Last month the Centers for Medicare and Medicaid Services (CMS) released MLN Matters MM9078 along with change request 9078 that specifies the coverage and coding for permanent pacemakers which has been in flux for the last 18 months. CMS has now established July 6, 2015 as the date on which all claims for pacemakers must include the –KX modifier. But the history of this modifier and the coverage determinations for pacemakers …Read more
Evaluation and Management (E/M) services have many gray areas from an auditing standpoint, yet they continue to represent a top audit target for payers and the government. The documentation guidelines for E/M services are now 20 years old and have seen no significant changes. What has changed, however, is how the medical record is created, analyzed, and scored. What we have been left with are guidelines that are suggestive in nature and …Read more
Pursuant to the calendar year (CY) 2015 Home Health Final Rule published by the Centers for Medicare & Medicaid Services (CMS) on Nov. 6, 2014, effective Jan. 1, 2015 new rules for home health agencies face-to-face encounter documentation were implemented. One of the most notable revised rules was the elimination of the brief narrative requirement in almost all cases for home health face-to-face encounter documentation. The home health industry accepted this …Read more
One of the objectives of the Centers for Medicare & Medicaid Services (CMS) is to move away from fee-for-service healthcare and toward pay-for-performance. But the road to pay-for-performance has not been a smooth one. The initial accountable care organization (ACO) program design was flawed, with ACOs held financially responsible for the yearly expenses of a “mystery cohort,” a group of beneficiaries...Read more
Here it is January 2015, and we are still struggling with a rule put in place back in October 2013. The reasons behind the struggles vary from hospital to hospital but have a resounding theme behind most of them. If only the Centers for Medicare & Medicaid Services (CMS) could be clear in its definition of inpatient versus outpatient, we...Read more
The following are a few practical tips for responding when you get a request for medical records from Medicare or a private insurer. First, make sure that whoever is opening the mail keeps the envelope. It is relatively common for the date on a letter and the date of the postmark to be extremely disparate. In one case, a letter dated...Read more
Thursday, April 2, 2015
Depending on your role, “medical necessity” likely has its own meaning. Was it medically necessary for the patient to be admitted to the hospital? Did the provider select the correct code for the service provided based on medical necessity standards? While these medical necessity criteria are important and are being actively audited, this presentation will not address them because the target of audits is now shifting to the “real” medical necessity - does the patient really need to have done to them what the provider has ordered.
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