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UB04 Update
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Form Locator 06 Statement Covers Period (From-Through)
The Statement Covers Period "From Date" found within Form Locator 06 ("From Date") may be the same or a different date than the "Admission Date" found within Form Locator 12. The dates may coincide in some circumstances, but should not be confused.
Issue: When a patient receives outpatient services 3 calendar days prior to an inpatient admission, the outpatient charges may need to be included on the inpatient bill. On an initial bill the "From Date" would be prior to the "Admission Date" FL 12. Some payers will not accept a claim in this format.
Today, Medicare has edits prohibiting a PRIOR "Admission Date" to the Statement "From Date" and will reject claims for submission.
Resolution: Medicare will modify edits October 2011.
NUBC Billing Alert
Correct Provider Billing of Admission Date and Statement Covers Period
MLN Matters SE1117
UB04 Version 6.00 Clarifications/Errata/Updates as of 10/7/11
UB04 Implementation Calendar as of 08/10/11
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Payer Update
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United Healthcare
Reimbursement Policy - Revised Professional/Technical Component Policy, Contrast and Radiopharmaceutical Materials Policy and Laboratory Rebundling Policy Revisions - Place of Service 24 - Effective Q4 2011
UHC Network Bulletin
UHC Standard Companion Guide-Billing 5010 Claims
Self Pay--QR Codes can link patients to secure online payment websites through their smartphones to pay their medical bills.
Full article here
CIGNA
Network Newsletter
Aetna
Regional Newsletters
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Medicare Quarterly News
Additional Fields for Additional Documentation Requests (ADR) Letters
Effective: January 1, 2012
A documentation case ID number that may facilitate tracking of submitted documents.
Outpatient Code Editor Version 12.3
Effective: October 1, 2011
NEW Modifier 92 accepted: With the latest CDC recommendations and the move toward HIV testing as a routine part of care, more providers are using rapid test kits. Effective Jan. 1, 2008, providers can bill for performing an HIV test with a rapid test kit. Providers can add modifier "92" for "Alternative Laboratory Platform Testing" to the usual laboratory procedure code for HIV testing within the CPT® system. The following is the CPT language for this service: "When laboratory testing is being performed using a kit or transportable instrument that wholly or in part consists of a single use, disposable analytical chamber, the service may be identified by adding modifier 92 to the usual laboratory procedure code (HIV testing 86701-86703)." The test does not require permanent dedicated space; hence, by its design, it may be hand carried or transported to the vicinity of the patient for immediate testing at that site, although location of testing is not in itself determinative of the use of this modifier.
CMS Transmittal 2277 CR 7541
MLN Matters MM 7541
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Claims Processing Guidance for Implementing ICD-10
Effective: October 1, 2013 See Tables on Page 3 as this provides a detailed guidance on types of claims and the required ICD-9 or ICD-10 diagnostic and procedure codes. MLN Matters MM7492
Clarification of E&M Payment Policy Implementation: November 28, 2011CMS recognized the newly created CPT subsequent observation care codes (99224-99226). Payment for a subsequent observation cared code is for all the care rendered by the treating physician on the day(s) other than the initial or discharge date. CMS Transmittal 2282 CR 7405 MLN Matters MM7405 Predictive Modeling Analysis of Medicare Claims As of June 30, 2011, CMS has implemented a predictive analytics system that will analyze all Medicare FFS claims to detect potentially fraudulent activity. MLN Matters SE1133
Common Edits and Enhancements Modules (CEM) Code Set Update
Effective: January 1, 2012 Implementation Date: January 3, 2012
In order for the CEMs to correctly and accurately edit the inbound Accredited Standards Committee(ASC)X12 version 5010 837 Institutional, 837 Professional claims and the 276 Claim Status Inquiry, several code set updates are required.
CMS Transmittal 921 CR7491
Process all ambulance transportation healthcare HCPCS codes
Effective: January 1, 2012 Medicare will accept no-pay bills for statutorily excluded ambulance transportation services and transportation related services to obtain a Medicare denial to submit to beneficiary's secondary insurance. MLN Matters7489
Hospice Claims Processing Procedures When Required Face-to-Face Encounters Do Not Occur Timely
Effective: January 1, 2011 Implementation: January 9, 2012
If the required face-to-face encounter does not occur on time, the beneficiary is no longer certified as terminally ill, and consequently is not eligible for the Medicare Hospice Benefit.
Corrections to Processing of Hospice Discharge Claims
Effective: January 2, 2012
Revises Medicare systems to ensure hospice discharge claims update the hospice benefit period correctly. Medicare contractors will set the revocation indicator on a beneficiary's hospice benefit period when a hospice claim is receive with any discharge status code other than 30,40,41,42,50 or 51 and occurrence code 42 is not present.
CMS Transmittal 2258 CR 7473
MLN Matters MM7473
Billing Requirements for ESRD Claims
CMS will require All ESRD claims with dates of service on or after January 1, 2012: The hemoglobin and/or hematocrit value(s); The route of administration of Erythropoiesis Stimulating Agents (ESAs) using the JA or JB modifier code for any claim indicating the administration of the ESA's.The Kt/V (calculated using a specified formula) indicating the measurement of dialysis adequacy.
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Are you tired of being hung out to dry with RAC audits?
As of January 3, 2012, the Centers for Medicare & Medicaid Services (CMS) is transferring the responsibility for issuing demand letters to providers from its Recovery Auditors to its claims processing contractors. This change was made to avoid any delays in demand letter issuance. As a result, when a Recovery Auditor finds that improper payments have been made to you, they will submit claim adjustments to your Medicare (claims processing) contractor. Your Medicare contractor will then establish receivables and issue automated demand letters for any Recovery Auditor identified overpayment. The Medicare contractor will follow the same process as is used to recover any other overpayment from you.
The Medicare contractor will then be responsible for fielding any administrative concerns you may have such as timeframes for payment recovery and the appeals process. | |
CMS Transmittal 192 CR 7436
MLN Matters7436
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"In the five months since we installed the 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.
Thanks."
Mike Laidlaw
Regional Director
Patient Financial Services
Sutter Health West Bay Hospitals
Get accurate automated calculated contract terms including second day stop loss, per diems, implants, case rates, MS-DRG's, APR-DRG's or identification of any payer underpayment with a business partner that SUPPORTS YOU! Get Cirius and Get Paid.
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 | Pink Glove Dance Sequel
This video is certain to lift your spirits - from hospitals around the country. |
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Navigating 5010
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Health Care Reform
What's it all about?
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Watch this!
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On the Horizon
APR-DRG
Medicaid plans are adjudicating claims according to APR-DRG's, NY,PA,MD,MT,RI,CO,SC, and ND. Will your state Medicaid reimbursement be next and what impact will it have on reimbursement?
ICD-10 Transition
Focus on Non-Covered Entities-Who are they?
Click here
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 | Compliance Corner
Section 1011 Compliance | |
Teaching aid here
All Medicare physicians, providers and suppliers who offer services and supplies to QMB's must be aware that they may NOT bill QMB's for Medicare cost-sharing. This includes deductibles, coinsurance and co-payments known as balance billing.
MLN Matters SE1128
Office of Inspector General
Audit Results
A Medicare payment that significantly exceeds the billed charges is likely to be an overpayment and is subject to review.
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Medicaid Program Integrity Manual-Initial Release Manual provides information on the operating procedures for the MIP, the first comprehensive; Federal strategy to prevent and reduce provider fraud, waste and abuse in the Medicaid program. CMS Transmittal 1 |
 | Medicare Pilot Project for Electronic Submission of Medical Documentation (esMD)
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Submit medical documentation by mail paper, or send a fax OR voluntarily join CMS in submission of electronic medical records.
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