340B Pharmacy Program
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Starting March 1, 2011, the Office of Pharmacy Affairs (OPA) will be implementing a new 340B technical assistance (TA) model in order to maximize utilization of resources and maintain a high level of customer service to 340B covered entities. The new TA model will employ the efficient use of technology and peer-to-peer learning.
Under this new TA model, OPA will continue to enroll all individual eligible entities into the 340B Program and will conduct annual recertification of participating covered entities as resources allow.
New entities added by the Affordable Care Act (children's hospitals, free-standing cancer hospitals, rural referral centers, and sole community hospitals) will receive all levels of TA from the HRSA PSSC while funds are available. If and when funds have been expended, these entities will be classified with non-HRSA supported covered entities and will receive the corresponding level of TA.
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CIGNA-Clinical Reimbursement and Administrative Update Requirements
Pre-certification Requirement
Injectables & Nuclear Cardiac Services
NCCI and MUE Editing for Facilities
Assistant Surgeon Modifiers
Contiguous Body Parts
Transthoracic Echocardiography
CIGNA Network News Bulletin
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UNITED HEALTHCARE
Redesign of UHC Predetermination Process for Commercial Patients- Submission of elective requests for clarification of coverage, eligibility or verification of benefits call pre-determinations. The new process is focused on UHC Choice, Choice Plus, UHC Select & Select Plus.
UHC Network Bulletin
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Medicare Billing Update
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ABN-Part A and Part B First Edition Billing for Services CMS ABN BookletPreventative Services MPS Quick Reference Chart Therapy Code List-Update
Effective: January 1, 2011 Implementation: July 5, 2011 Adds one 'sometimes therapy' CPT code 95992 MLN Matters MM7364 Internet Only Manual, Pub. 100-04 Medicare Claims Processing Manual, Chapter 3: Inpatient Hospital BillingEffective: July 23, 2011- Corrects hemophilia diagnosis codes 286.2 Congenital factor XI deficiency, 286.3 in order to make it plural, and 286.5 Hemorrhagic disorder due to intrinsic circulating anticoagulants.
- Clarifies processing instructions for the non-outlier period after regular benefit days are exhausted in Section 40, to show that IPPS uses Occurrence Span Code 70 with the from and through dates of the non-outlier period after regular benefit days are exhausted.
- Clarifies application of the Code First policy in Section 190.5.2 to show that Medicare system searches only the first secondary code for a psychiatric diagnosis code to assign MS-DRG in order to pay Code First claims properly when the submitted PPS claims from an IP Psychiatric Facility shows the principal diagnosis code as non-psychiatric.
MLN Matters MM 7385 CMS Transmittal 2193 CR7385 Auto Denial of Claim Line Items Submitted with a GZ modifierEffective for dates of service on or after: July 2, 2011Contractors provided discretion to process both institutional and professional claims to automatically deny claim line items billed with the GZ modifier. The GZ modifier indicates that an ABN was not issued to the beneficiary and signifies that the provider expects a denial due to a lack of medical necessity based on an informed knowledge of Medicare policy. Further you contractor will not perform complex medical review on any claim line item(s) submitted with the GZ modifier. MLN Matters MM7228 CMS Transmittal 2148 CR7228 New K codes for Suction Pumps & Wound Dressings
Effective: July 1, 2011 Implementation: July 5, 2011
K0743, K0744, K0745, K0746 added with coverage type of "C" and the coverage is subject to contractor's discretion. The addition of these codes does not imply their coverage, character and editing requirements.MLN Matters MM 7411
Clarifications for Home Health Face-to-Face Provisions
Effective: January 1, 2011 Implementation: March 10, 2011
Update to FISS End of Present on Admission (POA) Indicator Logic for Version 5010 837I electronic health care claim submissions
Effective: July 1, 2011 Implementation: July 5, 2011
This instruction modifies FISS logic to auto-populate the End of the POA indicator "Z" for IPPS hospital providers using the version 5010 837I health care claim format. This assures grouper will apply the appropriate HAC logic, when applicable.
CMS Transmittal 851OTN CR7280
MLN Matters MM7280
Medicare Secondary Payer
Effective: April 1, 2011 Implementation: April 1, 2011
Process 5010 professional Medicare secondary payer and paper claims where claim adjustment reason code (CARC) amounts appear at the claim level and not at the detail line.
CMS Transmittal 75 CR7027
The shared systems and CWF shall allow MSP claims to contain both MSP and non-MSP lines on the same claim. CMS Transmittal 869 CR7335
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Implementation of Errata for Version 5010 of HIPAA Transactions and Updates in 837I, 837P, and 835 Flat Files-Priority (Type) of Admission or Visit Code and Reason Code 11701
CMS does not have a version 4010A1 direct data entry (DDE) and a separate 5010 DDE. The Priority (Type) of Admission or Visit code is now required on all 4010A1 institutional claims submitted or corrected via DDE, as well as on version 5010 institutional claims, regardless of how they are submitted. Providers that are unsure which code to use are instructed to use a code 9 (Information not Available). Additional Priority (Type of Admission or Visit codes and descriptions are available from the National Uniform Billing Committee (NUBC) or from your servicing MAC. The Priority (Type) of Admission or Visit code is not required on 4010A1 institutional claims submitted or corrected via an 837. | | Learn more |
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OIG Audit 2011
Real Hospital Case Study
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Reviewed claims and medical records containing topics:
A. Hemophilia Drugs
B. DRG Window
C. One Day Inpatient Stays
D. Medical Devices
E. Transfer DRG's
F. DRG's with Major Co-morbidity or Major Complications
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| Compliance Alphabet Audit Soup |  AHA states "Medicare's recovery audit contractors have collected $313.2 million in alleged overpayments from health care providers since October 2009, and paid them $52.6 million in underpayments, according to a new report from CMS."
AHA Full report here
- Complex Denials-Incorrect MS-DRG continues to represent the top reason by dollars for complex denial, but 23% of hospitals are now ranking medically unnecessary as the top reason for denial.
- Automated denials for outpatient billing errors had the largest financial impact on reporting hospitals.
- Appeals-Of the claims that have completed the appeals process, 85% were overturned in favor of the provider.
CMS RAC nationwide results from 2010-2011 program Billing Errors to review IRF-Incorrect Discharge Status Code IRF-Incorrect Patient Status Code IP-Hospital-Improper coding of MS-DRG 813 IP-Hospital-Wrong Diagnosis/Principal diagnosis code billed HIV OP-Hospital-Oxaliplatin-Dose vs. Billed Units IP-Hospital-Extensive OR procedure unrelated to principal diagnosis Medicare Quarterly Provider Compliance Newsletter |
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ICD-10-CM
AHIMA Top 10 List:
Phase 1
1. Ensure organizational awareness 2. Establish executive leadership 3. Perform Impact Assessment 4. Conduct Systems Inventory 5. Complete Gap Analysis 6. Establish Internal Timeline 7. Determine Plan for Training 8. Prepare multi-year budget 9. Manage contractual changes 10. Correlate continued organizational management of 5010 implementation processes and planning.
ICD-10-CM/PCS Transition: Planning and Preparation Checklist
CMS Quick Reference Tool
Sample of Staff Survey
CMS Reimbursement Guide
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Denial Prevention
Government Accountability Office (GAO) states as many as 50% of appeals prompt insurers to reverse their decisions.
The GAO studied health insurer rejection rates at the request of Congress.
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- % of denials compared to gross remits
- % of direct denial write off's
- # of accounts worked per day
- individual average worked
- % of denials compared to gross remit charges
- $ of denials per month
- department average worked
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"In the five months since we installed the Cirius Reimbursement Manager we have identified $4 million in underpayments. It is expected that we will identify approximately $10 million for the year. Many of our contracts have changed otherwise the number would be closer to $15 million dollars.
Our partners at the Cirius Group, Inc. have been most helpful and attentive throughout the entire process."
Mike Laidlaw
Regional Director
Patient Financial Services
Sutter West Bay Hospitals
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837P and 837I guidelines
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Look for Cirius Group in the exhibit hall next to our friends 'Bumblebee' and 'Optimus Prime'. Transform your Revenue Cycle using Cirius Group software solutions and services.
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