Ensuring your documentation meets medical necessity standards In 2003, the Centers for Medicare & Medicaid Services (CMS) made a change within the Claims Processing Manual regarding the selection of the evaluation and management (E&M) level of service to be effective in 2004. This change made the need, reason, or extensiveness…
Payers and providers square off to ensure patients aren’t stuck with huge costs. EDITOR’S NOTE: Matthew Albright, chief legislative affairs officer for Zelis and the former Director of the Administrative Simplification Group of the Centers for Medicare & Medicaid Services (CMS), granted me an interview recently. What follows are excerpts…
Major realignment is scheduled for this weekend. As reported last week by RACmonitor, in a restructuring of the Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO) jurisdictions, the Centers for Medicare & Medicaid Services (CMS) created 10 regions across the United States and awarded KEPRO, a BFCC-QIO, a new five-year…
CORRECTION: Because of a publishing error, this article, written by healthcare attorney David Glaser, was published on May 30 by RACmonitor after the new guidance was actually published. That guidance can be found here, https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO-19-13-Hospital.pdfIn a statement to RACmonitor, Glaser offered comments about the new guidance from the Centers for…
The MAC is proposing an LCD for vertebral augmentation procedures. The controversy over the vertebral augmentation procedures kyphoplasty and vertebroplasty continues with a just-released proposed Local Coverage Determination (LCD) from Noridian, a Medicare Administrative Contractor (MAC). In this LCD, for which comments are now being accepted, Noridian is proposing to…
Outreach to providers on the topic continues. From the same folks who brought you the Electronic Submission of Medical Documentation (esMD), there is a new initiative from the Centers for Medicare & Medicaid Services (CMS) known as the Medicare Fee-for-Service (FFS) Documentation Requirement Lookup Service (DRLS) pilot. Melanie Combs-Dyer, who…
A search for a national review HWDRG contractor is expected in the third quarter. In a restructuring of the Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO) jurisdictions, the Centers for Medicare & Medicaid Services (CMS) has created 10 regions across the United States and awarded KEPRO, a BFCC-QIO, a…
Adding TKA to the BPCI appears to be more involved than anticipated. As reported by the American Hospital Association and other organizations, starting in 2020, the Centers for Medicare & Medicaid Services (CMS) will be adding outpatient total knee arthroplasty (TKA) to the list of episodes in the Bundled Payment…
Last week the Centers for Medicare & Medicaid Services (CMS) released a blog post from agency Administrator Seema Verma titled “Recovery Audits: Improvements to Protect Taxpayer Dollars and put Patients over Paperwork.” In the post, Ms. Verma talked about the Recovery Audit Contractor (RAC) changes CMS made back in 2015,…
Let’s talk targeted probe-and-educate (TPE) audits. TPE audits have turned out to be “wolf audits” in sheep’s clothing. The Centers for Medicare & Medicaid Services (CMS) asserted that the intent of TPE audits is to reduce provider burden and appeals by combining medical review with provider education. But the “education”…