Current Medicare News
Please select the links below for complete Medicare articles and events of the current year.
Audit & Enforcement
11.18.10 CMS not yet rejecting Medicare claims based on PECOS requirement
The Centers for Medicare and Medicaid Services (CMS) has reportedly said that it has not yet begun enforcing the July 6 deadline requiring all physicians (except those who have opted-out of Medicare) who refer or order services for Medicare patients to be enrolled in the PECOS database. For now, CMS reportedly says that it will not reject claims as long as orders include the referring/ordering physician’s legal name and National Provider Identifier. CMS is supposed to provide additional information on the subject in the near future, but it has reportedly indicated that it will not begin rejecting claims for this reason until the vast majority of referring/ordering physicians are enrolled in the PECOS system. CMS has also reportedly said that it will notify physicians 30 days before it starts rejecting claims.
Click here for additional information on PECOS system enrollment
11.12.10 Submitting appeals on overpayment, PSC, and RAC demand cases
Read details from Cahaba GBA
11.01.10 MAG helps physicians recoup an estimated $400,000 in cataract claims denials
MAG recently discovered that Cahaba Government Benefit Administrators®, LLC has been improperly denying cataract claims for Medicare practices that submitted claims using the RT (right) and LT (left) modifiers. Cahaba updated its system to accept these modifiers as a result of MAG's intervention. Cahaba says the services will not be denied in the future, but it's stressing that affected physicians must re-file all denied claims for payment. Physicians in the state saved an estimated $400,000 because of MAG's efforts. Contact Craig Hess at 205.220.1372 or crhess@cahabagba.com with questions.
10.28.10 PECOS system technical problems reportedly resolved
The Center for Medicare and Medicaid Services (CMS) reportedly experienced some technical problems with its PECOS Provider Enrollment, Chain and Ownership System (PECOS) application and certification system between October 10, 2010 and October 20, 2010. The issues have reportedly been resolved. Complaints can be submitted at www.ama-assn.org/ama1/pub/upload/mm/399/medicare-complaint-form.pdf.
Go to the PECOS Website
10.27.10 CMS: Physicians not enrolled in PECOS face claims rejection in near future
The Centers for Medicare and Medicaid Services (CMS) has posted a list of the physicians who are enrolled in the Provider Enrollment, Chain and Ownership System (PECOS) system on its Website. CMS says the Website also includes a list of physicians who are in the process of enrolling in the PECOS system. Medicare physicians were required to be in the PECOS enrollment database effective July 6, 2010, according to CMS. CMS is encouraging Medicare physicians who are not yet enrolled in the PECOS system to do immediately. CMS has not yet begun to reject the claims of physicians who are not yet enrolled in the PECOS system, but it says it will start doing so in the near future.
09.28.10 CMS releases Recovery Audit Contractor (RAC) vulnerabilities
Recovery Audit Contractor (RAC) demonstration high-risk medical necessity vulnerabilities for inpatient hospitals
Recovery Audit Contractor (RAC) demonstration high-risk diagnosis related group (DRG) coding vulnerabilities for inpatient hospitals
07.14.10 Recovery Audit Contractor (RAC) demonstrates high-risk vulnerabilities: No documentation or insufficient documentation submitted
The Centers for Medicare & Medicaid Services (CMS) has released MLN Matters Special Edition Article #SE1024 as the first in a series of articles concerning RAC high-dollar improper payment vulnerabilities. These articles are intended to provide education about RAC demonstration-identified vulnerabilities in an effort to prevent these same problems from occurring in the future. This article in particular focuses on Medicare’s documentation requirements and how to avoid unnecessary denial of claims.
Read more
07.07.10 Clarification regarding date all referring/ordering providers must be enrolled in PECOS
Read details from Cahaba GBA
07.06.10 CMS details new Medicare provisions in the Affordable Care Act of 2010 (ACA)
Read CMS newsletter
07.01.10 CMS to review PECOS enrollment process
Read statement from CMS
06.24.10 CMS gives updated RAC report
Read more
06.04.10 Cahaba warns physicians about duplicate Medicare claims
Click here for details
05.25.10 CMS provider enrollment and upcoming PECOS deadline
The American Medical Association says that any physician who refers or orders services (DMEPOS, home health, specialist services [not defined by CMS], lab, or imaging) will need to be enrolled with Medicare in the PECOS system by July 6, 2010. This includes any physician who has not submitted an updated enrollment application to Medicare in the past six years or has had a change to their enollment information during this time but has not reported the change. If they are not enrolled by July 6, the physicians who they refer patients to (and thus must list the name and NPI of the physician they referred/ordered) could see their claims reject. The AMA says that this goes beyond what is in the new health system reform law which says that by July 1 all physicians who refer/order home health and DMEPOS must be enrolled. The law does provide allow for the Secretary to require physicians who order/refer other services to be enrolled later but CMS decided to require them all to be enrolled in PECOS by July 6.
Also, under the new CMS policy physicians who have opted-out of Medicare will not be required to enroll in PECOS - they must just have the correct paperwork filed with CMS indicating this status. However, there is no description of what this means (i.e., a specific form) in the rule. Physicians who have opted-out should call their contractor to see if they are listed.
Click here for a complete list of who must enroll (see page 24443-24444)
04.06.10 CMS responds to MAG inquiry on Medicare Advantage requests, audits
Click here for response
03.05.10 UnitedHealthcare expands Medicare Solutions Radiology Authorization Program
Read UHC Medicare Solutions notice
Radiology Prior Authorization Program
Frequently Asked Questions
SecureHorizons and Evercare Medicare Advantage Radiology Prior Authorization Program Included and Excluded Plans
Medicare Advantage Radiology Prior Authorization Program: Quick Reference Guide
02.25.10 Update on claims processing for ordering/referring providers
Click here for CMS alert
02.18.10 Medicare claims crossover to supplemental payer problem
Click here for CMS alert
Coding
03.18.11 Top 5 Reasons for Claims Rejections in February
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02.21.11 Top 5 Reasons for Claims Rejections in January
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12.15.10 Top 5 Reasons for Claims Rejections in November
View PDF
11.16.10 2010 e-prescribing incentive program measurement code reporting update
All Eligible Professionals (EPs) are encouraged to follow the current 2010 E-Prescribing (eRx) incentive program requirements. EPs should check the measure specifications at the beginning of each year because they may change. The correct measurement code to bill in 2010 for calculations of the 2010 eRx incentive payment is G8553.
The 2009 eRx measurement codes have been accepted for processing by the Medicare claims systems. However, in October, a temporary change occurred that led to the rejection of 2009 eRx codes. EPs cannot resubmit claims that may have been rejected with the 2009 eRx measurement codes. Submissions reported using a qualified registry or a qualified Electronic Health Record, will not be affected by this situation.
All EPs should work with their vendors and clearinghouses to make sure they are aware of any measure specification changes.
Click here for the latest information and requirements
11.03.10 New practice management cost analysis tool now available
Read more from AMA
10.08.10 Top 5 Reasons for Claims Rejections in September
View PDF
10.08.10 Part B medical review and appropriate documentation of outpatient therapy services
Medical review of Outpatient Therapy Services has shown consistent documentation and coding errors for therapy services. The Comprehensive Error Rate Testing (CERT) program also has shown documentation errors for Outpatient Physical Medicine and Rehabilitation services.
Appropriate documentation of outpatient therapy services
CMS billing scenarios for physical therapy and occupational therapy servicess
CMS Change Request 6980: Therapy cap update
Outpatient therapy services (PowerPoint)
CMS rehabilitation therapy information resource guide
CMS signature requirements (MLN 6698)
10.07.10 Office of Inspector General increases auditing efforts, resource can help physician practices prepare
In September 2010, the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services published its 2011 Work Plan, which became effective on Oct. 1, 2010. The Work Plan describes the areas in which the OIG will focus specific audit, investigation, enforcement and compliance activities. The OIG indicated that it will review the extent of potentially inappropriate payments for evaluation and management (E&M) services. The OIG stated that Medicare contractors have noted an increased frequency of medical records with identical documentation across services.
The AMA's new Practice Analysis Tools for Healthcare (AMA PATH™) can help physicians analyze their individual coding and billing practices and compare them with national averages by specialty. Using AMA PATH, a physician can analyze his or her billing patterns with respect to individual E&M codes and, in so doing, enable the physician to identify and rectify any billing or coding practices or patterns that might draw the attention of the OIG or other governmental agencies.
View the OIG's work plan
Learn more about AMA's online tool
09.16.10 Type of Bill 13X: Appropriate Medical Record Documentation for Critical Care (CPT 99291)
An article titled "Type of Bill 13X: Appropriate Medical Record Documentation for Critical Care Services (CPT 99291), Evaluation and Management of the Critically Ill or Injured Patient; first 30-74 minutes" was posted to the Cahaba GBA Website in September 2009 at http://www.cahabagba.com/part_a/whats_new/20090923_criticalcare.htm.
Medical review data analysis and medical record reviews continue to identify provider documentation errors for claims billed with CPT 99291. The submitted medical record documentation did not support that critical care evaluation and management services were provided and documentation of critical care time requirements was not met.
Providers are reminded that medical record documentation of critical care services should demonstrate the patient's condition warranted the type and amount of services provided. The medical necessity of the services must be documented with the total time the physician and/or hospital staff were engaged in active face-to-face critical care of a critically ill or critically injured patient.
09.10.10 Top 5 Reasons for Claims Rejections in August
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08.24.10 CMS issues reminder on January 2011 target for testing transaction standards; 2013 compliance date for ICD-10 code sets
Click here for details from CMS
08.05.10 AMA's 'How you can prepare now for ICD-10'
Click here for details from AMA
07.28.10 AMA-MGMA unveil 'Selecting a Practice Management System Toolkit'
Click here for resources
07.10.10 Top 5 Reasons for Claims Rejections in June
View PDF
06.30.10 CMS and Cahaba reconciling Medicare fee schedule error
Click here for 'News from MAG' article
06.07.10 Revised payment files for the 2010 Medicare Physician Fee Schedule Database (MPFSDB)
According to Cahaba GBA, the change request (CR) 6973 was released to Medicare contractors on May 10 releasing updated Physician Fee Schedules retroactive to January 1, 2010. Due to an oversight when CMS created the new files, there were some entries to the files that were omitted.
CPT Codes 78811-78816 and 78811 TC - 78816 TC did not contain the CMS capped rate, and since May 24 these codes have generated overpayments. A temporary fix was installed into the Cahaba GBA system on June 3 to avoid additional overpayments from being generated on claims received June 4 to July 5.
CMS said it plans on correcting the Physician Fee Schedule File with the July release, being installed on July 6. Once all the claims that generated the overpayments have completed processing, Cahaba GBA will initiate the overpayment recovery for the codes mentioned above that generated the overpayments.
06.02.10 AMA alert: "5010" standard transactions and ICD-10 code sets compliance deadlines approaching
To avoid disruptions in cash flow and transaction processing, physician practices must be ready to send and receive only the updated version of Health Insurance Portability and Accountability Act (HIPAA) electronic transactions, commonly known as "5010," beginning Jan. 1, 2012.
To meet this deadline, practices will need to begin testing the upgraded electronic administrative transactions with their trading partners in 2011. In addition to the 5010 transactions, the ICD-10 code set must be used for all services provided beginning Oct. 1, 2013.
The Centers for Medicare & Medicaid Services, which oversees compliance of the HIPAA standard transactions and code sets, has made it clear that the compliance deadlines will not be extended. In fact, Medicare expects to begin testing the 5010 transactions with physicians and other health care providers in 2011.
05.27.10 ICD-10: AMA's overview slides
Review slides
05.10.10 Top 5 Reasons for Claims Rejections in April
View PDF
04.24.10 CMS issues signature guidelines for medical review purposes
The Centers for Medicare & Medicaid Services (CMS) have issued a change request (CR 6698) to clarify for providers how Medicare claims review contractors review claims and medical documentation submitted by providers. CR 6698 outlines the new rules for signatures and adds language for e-prescribing.
Click here for details from CMS
04.14.10 AMA payment policy committee prepares chart showing how private health plans intend to treat consultation codes eliminated by Medicare
Click here for chart
04.12.10 Top 5 Reasons for Claims Rejections in March
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02.19.10 Medicare claims crossover to supplemental payer problem
Read news article
02.11.10 Top 5 Reasons for Claims Rejections in January
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01.25.10 CMS delays implementation of ordering referring report
Click here for details from CMS
01.08.10 Top 5 Reasons for Claims Rejections in December
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Payment
06.04.10 21.3 percent Medicare payment cut in effect
Click here for details
06.03.10 MPFS claims on hold for 10 business days
Read statement from CMS
05.28.10 Bill with Medicare SGR "patch" not expected to pass House
MAG has learned that the U.S. House of Representatives will reportedly consider "extender" legislation (H.R. 4213) on Friday, May 28 that contains a $22.9 billion Medicare "patch" - though it's not expected to pass given the overall cost of the bill.
The proposal would increase Medicare physician payment by 2.2 percent for the remainder of 2010 and another 1 percent in 2011 - but it would also then revert to the current SGR formula in 2012, resulting in a cut that's been placed at 30 percent or more.
Given a week-long Memorial Day holiday recess, it's not clear if lawmakers have enough time to pass legislation to stop the 21 percent Medicare physician pay cut that is scheduled to go into effect on June 1, when the most recent extension expires.
Monitor www.mag.org for the latest Medicare SGR developments.
05.26.10 SGR "extender" bill reportedly in works
Read News from MAG article
05.26.10 Understanding Medicare recoupment rules
Read News from MAG article
05.24.10 CMS adjusting PQRI payments for 2008
Click here for details
05.11.10 AMA's 'Understanding New Medicare Recoupment Rules'
Click here for article
04.30.10 Filing requirements for Medicare FFS claims change with H.R. 3590
Click here for full news article
Physician Relations
03.01.11 Cahaba GBA to hold several Medicare Part B Webinars for Georgia physicians in March
Click here for details on Cahaba GBA's Medicare Part B events
11.23.10 New resource helps physicians weigh Medicare options
The American Medical Association has developed a resource to help physicians "choose the (Medicare participation) direction that is right for their practice…" The Medicare "kit" includes a detailed explanation of the three available options (participation, nonparticipation and private contracting), as well as a revenue calculator and patient communications resources. Physicians have until December 31, 2010 to modify their status with the Medicare program.
Click here for the Medicare options kit
11.16.10 New CMS Webpage available for the Medicare Fee-For-Service Physician Feedback/Value Modifier Program
CMS uses claims data to create confidential reports measuring the resources and quality of care involved in furnishing care. In 2010, the Physician Feedback Program is limited to physicians and groups that have been notified - and if you have not received notification then you will not receive a report. Feedback reports will be distributed in a multi-year, phased, implementation schedule to medical professionals and medical group practices.
Click here to learn more
09.15.10 CMS releases its 'Medicare Contractor Provider Satisfaction Survey (MCPSS) Public Report'
Read report
07.13.10 Cahaba GBA closing Savannah office by April 2013
Read letter from Cahaba GBA
06.24.10 Humana issues Medicare Advantage contract amendment
Message from Humana:
"We are beginning to send contractual amendments to physicians and will continue to do so through the first part of July. The amendment notifies physicians of adjustments to certain radiology-related fees rendered to our Medicare Advantage members (Commercial products are not impacted). The amendment will become effective 90 days from the date of the notice to providers. It will impact 24,000 physicians and other providers across the country who bill Humana for radiology services on a global or technical basis. The intent is to more closely process and reimburse radiology-related claims similar to the CMS methodology. The radiology fee schedule referenced in the amendment is based on a modified version of the unadjusted Outpatient Prospective Payment System (OPPS) fee schedule and unadjusted Physician Fee Schedule (PFS). The schedule is reviewed and updated annually to reflect the annual updates to the OPPS and PFS schedules made by CMS. Annual updates to the schedule by CMS may result in fees being adjusted accordingly. Providers will have the opportunity and right to object to the notice and instructions for doing so will be relayed in the notice."
06.14.10 PECOS enrollment required for Medicare Electronic Health Record (EHR) Incentive Program
Click here for CMS announcement
06.08.10 CMS enrollment applications - Processing status update
Read announcement from Cahaba GBA
05.25.10 Opt-out procedure for physicians who have never enrolled in Medicare
The opt-out procedure for physicians who have never enrolled in Medicare can be found in the Centers for Medicare and Medicaid Services (CMS) Internet-only manuals (Publication 100-2, Chapter 15, Section 40.13). These instructions are as follows...
"40.13 - Physician/Practitioner Who Has Never Enrolled in Medicare (Rev. 92; Issued: 06-27-08; Effective/Implementation Date: 09-29-08)
For a physician/practitioner who has never enrolled in the Medicare program and wishes to opt out of Medicare, the physician/practitioner must provide the carrier with a National Provider Identifier (NPI). The carrier must annotate its in-house provider file that the physician/practitioner has opted out of the program. The carrier can get the full name, address, license number, and tax identification number from the physician's/practitioner's opt out affidavit. All other data requirements should be developed from other data sources (e.g., the American Medical Association, State Licensing Board, etc.). The physician/practitioner must not receive payment during the opt-out period (except in the case of emergency or urgent care services). If the carrier needs additional data elements and cannot obtain that information from another source, it may contact the physician/practitioner directly. It must notify the physician or practitioner that in order to refer or order services for a Medicare patient, the physician or practitioner must have an NPI.
If an opt-out physician/practitioner provides emergency or urgent care service to a beneficiary who has not signed a private contact with the physician or practitioner and the physician/practitioner submits an assigned claim, the physician or practitioner must complete Form CMS-855 and enroll in the Medicare program before receiving reimbursement. Under a similar circumstance, if the physician or practitioner submits an unassigned claim, the carrier must pay the beneficiary directly without requiring a completed Form CMS-855. It may use the information from the affidavit to begin the enrollment process."
The Medicare contractor will establish an "affidavit record" in PECOS for the opt-out physician. This record will allow the physician to order and refer in the Medicare program.
05.07.10 CMS: Medicare reporting requirements for change of address
Read full news article
04.30.10 CMS: Medicare covers key cancer screenings
Read full news article
04.20.10 CMS prepares rules for new HIPAA transaction standards
Read full news article
04.14.10 Cahaba GBA posts online training tool
Cahaba GBA says it recently introduced "Cahaba University" - an online self-service training tool for physicians and their staff. Cahaba GBA says the online university is designed to give health care professionals the information, tools and confidence they need to successfully implement and manage their learning within the Medicare program. Cahaba University members have access to resources and benefits that include coding and reimbursement assistance and practice promotion tools.
Cahaba University for Medicare Part A
Cahaba University for Medicare Part B
02.26.10 Physicians need to choose Medicare participation status by March 17
Click here for details
02.09.10 CMS approves three national organizations to accredit suppliers of Advanced Imaging Services
Click here for details from CMS
02.09.10 Georgia not in first phase of Medicare DMEPOS competitive bidding program
The Centers for Medicare & Medicaid Services has announced that Medicare will begin phasing in a competitive bidding program for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) in 2011. Georgia is not included in the first phase of the transition.
Click here for additional information
01.12.10 CMS offers revised 'Medicare Physician Guide'
The revised Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals) offers general information on the Medicare program, including how to become a Medicare provider or supplier and Medicare payment policies, is now available in CD-ROM format from the Centers for Medicare & Medicaid Services (CMS) Medicare Learning Network. To place your order, go to www.cms.hhs.gov/MLNGenInfo/, scroll down to "Related Links Inside CMS" and select "MLN Product Ordering Page."
Click here to place your order
Prescription Drug Plan
01.25.10 Annual Physician Injectable Drug List (PIDL) Re-pricing
Medicare recently published its January 2010 Average Sales Price (ASP) rates on the Centers for Medicare and Medicaid Services (CMS) Web site.
Effective for dates of service (DOS) on and after January 1, 2010, the Georgia Department of Community Health (DCH) will expedite its annual re-pricing of the Physician Injectable Drug List (PIDL), using Medicare's January 2010 ASP rates for applicable physician administered injectable drugs. This action serves to ensure compliancy with the 2009 Georgia Legislative mandate and the State Plan.
Click here for full announcement, price list
Related Links
- AMA's 2010 Medicare Physician Payment Schedule
- AMA's 2010 Medicare physician payment cut action kit
- CAHABA GBA and CMS Updates
- CMO hassle factor log sheet
- CMS Medicare Learning Network
- CMS NPI Lookup Function
- Medicare
- Contracted fee schedule
- Payment rules
- Prior authorization
- Payer-specific claim edits
- Medical unlikely edits (MUEs)
- Medical policies
- Medicare Diabetes Screening Project
- Provider-supplier enrollment
- Multiple procedure reduction logic
- NPI News
*Many of the documents listed here are available in PDF format and can be viewed using Adobe Acrobat Reader.® This free software can be downloaded from the Adobe® site, http://www.adobe.com.