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Rount 2 of DME Competitive Bidding delayed by about six months, for new timeline click here

The Centers for Medicare & Medicaid Services (CMS) would like to remind Medicare Fee-For-Service physicians, providers and suppliers submitting claims to Medicare for payment, as a result of the Patient Protection and Affordable Care Act (PPACA), effective immediately, all claims for services furnished on or after Jan 1, 2010, must be filed with your Medicare contractor no later than one calendar year (12 months) from the date of service – or Medicare will deny them.

In general, the start date for determining the 1-year timely filing period is the date of service or “From” date on the claim. For institutional claims that include span dates of service (i.e., a “From” and “Through” date on the claim), the “Through” date on the claim is used for determining the date of service for claims filing timeliness. For claims submitted by physicians and other suppliers that include span dates of service, the line item “From” date is used for determining the date of service for claims filing timeliness.

Timely Claims Filing: Additional Instructions

(Cigna Government Services)

Effective Friday, March 25, 2011, Medicare Administrative Contractors (MACs) will begin collecting application fees with certain provider/supplier enrollment applications (both paper and online applications) as described below. The application fee is currently $505 for CY2011 and will affect institutional providers of medical or other items or services or suppliers using the CMS-855A; CMS-855B, not including physician and non-physician practitioner organizations; CMS-855S; or the associated Internet-based PECOS enrollment applications).

For full article click here

(Cigna Government Services)

Effective Friday, March 25, 2011, newly-enrolling and revalidating providers and suppliers will be placed in one of three screening categories – limited, moderate, or high. These categories represent the level of risk for fraud, waste, and abuse to the Medicare program for the particular category of provider/supplier, and determine the degree of screening to be performed by the Medicare Administrative Contractor (MAC) processing the enrollment application.

Screening procedures for the “limited” screening category will largely be the same as those currently in use; screening procedures for the “moderate” screening category will include all current screening measures, as well as a site visit; screening procedures for the “high” screening category will include all current screening measures, as well as a site visit and, at a future date a fingerprint-based criminal background check.

For full article click here

(Cigna Government Services)

Accessories and supplies for use with positive airway pressure (PAP) devices have maximum utilization parameters outlined in the PAP local coverage determination. Supplies in excess of the LCD’s utilization parameters will be denied as not reasonable and necessary.

For a list of those parameters click here

CIGNA Government Services, the Jurisdiction C DME MAC, will be implementing a service-specific prepayment edit for Healthcare Common Procedure Coding System (HCPCS) code K0823 (Power wheelchair, Group 2 standard, captains chair, patient weight capacity up to and including 300 pounds). This edit is the result of data demonstrating a high claims payment error rate for this power wheelchair product category.

For full details click here

There are more questions than answers about Round 2 of competitive bidding, but that may be a good thing...For full story, click here

On February 2, 2011, Centers for Medicare & Medicaid Services (CMS) published a final rule in the Federal Register implementing fraud and abuse controls provided in the Affordable Care Act. The new rule includes procedures for enrollment requirements, license, and database verifications, unscheduled site visits, criminal history record checks and creates a new application fee requirement for new enrollments, new practice locations and revalidations. The rule also permits CMS to place a moratorium on the enrollment of certain types of providers and to suspend payments to providers under certain circumstances. CMS will accept comments on the rule until April 4, 2011. The rule becomes effective on March 25, 2011.

For story click here

Full text of proposed final rule click here

CR 7182, from which this article is taken, announces the requirement (effective January 1, 2011) to report additional, and more specific, data about therapy and nursing visits on your home health (HH) claims. The January 1, 2011, effective date means that these new and revised G-codes should be used for home health episodes beginning on or after January 1, 2011.

This requirement includes:

• The revision of the current descriptions for the G HCPCS codes for physical therapists (HCPCS code G0151), occupational therapists (HCPCS code G0152), and speech-language pathologists (HCPCS code G0153), to include that they are to be used to report services that are provided by a qualified physical or occupational therapist, or speech language pathologist;
• The addition of two new G HCPCS codes (G0157 and G0158) to report restorative physical therapy and occupational therapy provided by qualified therapy assistants;
• The addition of three new G HCPCS codes (G0159, G0160, and G0161, physical therapist, occupational therapist, and speech-language pathologist, respectively) to report the establishment, or delivery, of therapy maintenance programs by qualified therapists;
• The revision of the current G HCPCS code definition for skilled nursing services (G0154), and the requirement that HHAs use this code only for the reporting of direct skilled nursing care to the patient by a licensed nurse (LPN or RN); and
• The addition of three new G HCPCS codes (G0162, G0163, and G0164) that are required to report: 1) the skilled services of a licensed nurse (RN only) in the management and evaluation of the care plan;; 2) the observation and assessment of a patient’s conditions when only the specialized skills of a licensed nurse (LPN or RN) can determine the patient’s status until the treatment regimen is essentially stabilized; and 3) the skilled services of a licensed nurse (LPN or RN) in the training or education of a patient, a patient’s family member, or caregiver.

For Full Article click here 

This article, based on Change Request (CR) 7248, advises you of the CY 2011 annual update for the Medicare DMEPOS fee schedule. The instructions include information on the data files, update factors, and other information related to the update of the DMEPOS fee schedule. The annual update process for the DMEPOS fee schedule is documented in the Medicare Claims Processing Manual, Chapter 23, Section 60 at http://www.cms.gov/manuals/downloads/clm104c23.pdf on the Centers for Medicare & Medicaid Services (CMS) website.

For Full Article click here

Today, HHS also announced new rules authorized by the Affordable Care Act which will help stop health care fraud.  The provisions of the Affordable Care Act implemented through this final rule include new provider screening and enforcement measures to help keep bad actors out of Medicare, Medicaid and CHIP.  The final rule also contains important authority to suspend payments when a credible allegation of fraud is being investigated.  

Specifically, the final rule:  

• Creates a rigorous screening process for providers and suppliers enrolling Medicare, Medicaid and CHIP to keep fraudulent providers out of those programs.  Types of providers and suppliers that have been identified in the past as posing a higher risk of fraud, for example durable medical equipment suppliers, will be subject to a more thorough screening process. 
• Requires new enrollment process for Medicaid and CHIP providers.  Under the Affordable Care Act, States will have to screen providers who order and refer to Medicaid beneficiaries to determine if they have a history of defrauding government.  Providers that have been kicked out of Medicare or another State’s Medicaid or CHIP will be barred from all Medicaid and CHIP programs.
• Temporarily stops enrollment of new providers and suppliers.  Medicare and state agencies will be on the look out for trends that may indicate health care fraud – including using advanced predictive modeling software, such as that used to detect credit card fraud.  If a trend is identified in a category of providers or geographic area, the program can temporarily stop enrollment as long as that will not impact access to care for patients.
• Temporarily stops payments to providers and suppliers in cases of suspected fraud.  Under the new rules, if there has been a credible fraud allegation, payments can be suspended while an action or investigation is underway. 

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The criteria are as follows:

1. The pharmacy has been enrolled in Medicare as a DMEPOS supplier for at least 5 years;

2. The pharmacy has not had an unrescinded final adverse action during the past five years;

3. The pharmacy’s Medicare billing for DMEPOS, other than drugs and pharmaceuticals which are not subject to accreditation, is less than 5 percent of pharmacy sales for the previous 3 calendar or fiscal years. Pharmacy sales are those that are in a separate pharmacy account(s) for entities whose accounting system has such a breakout. For pharmacies whose accounting system does not provide a breakout of pharmacy items versus non-pharmacy items (usually small pharmacies), the total gross sales of the pharmacy shall be considered to be the pharmacy sales.

For full language, click here

June 15, 2010
CIGNA Government Services, the Jurisdiction C DME MAC, will be implementing a service-specific Medical Review edit for Healthcare Common Procedure Coding System (HCPCS) code E1390 (OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT). This edit is the result of data demonstrating a high claims payment error rate for this product category. Read More

Medicare requires an order for every item (except repairs) of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). Detailed written orders are used to confirm what was ordered by the treating physician following the supplier’s receipt of a verbal or written dispensing order. Detailed written orders must include separately billable options, accessories or supplies related to the base item that is ordered. Detailed written orders must not be used to add unrelated items, whether requested by the beneficiary or not, in the absence of a dispensing order from the physician for that item. read more