority to Question Nonprofit Hospitals About Charity Care

“We don’t see much of a difference between nonprofit hospitals and for-profit hospitals,” said Theresa Pattara, a staff member of the office of Senate Finance Committee (SFC) ranking member Charles E. Grassley (R-Iowa), at an American Health Lawyers Association program on September 12 in Washington D.C.

ICD-10: The New Standard in Coding

Nicole.Stone — Tue, 07 Oct 2008 19:27:17 -0500

CMS Proposes Adopting ICD-10 Codes as Standard

The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) have been proposed to be concurrently adopted as the standard code sets for coding diagnoses and inpatient hospital procedures, respectively.

FTC Red Flag Rules Alert!

Darci.Friedman — Tue, 07 Oct 2008 11:51:00 -0500

MediRegs Resources on the FTC Red Flag Rules

New rules take effect November 1, 2008 that may require health care providers to develop and implement a written identity theft prevention program. Health care providers can be "creditors" under the broad definition set forth in the rules. Indeed, health care entities are specifically mentioned in the Federal Register article promulgating the rules. Red Flags are a pattern, practice, or specific activity that could indicate identity theft. To help you identify whether these rules apply to yo

CMS announces new recovery audit contractors

Paul.Clark — Tue, 07 Oct 2008 11:06:52 -0500

On October 6, 2008, CMS announced the names of the new national recovery audit contractors (RACs). The new RACs are:

Diversified Collection Services, Inc. of Livermore, California, in Region A, initially working in Maine, New Hampshire, Vermont, Massachusetts, Rhode Island and New York.

CGI Technologies and Solutions, Inc. of Fairfax, Virginia, in Region B, initially working in Michigan, Indiana and Minnesota.

Attention District of Columbia, Maryland, New Jersey and Pennsylvania LCD users…..MAC J12 Part A LCD’s are here!!

admin — Sun, 05 Oct 2008 21:42:01 -0500

Attention District of Columbia, Maryland, New Jersey and Pennsylvania LCD users…..MAC J12 Part A LCD’s have been posted on the MediRegs Regulation and Reimbursement Suite site as of today (10/03/08). Please see your state library or the LCD library to view the new MAC J12 Part A LCD’s today!

Effective Dates and Grace Periods for New Codes

Rayellen.Gilles — Fri, 03 Oct 2008 12:30:00 -0500

A smart user has asked: “Our system does not have the new codes effective 10/1/2008 loaded yet. Can I still use the old codes?”

The short answer is: there is NO grace period.

WK strives to deliver coding content as quickly as possible, and certainly before the effective date. Generally, content is posted to ChargeMaster comply within 48 hours, and to the coding tools and codebooks within a week. This can be difficult when CMS publishes data late. Please feel free to e-mail with any questions!!

MAC J12 Part A LCDs added to Regulation and Reimbursement Suite

Fri, 03 Oct 2008 12:30:00 -0500

Attention District of Columbia, Maryland, New Jersey and Pennsylvania LCD users…..MAC J12 Part A LCD’s are here!!

Medically Unlikely Edits (MUE) lists now available

Rayellen.Gilles — Thu, 02 Oct 2008 09:52:00 -0500

According to CMS FAQ #8734:

An MUE (Medically Unlikely Edit) is a unit of service (UOS) edit for a Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code for services rendered by a single provider/supplier to a single beneficiary on the same date of service. The ideal MUE is the maximum unit of service that would be reported for a HCPCS/CPT code on the vast majority of appropriately reported claims. The MUE program provides a method to report medically reasonable and necessary UOS in excess of an MUE.

CCH Medicare and Medicaid Guide- September 2008

Jonathan.Schwartz — Mon, 15 Sep 2008 12:18:00 -0500

Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) (PubLNo 110-275)

The Social Security Act sections related to the Medicare and Medicaid programs, as published in the CCH Medicare and Medicaid Guide, have been updated to reflect the “Medicare Improvements for Patients and Providers Act of 2008” (MIPPA) (PubLNo 110-275). The law section now includes revisions of existing law, the addition of new sections enacted by MIPPA, and updated amendment notes and histories.

Health care compliance-Latest Information

Jonathan.Schwartz — Mon, 15 Sep 2008 11:58:00 -0500

Health Care Compliance Letter

Volume 11-16, August 5, 2008

Reimbursement for Re-Processing "Single-Use" Devices

Rayellen.Gilles — Tue, 09 Sep 2008 11:21:00 -0500

A smart user asked for help researching this subject, and I’d like to share what we found.

This was a fun one for me to research, as it illustrates the increasing complexity of compliance where FDA and CMS have joint jurisdiction. I think we’ve gotten off in the right direction with this research, but FEEDBACK FROM OUR COMMUNITY Click the “leave a comment link” will really help flesh out a solid understanding of this issue.

Hospital APC Payment Tools

Rayellen.Gilles — Fri, 01 Aug 2008 14:17:00 -0500

A smart user who has access to both the CCH Reimbursement Toolkit Hospital Outpatient PPS Calculator and the MediRegs APC Grouper & Calculator in RRS/Plus has asked:
What is the difference between these 2 calculators?
I thought I’d share the summary with MediBloggers. Note that you’ll see reference here to the exciting new Coding & Audit Suites which will be available shortly.

There are 2 APC Calculators Available. Let me summarize them for you here:

Coding Update- July 2008

Jonathan.Schwartz — Thu, 31 Jul 2008 15:42:00 -0500

Medicare Improvements for Patients and Providers Act of 2008

On July 15, 2008, the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) (PubLNo 110-275) was enacted. As a result of this new legislation many payment systems and other Medicare programs were immediately affected. Below is a brief summary of how different providers are affected by this new legislation.

Reimbursement Integrated Library- July 2008

Jonathan.Schwartz — Mon, 07 Jul 2008 15:45:00 -0500

Reimbursement Integrated Library

Dennis Barry’s Reimbursement Advisor

Each month, Dennis Barry’s Reimbursement Advisor includes two or three articles the offer practicalanalysis on specific aspects of healthcare provider reimbursement. Thenewsletter is particularly helpful in explaining some of the more complex areasof Medicare reimbursement and regulation. A good example of this is the leadstory in the July 2008 issue on Medicare bad debt. The article explains how a

ComplyTrack Changes

Tue, 01 Jul 2008 11:52:00 -0500

Catch the Latest ComplyTrack Wave -- What's New in 5.0 This Week

This week’s changes focused mostly on the Contract and Relationship Manager.

Some new fields were added

In Manage Representatives, a new field was added to record the effective date for each permission and review. We also added a field to record the representative’s birthday.

In the contract sub-agreement, a new field was added to record description and notes.

In the contract, we added a field to record the Owner.

Health Care Compliance Update: June 2008

Jonathan.Schwartz — Tue, 17 Jun 2008 14:41:00 -0500

Health Care Compliance Update: June 2008

Hot Topics• Recovery Audit Contractors• Medicaid Enforcement• OIG’s revised self-disclosure requirements• Electronic medical records/Health information technology• Quality of care• Hospital acquired conditions or “Never events”

Health Care Compliance LetterVolume 11-10, May 13, 2008

Fraud and Abuse

More MAC J1 LCD's added to MediRegs

Mon, 16 Jun 2008 12:00:00 -0500

MAC J1 LCDS for CA, Guam, HI, NV, American Samoa and North Marianna Islands

Attention American Samoa, California , Guam, Hawaii, Nevada and North Marianna Islands LCD users.....MAC J1 LCD's are here!!Attention American Samoa, California , Guam, Hawaii, Nevada and North Marianna Islands LCD users…..MAC J1 LCD’s have been posted on the MediRegs Regulation and Reimbursement Suite site as of today (6/16/08). Please see your state library or the LCD library to view the new MAC J1 LCD’s today!