On April 10, 2015, the Centers for Medicare & Medicaid Services (CMS) released Change Request 9119 that implements changes to Chapter 7 of the Medicare Benefit Policy Manual pursuant to the CY 2015 Home Health PPS Final Rule published in November 2014. The changes to the Medicare Benefit Policy Manual will be effective May 11, 2015. Change Request 9119 introduces changes to the Medicare Benefit Policy Manual, Chapter 7, Section 30.5.1 – Physician …Read more
Therapy providers no doubt will take comfort in the familiar, as we are once again back to the future with the therapy caps exceptions process that is applicable to all therapy providers billing under Medicare Part B. The U.S. Senate voted Tuesday evening on HR-2, the “doc fix” bill, to repair the sustainable growth rate (SGR). Tied to the legislation, which had passed in the House prior to Congress recessing for …Read more
To begin, I believe that the recent audit of Northwestern reflects the generally poor processes and statistical modeling used by Centers for Medicare & Medicaid Services (CMS) auditors when scrutinizing a healthcare provider. In particular, there seems to be this general idea that there is some degree of homogeneity within the broad range of diagnostic and therapeutic treatments (as well as the delivery of medical supplies, drugs, and other services and …Read more
On April 7, the Centers for Medicare & Medicaid Services (CMS) released an update to the State Operations Manual, Appendix W, which provides the survey protocol, regulations, updates for conditions of participation (CoP), and interpretive guidelines for critical access hospitals (CAHs) and swing beds in CAHs. The 89-page document is wide-reaching, including changes to bed number counting, use of observation...Read more
Medicare has been sending comparative billing reports (CBRs) for some time. One recent CBR examined the use of modifier -25 by nurse practitioners (incidentally, if you receive an interesting CBR or other communication from Medicare or any other payer, please consider sending me a copy). There is a LOT to discuss in this report, but before focusing on its specifics, it...Read more
Two weeks ago the Centers for Medicare & Medicaid Services (CMS) published an update to the 2015 Hospital Outpatient Prospective Payment System that included two paragraphs that appear to change a longstanding CMS policy that required an inpatient admission order prior to every inpatient-only surgery. CMS seems to be saying that as of April 1, it is allowing the three-day...Read more
With goals to lessen provider burden, increase transparency, and enhance oversight, Recovery Audit Contractors (RACs) are changing. And even bigger changes are around the corner. The most important advice for healthcare providers is to get ready. To help reduce provider burden, the Centers for Medicare & Medicaid Services (CMS) will begin implementing modifications to the RAC program. These include: Placing limits on...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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