Medicare News Archive
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Audit & Enforcement
10.05.09 MAC submitters in Georgia asked to use new Cahaba workload number
The Centers for Medicare & Medicaid Services (CMS) says that Georgia Part B submitters should only use the Cahaba Government Benefit Administrators, LLC, MAC workload number instead of the old receiver ID.
Click here for full news article
08.04.09 Cahaba clarifies GBA Medicare Part B reopening request form
Cahaba recently introduced the GBA Medicare Part B Reopening Request form as a way for providers to submit written reopening requests when the telephone reopening line is not an option for corrections. Cahaba’s Provider Outreach and Education (POE) group has offered several clarifications...
Click here for full news article
07.23.09 Cahaba GBA's top ten electronic data interchange (EDI) and electronic funds transfer (EFT) frequently asked questions
Read Cahaba's frequently asked questions
06.18.09 Physicians cautioned to be on lookout for Medicare fax scam
The American Medical Association is warning physicians/staff about a scam whereby the perpetrators are sending faxes to physician's offices posing as a Medicare carrier or a Medicare Administrative Contractor (MAC). The fax reportedly instructs the physician/staff to provide account information by completing a questionnaire within 48 hours to prevent a gap in Medicare payments. The faxes have reportedly included the CMS logo and/or the contractor logo to enhance the appearance of its authenticity. AMA is advising Medicare providers to contact the applicable contractor before submitting any such information. Medicare providers should only send information to a Medicare contractor using www.cms.hhs.gov/MLNGenInfo/ or www.cms.hhs.gov/MedicareProviderSupEnroll.
06.12.09 Cahaba GBA preparing for transition of Georgia Part B providers into the MAC environment
Cahaba GBA has issued a special bulletin to help providers prepare for the transition, which is effective August 1, 2009.
View Cahaba A/B Newsline
06.10.09 Medicare Part B claims system will be down on August 3
To transfer the workload successfully to the J10 A/B Medicare Administrative Contractor (MAC), Georgia Medicare Part B will impose a system-wide "dark day." It has to be a business day during the cutover period when the Medicare claims processing systems, customer service, and the Interactive Voice Response (IVR) service will not be available for normal business operations. The dark day for Georgia B providers is August 3, 2009. The first date that providers can begin contacting Cahaba GBA's Customer Service and Interactive Voice Response (IVR) service will be August 4.
Also, the J10 A/B MAC workload number will change for Georgia Part B. The change is necessary because certain CMS applications need to individually identify each workload. The new Georgia Part B MAC Workload number is 10202, effective August 1. It replaces the contractor number 00511.
Click here for transition details
03.25.09 Cahaba Government Benefit Administrators awarded jurisdiction 10 A/B MAC
Cahaba GBA was awarded the Jurisdiction10 A/B Medicare Administrative Contractor (MAC) contract on January 7, 2009 from the Centers for Medicare & Medicaid Services (CMS). This contract gives Cahaba GBA responsibility for the administration of all Part A and Part B claims processing in Alabama, Georgia, and Tennessee.
View Cahaba A/B Newsline
02.24.09 Medicare Fraud & Abuse fact sheet now available
The Centers for Medicare & Medicaid Services (CMS) works with other government agencies and law enforcement organizations to protect the Medicare program from fraud and abuse. Together with CMS, providers can help identify and prevent fraud and abuse; the first step for providers to protect themselves is to understand the legal definitions and be able to identify fraudulent and abusive practices. This fact sheet provides information on many available resources to help you understand what to do if you suspect or become aware of incidents of potential Medicare fraud or abuse.
View updated Medicare Fraud & Abuse Fact Sheet
Coding
12.09.09 Top 5 Reasons for Claims Rejections in November
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12.09.09 Cahaba explains 'audit trails'
Electronic Report Files (ERF) are also called "audit trails." These reports are created automatically by the Cahaba GBA system for electronic claim files that pass through preliminary editing. These reports will show a submitter which claims were accepted by the Medicare processing system, which claims were rejected, and the reasons for the rejection. It is essential that submitters check their audit trails to see if their claims are being accepted by the Medicare processing system. Audit trails are created after the claims have gone through a nightly cycle; claims received after 4:30 p.m. ET will produce an audit trail two business days after being transmitted. Files received before the cutoff time will produce an audit trail that will be available the next business day.
10.22.09 CMS reminding billing staffs about HIPAA 835/5010 implementation
Cahaba GBA J10 A/B MAC is reminding billing staffs that the new HIPAA transaction 835 version 5010 is being implemented, and Medicare can begin to generate the 835 version 5010 for testing with trading partners and/or for transitioning early adopters of the new standard as of January 1, 2011.
Click here for more information
10.22.09 CR 6608 Flu Vaccine Payment Allowances Annual Update
As part of the annual September 1 update, Cahaba GBA J10 A/B MAC says that the CR 6608 allows for the following payment allowances for influenza virus vaccines: Current Procedural Terminology (CPT) codes 90655, 90656, 90657, 90658, and 90660 when payment is based on 95 percent of the AWP.
Click here for more information
07.13.09 Top 5 Reasons for Claims Rejections in June
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07.09.09 Cahaba revises ruling on wrong surgical or other invasive procedure performed on a patient
Effective January 15, 2009, the Centers for Medicare & Medicaid Services (CMS) does not cover a particular surgical or other invasive procedure to treat a particular medical condition when the practitioner erroneously performs: 1) a different procedure altogether; 2) the correct procedure but on the wrong body part; or 3) the correct procedure but on the wrong patient. Medicare also will not cover hospitalizations and other services related to these non-covered procedures as defined in the Medicare Benefit Policy Manual (BPM) Chapter 1, sections 10 and 180 and Chapter 16, section 120. This is pursuant to the National Coverage Determinations (NCDs) made as part of CR 6405.
Click here to read more
07.09.09 Rejections for edit 482 - Invalid Adjustment Reason code (xx) in loop 2430
Cahaba Government Benefit Administrators®, LLC, EDI Services Department has identified an issue with Part B Medicare Secondary Payer claims submitted electronically on July 7, 2009. These claims rejected on the audit trail system for an invalid adjustment reason code.
This issue has been corrected. Cahaba says if your claims rejected for edit 482, please resubmit them for processing. Please keep in mind that there will be some claims that reject legitimately for an invalid or deactivated adjustment reason code, so if your claims reject again for this same edit you will need to verify that the action reason code you are using is valid. For a list of reason codes, go to www.wpc-edi.com/content/view/695/1.
07.06.09 Claims rejecting for edit 307 - Diagnosis code inactive or invalid
Medicare Part B claims for Alabama, Georgia, and Mississippi submitted on July 2, all rejected on audit trails for invalid diagnosis codes. This affected all submitters. Cahaba is reprocessing these claims so they will not need to be resubmitted. These claims will be backdated to the correct date of receipt. Corrected audit trail reports will be created and should be available by 5 p.m. CT today. Cahaba Government Benefit Administrators, LLC, apologizes for any inconvenience this may have caused. Please contact EDI Services at 866.582.3253 with questions.
05.18.09 Top 5 Reasons for Claims Rejections in April
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04.10.09 Top 5 Reasons for Claims Rejections in March
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03.31.09 Medicare Part B review shows increase in "Incident To" errors
The Centers for Medicare & Medicaid Services' (CMS) Part B Medical Review Department says that a data analysis and medical record review of Evaluation and Management (E&M) Services shows an increase in provider documentation errors in "Incident To" services. This included the following errors…
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01.05.09 Top 5 Reasons for Claims Rejections in December
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Payment
12.30.09 CMS holding payments during January to adjust for new fees
Centers for Medicare & Medicaid Services (CMS) is working with Congress, health care providers, and the beneficiary community to avoid disruption in the delivery of health care services and payment of claims for physicians, non-physician practitioners, and other providers of services paid under the Medicare physician fee schedule, beginning January 1, 2010. In this regard, CMS has instructed its contractors to hold claims for services paid under the MPFS for up to the first 10 business days of January (January 1 through January 15) for 2010 dates of service. This should have minimum impact on provider cash flow because, by law, clean electronic claims are not paid any sooner than 14 calendar days (29 days for paper claims) after the date of receipt. Meanwhile, all claims for services delivered on or before December 31, 2009, will be processed and paid under normal procedures.
The holding of claims allows Medicare contractors time to receive the new, updated payment files and perform necessary testing before paying claims at the new rates. CMS has instructed contractors to begin processing claims at the new rates no later than January 19, 2010. Please note that most contractors are closed on January 18. Therefore, even absent a new update, most claims likely would not have been paid any sooner than January 19, 2010, given the aforementioned statutory 14-day payment floor.
CMS has extended the 2010 Annual Participation Enrollment Program end date from January 31, 2010, to March 17, 2010; therefore, the enrollment period now runs from November 13, 2009, through March 17, 2010.
12.17.09 Revisions to consultation services payment policy
Click here for details from CMS
Click here for CMS manual system document
12.16.09 2010 Physician Quality Reporting Initiative (PQRI) program announcement
Click here for details from CMS
12.09.09 Accessing 2007 re-run and 2008 Physician Quality Reporting Initiative (PQRI) feedback reports
The Centers for Medicare & Medicaid Services (CMS) would like to remind Physician Quality Reporting Initiative (PQRI) participants that there is a "Verify Report Portlet" look-up tool available on the PQRI Portal for Eligible Professionals (EPs) to verify if a 2007 re-run and/or 2008 PQRI feedback report exists for your organization's Tax Identification Number (TIN) or National Provider Identifier (NPI). The TIN or NPI must be the one used by the EP to submit Medicare claims and valid PQRI quality data codes.
Click here for PQRI tool
12.09.09 Providers must wait for Medicare claim crossover process to work
The Centers for Medicare & Medicaid Services (CMS) reminds all providers, physicians, and suppliers to allow sufficient time for the Medicare crossover process to work - approximately 15 work days after Medicare's reimbursement is made before attempting to balance bill their patients' supplemental insurers.
Click here for full news article
07.30.09 CMS offers NPIs/NPPES health care provider recommendations
The Centers for Medicare & Medicaid Services (CMS) is recommending that physicians and non-physician health care providers who have obtained National Provider Identifiers (NPIs) and who have records in the National Plan and Provider Enumeration System (NPPES)...
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07.07.09 CMS rule to exclude drugs from Medicare physician payment formula
The American Medical Association (AMA) says that The Centers for Medicare and Medicaid Services (CMS) has released the proposed Medicare physician payment schedule rule for 2010, including a "long-awaited announcement that the Obama Administration will change the definition of physician services under the SGR to exclude physician-administered drugs." AMA is reporting that the drug costs will be removed retroactive to the 1996/97 base year of the SGR formula, which will greatly lessen the forecast SGR cuts in future years, although there is still a 21.5 percent cut scheduled for 2010.
View news article and chart
05.22.09 Medicare urges early preparation for new HIPAA 5010 requirements
The Administrative Simplification Act (ASCA) requires the use of electronic claims in order for providers to receive Medicare payment. Effective January 1, 2012, physicians must submit claims electronically using the X12 Version 5010 and NCPDP Version D.0 of the HIPAA standards.
The HIPAA standards, including the X12 Version 5010 and Version D.0, are national standards and apply to transactions with all payers, not just with Fee-for-Service (FFS) Medicare. Therefore, physicians must be prepared to implement these transactions with non-FFS Medicare business.
Medicare expects to begin transitioning to the new formats January 1, 2011 and end the exchange of current formats on January 1, 2012. The new claim format accommodates the ICD-10 codes. Medicare says its system will be ready to handle the new standards by January 1, 2011.
Go to www.cms.hhs.gov/ElectronicBillingEDITrans/18_5010D0.asp on the Electronic Billing & EDI Transactions page on the CMS Web site for more information.
04.20.09 CMS announces data submission specifications
The Centers for Medicare & Medicaid Services (CMS) has announced that the 2009 Data Submission Specifications for use in the 2009 PQRI Electronic Health Record (EHR) test are now posted on the QualityNet Web site.
As described in the Medicare Physician Fee Schedule (PFS) 2009 Final Rule, CMS is testing EHR data submission in cooperation with electronic health record vendors. These vendors were selected from those who self-nominated per a process described in the 2008 final PFS rule. The EHR vendors that are successful with the 2009 testing process will be "qualified" for possible PQRI data submission via EHRs if this means of data submission is used in a future PQRI reporting year. There is no incentive payment available through EHR-based data submission for 2009.
Go to the QualityNet Web site
02.27.09 MIPPA authorizes new E-Prescribing incentive
The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) has authorized a new incentive program for eligible professionals who are successful electronic prescribers. MIPPA says that the new incentive program is in addition to the quality reporting incentive program authorized by Division B of the Tax Relief and Health Care Act of 2006 - the Medicare Improvements and Extension Act of 2006 (MIEA-TRHCA), also known as the Physician Quality Reporting Initiative (PQRI).
An MIPPA fact sheet says that the e-prescribing incentive has been placed at two percent for reporting years 2009-2010; one percent for reporting years 2011-2012, and 0.5 percent for reporting year 2013.
Click here for a copy of the fact sheet
Click here for additional information on electronic prescribing
02.18.09 Medicare issues reminder on appeals redetermination forms
Medicare regulations allow providers and beneficiaries who are dissatisfied with Medicare's determination to request that the determination be reconsidered. Through this process, Medicare seeks to ensure that the correct payment is made or a clear and adequate explanation is given supporting nonpayment.
Lately, there has been an increase of providers using the incorrect form when requesting a redetermination.
Click here for the redetermination request form
Click here for the reconsideration request form
Physician Relations
12.15.09 Physicians should enroll in PECOS to avoid Medicare payment interruption
The Medical Association of Georgia is reminding physicians to enroll in Medicare's new Provider Enrollment, Chain and Ownership System (PECOS) to avoid an interruption in payments beginning on April 5, 2010 - the extended enrollment deadline. This requirement applies to all Medicare providers who are not yet enrolled in the PECOS database.
Click here for full news
Read AMA's announcement
11.17.09 CMS extends annual enrollment date for Medicare
The Centers for Medicare & Medicaid Services (CMS) has extended the annual participation enrollment deadline for Medicare for 2010 from December 31, 2009 to January 31, 2010 due to recent revisions that were made to the 2010 Medicare Physician Fee Schedule (MPFS), according to Cahaba GBA, which is the J10 A/B Medicare Administrative Contractor (MAC) for Georgia.
Cahaba GPA says that this is an extension of the annual participation enrollment period dates in CR 6637 (Transmittal 1832 – Calendar Year (CY) 2010 Participation Enrollment and Medicare Participating Physicians and Suppliers Directory (MEDPARD) Procedures), dated October 16, 2009.
Cahaba GPA says the "Participation Agreement" (CMS-Form 460) is available on a CD that was mailed to providers on November 10, 2009.
Click here to enroll via Cahaba's Web site
11.17.09 Medicare enrollment memo from AMA
Medicare has made numerous changes to the enrollment process over the past few years, including significant changes effective April 1, 2009. The American Medical Association (AMA) continues to advocate for streamlining the Medicare enrollment process. In its latest memo, AMA highlights a few enrollment areas including, the recently announced revalidation effort; the critical need for physicians to keep their Medicare enrollment information up-to-date; and revisions to the AMA’s Medicare Enrollment toolkit.
Click here for full memo
11.01.09 CMS announces payment, policy changes for physicians' services to Medicare beneficiaries in 2010
The Centers for Medicare & Medicaid Services (CMS) today announced final changes to policies and payment rates for services to be furnished during calendar year (CY 2010) by over one million physicians and nonphysician practitioners who are paid under the Medicare Physician Fee Schedule (MPFS). The MPFS sets payment rates for more than 7,000 types of services in physician offices, hospitals, and other settings. Today’s action complies with federal law, which requires these policies and payment rates to be announced by Nov. 1.
View a copy of the final rule with comment period and supporting documentation
Click here for a fact sheet on the e-Prescribing Program and PQRI provisions
11.01.09 CMS responds to Medicare Advantage audit inquiries
Click here for details
10.22.09 CMS asking Medicare beneficiaries to check DMEPOS suppliers
Click here for details
06.18.09 Physicians cautioned to be on lookout for Medicare fax scam
The American Medical Association is warning physicians/staff about a scam whereby the perpetrators are sending faxes to physician's offices posing as a Medicare carrier or a Medicare Administrative Contractor (MAC). The fax reportedly instructs the physician/staff to provide account information by completing a questionnaire within 48 hours to prevent a gap in Medicare payments. The faxes have reportedly included the CMS logo and/or the contractor logo to enhance the appearance of its authenticity. AMA is advising Medicare providers to contact the applicable contractor before submitting any such information. Medicare providers should only send information to a Medicare contractor using www.cms.hhs.gov/MLNGenInfo/ or www.cms.hhs.gov/MedicareProviderSupEnroll.
04.22.09 New project promotes diabetes screening
A coalition of public and private sector organizations recently formed The Medicare Diabetes Screening Project (MDSP) to urge seniors in Georgia to get tested for diabetes. Recent research from CDC and NIH shows that 72 percent of people 65 and older have diabetes or pre-diabetes. Of those with diabetes, it's estimated that almost half are undiagnosed - yet Medicare data shows a low rate of utilization of the diabetes screening benefit. For more information about the MDSP, visit www.screenfordiabetes.org or contact Maurice Madden, MDSP Georgia Director, at 404.483.2640.
Download "Quick Reference Information: Medicare Preventive Services"
"Could I Have Diabetes and Not Know It?" (for patients)
02.27.09 CMS offering updated Medicare reporting fact sheets, brochures
The Centers for Medicare & Medicaid Services (CMS) has revised its physician, non-physician practitioner and group practice reporting responsibility fact sheets and the physician, non-physician practitioner and other health care supplier brochures.
The fact sheets list the types of changes that enrolled physicians, non-physician practitioners, and group practices are required to report to Medicare; doing so, CMS says, will help ensure that claims are processed correctly.
Reporting Responsibilities for Individual Physicians Enrolled in the Medicare Program
Reporting Responsibilities for Individual Non-Physician Practitioners Enrolled in the Medicare Program
Reporting Responsibilities for Physician Group Practices Enrolled in the Medicare Program
Physicians, Non-Physician Practitioners, and Other Health Care Suppliers Brochure
02.19.09 Internet-based Medicare enrollment available for physicians and non-physician practitioners
Physicians and non-physician practitioners can now enroll or make a change in their Medicare enrollment information by using an Internet-based Provider Enrollment, Chain and Ownership System (PECOS). The new system will allow physicians and non-physician practitioners to enroll, make a change in their Medicare enrollment, or view their Medicare enrollment information on file with Medicare.
There are three basic steps to completing an enrollment action using Internet-based PECOS. Physicians and non-physician practitioners must:
- Have an NPPES User ID and password to use Internet-based PECOS. For security reasons, physicians and non-physician practitioners should change passwords periodically, at least once a year.
- Go to Internet-based PECOS at https://pecos.cms.hhs.gov and complete, review, and submit the electronic enrollment application via Internet-based PECOS.
- Print, sign and date the two-page Certification Statement and mail the Certification Statement and all supporting paper documentation to the Medicare contractor within 7 days of electronic submission.
Click here to access PECOS
Prescription Drug Plan
04.28.09 Medicare preventative services offers quick reference on Medicare Part B Immunization Billing
View Quick Reference Chart from the American Medical Association
03.20.09 DMEPOS suppliers' deadline is September 30
Time is running out for suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) who bill Medicare under Part B to obtain accreditation by the September 30, 2009 deadline or risk having their Medicare Part B billing privileges revoked on October 1, 2009. While the accreditation process takes on average 6-7 months to complete, the process could take as long as 9 months to complete. Accordingly, DMEPOS suppliers should contact an accreditation organization right away to obtain information about the accreditation process and submit an application.
Pharmacies, pedorthists, mastectomy fitters, orthopedic fitters/technicians and athletic trainers must also meet the September 30 deadline for DMEPOS accreditation. Certain eligible professionals and other persons as specified by the Secretary are exempt from the accreditation requirement.
Click here for more information
03.09.09 Medicare Part B review shows increase in “Incident To” services
Data analysis and medical record review of Evaluation and Management (E&M) Services, conducted by the Part B Medical Review department, has shown a continuous increase in provider documentation errors of “Incident To” services. The following errors were identified for inappropriate documentation to support “Incident To” services.
- E&M services were documented by the physician assistant; there was no indication that the physician was present in the office and/or that there was physician involvement in the patient’s care.
- There were no physician signatures that identified physician involvement in the patient’s treatment.
Read full news article
02.27.09 New Cahaba GBA-Medicare Part B requirement effective March 1
Cahaba GBA-Medicare Part B says that effective March 1, 2009 its Provider Contact Centers (PCCs) customer service staff will be required to authenticate the identity of providers before it can disclose protected health information.
Providers who call the Interactive Voice Response (IVR) system or speak with a customer service representative (CSR) will be required to provide the following...
- National Provider Identifier (NPI)
- Provider Transaction Access Number (PTAN), or OSCAR
- Last five digits of Tax Identification Number (TIN)
The PCC phone number for Georgia is 877.567.7271.
Cahaba GBA-Medicare Part B says that these data requirements also apply to written inquiries, though those inquiries that are submitted on official letterhead are exempt. In those instances, the letterhead must clearly establish the provider’s identity, and it must match the information that’s on file with the Fiscal Intermediary Standard System (FISS) for Part A inquiries or the Multi Carrier System (MCS) for Part B inquiries. The letterhead must also include and match the NPI, the PTAN, or the last five digits of the TIN.
Refer to the Medicare Learning Network (MLN) Matters article, Implementation of New Provider Authentication Requirements for Medicare Contractor Provider Telephone and Written Inquiries (MM6139) at www.cms.hhs.gov/MLNMattersArticles/downloads/MM6139.pdf for additional information.