Although the Medicare fee-for-service (FFS) error rate has dropped from 14 percent in 1996 to 3.6 percent in 2008, that’s still billions of dollars—$10.4 billion to be exact—in improper payments.

The news is always the same. “For Medicare FFS, most improper payments are due to claims for services that were medically unnecessary or incorrectly coded,” reports a Centers for Medicare & Medicaid Services Nov. 17 press release. Read more »

The Centers for Medicare & Medicaid Services (CMS) updated the therapy services chapter of the Medicare Claims Processing manual to reflect the extension of the therapy caps exceptions process to Dec. 31, 2009, mandated by the Medicare Improvements for Patients and Providers Act (MIPAA) of 2008. CMS also added HCPCS Level II coding requirements. Read more »

The Centers for Medicare & Medicaid Services (CMS) has named four personal health record (PHR) companies to participate in the Medicare PHR Choice Pilot, according to a Nov. 12 press release. The pilot will be conducted in Arizona and Utah, and is slated to begin early 2009.

The four PHR companies are: Google Health, HealthTrio, NoMoreClipboard.com, and PassportMD. Read more »

Senate Finance Committee Chairman Max Baucus published his plan for health care reform on Nov. 12, and it bears striking resemblance to President-elect Barack Obama’s plan. The message is the same: universal coverage, reduced health care costs, and improved quality care. Read more »

Physicians and non-physician practitioners (NPPs) who provide health care to people with Medicare can expect a pay hike next year, but just how much depends on their willingness to accept the conditions put forth in the 2009 Medicare Physician Fee Schedule (MPFS) final rule. Read more »

The rapid growth of imaging services paid for under the Medicare Part B physician fee schedule (MPFS) has slowed since Congress implemented a cap on the hospital outpatient prospective payment system (OPPS), but it has not limited access to Medicare beneficiaries, according to a Government Accountability Office (GAO) Sept. 26 report.

In accordance with the Deficit Reduction Act of 2005 (DRA), Medicare fees for certain imaging services covered by the physician fee-for-service (FFS) schedule may not exceed what Medicare pays for these services under the OPPS. Read more »

Professional services your physicians performed in an ambulatory surgical center (ASC) on or after Jan. 1 may qualify for payment at the facility rate, according to the Centers for Medicare & Medicaid Services (CMS). Read more »

When lawmakers included a provision in the Medicare Modernization Act (MMA) of 2003 to expand the role of private health care plans in Medicare, they thought it would reduce Medicare spending growth. They were right about one thing: Medicare Advantage (MA) enrollment has increased from 4.8 million in 2004 to 8.7 million to date. What they didn’t anticipate was MA costs exceeding the standard Medicare Fee-For-Service (MFFS) program. Read more »

The good news is that the standard Medicare Part B monthly premium in 2009 will remain at 2008 rates—$96.40 (for single filers who earned $85,000 or less in 2007). Want the bad news?

Well, there isn’t any bad news … yet.

For the first time in years, premiums will not increase because, in addition to an expected growth in the cost and use of outpatient health care providers and suppliers, the reserve in the Part B account of the Supplementary Medical Insurance (SMI) trust fund has “runneth” over. Read more »

HHS Publishes Proposed Changes to HIPAA Transaction and Code Set Standards

On August 22, 2008, the Department of Health and Human Services (HHS) published proposed changes to the HIPAA Transaction and Code Set Rules signaling the intent to eliminate use of ICD-9-CM as the codes for reporting diagnoses and implementation of ICD-10-CM with a proposed compliance date of October 1, 2011. See 73 Fed. Reg. 49796 (Aug. 22, 2008). There are no staggered implementation dates (for example, small vs. large entities) except for Medicaid Pharmacy Subrogation in the proposed ruling.

As best we can interpret, below is a summary of the ruling:

1. ICD-10-CM increases the number of codes from approximately 13,000 ICD-9-CM diagnosis codes to 68,000 ICD-10-CM codes.
2. An approximate 87,000 ICD-10-PCS codes will be required for inpatient procedure coding, up from the 4,000 codes currently used in ICD-9-CM.
3. The ICD-10-CM codes are up to seven characters in an alpha-numeric system and provide significantly increased granularity over ICD-9-CM codes.
4. HHS believes the long-term benefits of ICD-10-CM include:
   - Able to handle new procedures (estimated 1% of all procedures each year are new)
   - Potentially fewer improper and rejected claims
   - Improved disease management
   - Harmonization of disease monitoring worldwide since most of the rest of the world is already using ICD-10-CM codes

Read more »