How to Choose Between Modifiers 25 and 57

When reporting an evaluation and management (E&M) service on the same claim with another service or procedure, you must append either modifier 25 "Significant, separately identifiable evaluation and management service

6 Major Takeaways From the 2018 MACRA Proposed Rule

Below are important takeaways from the proposed rule:

1. Only 36% of clinicians will be eligible for MIPS after all exclusions, but they make up 58% of Medicare Part B charges...

Claims Rejected as Unprocessable with MA130 Cannot be Handled Within the NGS Telephone Reopening Unit

Avoid exhausting valuable time and delays in payment by resubmitting a new claim with the required or corrected information. NGS has seen an increased number of inquiries to their TRU for claims...

Request Permanent Immediate Recoupment/Offset for Medicare Overpayments and Streamline Your Processing

Providers can elect to request Permanent Immediate Recoupment/Offset of their demanded overpayments to avoid making payment by check or avoid the assessment of interest if the immediate recoupment pays the debt in full before day 31...

New Medicare Cards with New Numbers: 3 Changes You May Need to Make

The Medicare Access and CHIP Reauthorization Act of 2015 requires CMS to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019. CMS will begin mailing new Medicare cards with...

New Process for Providers and Suppliers Submitting Redeterminations and Reopenings via NMP

Noridian has added a feature to the Noridian Medicare Portal (NMP). Providers and suppliers who submit their Redetermination and/or Reopening requests through NMP will now receive Level 1 Medicare...

Tips Regarding Therapeutic Shoes

How criterion 2 of the Local Coverage Determination (LCD) is met:

In order to meet criterion 2, the certifying physician must either:

Personally document one or more of criteria 2a–2f..............

MIPS Participation Status Letter

CMS is reviewing claims and letting practices know which clinicians need to take part in the Merit-based Incentive Payment System (MIPS), an important part of the new Quality Payment Program (QPP). In late April through May, you will get a letter from your Medicare Administrative Contractor that processes......

Medicare Reporting & Returning of Self-Identified Overpayments-60 Days & 6 Years

Under this rule, providers and suppliers who receive Medicare funds have to report and return overpayments by the later of these two:

Multi-Factor Authentication Required on Noridian Medicare Portal

Beginning April 1, 2017 the Noridian Medicare Portal (NMP) will require a multi-factor authentication (MFA) process for users each time you need to log into NMP. MFA adds a second layer of security to your NMP account. The MFA process issues a one-time passcode that will be delivered to you........

1099s Returned with Insufficient Address

What You Should Know About a Significant Change to Type 2 Diabetes ICD-10 Coding

There have been some changes to the ICD-10-CM Official Guidelines for Coding and Reporting that impact podiatrists. These changes are for the 2017 fiscal year and went into effect October 1, 2016. In addition to the specific......

Judge Blocks Aetna's $37 Billion Deal for Humana

A federal judge has made a ruling on Monday January 23, 2017 that a $37 billion merger between will not be completed due to antitrust reasons in accordance with the U.S. Department of Justice. This ruling has taken place six.......

Pre-Payment of Prologned Service E&M Codes

The New York State Medicare Part B contractor, NGS Medicare, has been performing a complex medical review of add-on services related to evaluation and management codes...

Billing for Custom DMERC Products Not Picked Up By Patient

If a custom-made item was ordered but not furnished to a beneficiary due to individual passing away, order cancellation by the beneficiary, beneficiary's condition and the item is no longer being reasonable, necessary or appropriate...

2017 MACRA Final Rule Hits!

The Department of Health & Human Services (HHS) released its final rule on the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This act, which will go into effect January 01, 2017...

Centene to Acquire Fidelis Care Assets for $3.75B

Centene Corporation announced that it has signed a definitive agreement under which Fidelis Care will become Centene's health plan in New York State...

CMS-1500 Claim Form Must Be the 02/12 Version

Effective August 30, 2017 any CMS-1500 paper claim form submitted for Part B claims that is on a version other than the current 02/12 version will be returned to the provider. Per CMS...

Preventing Appeals Delays by Avoiding Duplicate Submissions

Providers and beneficiaries have the right to appeal claim determinations made by NGS. NGS has 60 days to process and complete your first level of appeal...

Transition and Flexibility-QPP 2018 Proposed Rule

CMS released the proposed 2018 Quality Payment Program (QPP) rule on June 20. To sum up the 1,000+ pages, 2018 will be something of a transition year like 2017 was for QPP, which was established under MACRA...

Redetermination Requests Which Contain Multiple ICNs

When submitting a Redetermination request that contains multiple Internal Control Numbers (ICNs), include and follow the below to ensure proper review and prompt response...

Advance Beneficiary Notice of Non CoverageNew Version Effective June 21, 2017

Effective June 21, 2017, providers must use the most recent version of the Advance Beneficiary Notice of Noncoverage (ABN) Form CMS-R-131 with the March.....

Mandatory Payment Reduction of 2% Continues for the Medicare FFS Program-Sequestration

For the Fee-for-Service (FFS) program, claims with dates of service or dates of discharge on or after April 1, 2013 will continue to incur a 2 percent reduction in the Medicare payment until further notice....

Tricare Changes Coming in October

There are changes coming to Tricare! Tricare is currently divided into 3 regions – North, South & West. The North is handled by Health Net Federal Service (HNFS), South is handled by Humana Military and West by United Healthcare.....

Claims Denied for Duplicate or Bundling

The Noridian Medicare Portal (NMP) offers Part B providers accessibility to obtain more information about a finalized claim that was denied or received a reduced payment due to related services. Types of claim situations providers can research include National Correct Coding Initiative edits, pre- or post-operative......

Ensure DMEPOS Claims for Dual Eligible Beneficiaries are Assessed Against Medicaid's Broader Criteria

Ensure DMEPOS Claims for Dual Eligible Beneficiaries are assessed against Medicaid’s Broader Criteria. On February 2, 2016, CMS issued updated regulations stating that Medicaid must cover appropriate medical supplies, equipment and......

ICD-10 Humor for the Holidays

Nothing like some ICD-10 humor to keep us in festive spirits...

The Quick CMS Approved Way to Avoid a MACRA Penalty

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) involves a shift to value based payment models...

Documentation Checklist - Knee Ankle Foot Orthoses

Simple checklist that puts the language of LCD in simpler terms to ensure that suppliers are meeting medical necessity requirements.

Medicare Revalidations

As of this year, all Medicare part B providers and DME suppliers were subject to a revalidation of their credentials in order to maintain their billing privileges with the program as part of the Accountable Care Act...

Correct Usage of CCI Edits to Prevent Improper Bundling and Denials

CCI includes two different sets of edits: Column 1 / Column 2 edits identify code pairs that should not be billed together because one service inherently includes the other... causing..

 Humana-Timely Filing Periods

The timely filing, otherwise referred to as proof of loss, period is the time-frame from the date of service until the date by which a claim must be submitted to Humana...

Beware of Medicare Scammers!!!

Having your Social Security number removed from your Medicare card helps fight medical identity theft and protect your medical and financial information. But even with these changes, scammers will still look for ways to...

Reminder for Using Modifier GZ

Modifier GZ must be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary, and they do not have an...

Revised Local Determination (LCD): Routine Foot Care and Debridement of Nails (L33636)

On 6/26/2017, a revision was published for LCD L33636 in the Medicare Coverage Database (MCD). To allow sufficient notice of the change to providers, the revised LCD can be found in the MCD on the Centers for Medicare & Medicaid Services (CMS) website...

Important Notice Regarding Handwriting on Claims Submitted to Medicare

Effective 7/1/2017, NGS will return any paper claims submitted with handwriting on the face of the claim that is not a signature field...

Tips Regarding Therapeutic Shoes

Supplier Billing for Custom Made Items Ordered but not Furnished:

Suppliers will bill the claim for the shoes/inserts with the supplier's expense at the time the order was cancelled or beneficiary expired for the custom made items...........

QMB Indicator in the Medicare Fee-For-Service Claims Processing System-Revised

Change Request (CR) 9911 modifies the Medicare claims processing systems to help providers identify the Qualified Medicare Beneficiary (QMB) status of each patient and to support providers' ability to follow QMB billing requirements. Beneficiaries enrolled in the QMB program are not liable to pay Medicare cost-sharing for all Medicare A/B claims...........

Final LCD Policy: Injections-Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton’s Neuroma

Medicare Coverage Database (MCD) Number/Contractor Determination Number: L34218

LCD Title: Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma

Effective Date: May 22, 2017.........

Appealing Medicare Demand Letters

When Medicare has determined that an overpayment has occurred, a Demand Letter is issued. Providers are given 30 days from the date of the Demand Letter to pay the requested overpayment amount. Timely payment is needed to avoid interest from accruing.......

Potential 2018 MACRA Coding Requirement for Patient Relationship Category

There could be new HCPCS modifiers approaching as part of MACRA to identify patient relationship categories...

Offer Medicaid Prior Authorization of DMEPOS for Dual Eligible Beneficiaries

CMS encourages states to offer a process for suppliers to request prior authorization of more costly DMEPOS for dual eligible beneficiaries. Many states have already instituted Medicaid prior authorization processes, but.....

Revised Announcement Regarding DEA Renewal Applications

Starting January 2017, DEA will no longer send its second renewal notification by mail. Instead, an electronic reminder to renew will be sent to the email address associated with the DEA registration......

HCPCS Modifier That Will Affect Reimbursement for 2017

The Centers for Medicare & Medicaid Services (CMS) has established a new HCPCS modifier that will affect reimbursement rates for the year 2017...

Medicare Number (HICN) Format Changes

Since the start of the Medicare program, beneficiaries have used their social security number in order to claim benefits with a suffix that designated how they are receiving their benefits (retired, disabled, railroad worker, etc.)...

Documentation Checklist - Theraputic Shoes

Simple checklist that puts the language of LCD in simpler terms to ensure that suppliers are meeting medical necessity requirements.

Noridian Healthcare Solutions: HCPCS Codes Pre-Payment Audits

Noridian Healthcare Solutions is implementing a service-specific pre-payment targeted audit of claims for selected HCPCS codes...

Life Care Centers of America Agrees to $145 Million Settlement!

The Department of Justice announced that Life Care Centers of America Inc. (Life Care) and its owner, Forrest L. Preston, have agreed to pay $145 million to resolve a government lawsuit that alleged that Life Care violated the False Claims Act, by intentionally causing..