Medicare Compliance & Reimbursement

Congress to Consider Repeal of Medicare Payments Advisory Board

Just what physicians need is another group to oversee whether payments to doctors will be slashed. The good news is that you may not have to face such a group going forward, if a new bill is approved.

As part of the Affordable Care Act, President Obama created the Independent Payment Advisory Board (IPAB), a 15-member government agency that had the power to change Medicare policy. Also referred to as a "Super PAC," the IPAB was considered a stronger version of the Medicare Payment Advisory Commission (MedPAC), which makes recommendations but cannot enact policies.

However, physician groups were quick to decry the IPAB, saying that cuts would be taking place at random and would affect not only medical practices, but also access to patient care. Last week, Rep. Phil Roe (R-Tenn.) introduced a bill that would repeal the IPAB. Roe had previously introduced the same bill in Congress last year. Medical groups cheered at the possibility of the IPAB’s dismantling.

"The AMA is pleased that legislation to eliminate the Independent Payment Advisory Board (IPAB) has been introduced in the House," said AMA President Jeremy Lazarus, MD, in a Jan. 23 statement. "Patients and physicians are still struggling with the frequent threat of drastic cuts from the broken SGR Medicare physician payment formula. IPAB would be another arbitrary system that relies solely on payment cuts."

Keep an eye on these pages for more information on whether Congress votes swiftly on the IPAB repeal.

CMS Urges Contractors to Add ICD-10 Codes to National Coverage Determinations

Ever since rumblings of ICD-10 first began, practices have wondered when National Coverage Determinations (NCDs) would replace applicable ICD-9 codes with the corresponding ICD-10 codes — and it appears that time has come.

On Jan. 18, CMS instructed contractors to start the process of creating and updating NCDs that contain ICD-9 codes. CMS said that carriers should assign comparable ICD-10 codes to them by the ICD-10 implementation date of Oct. 1, 2014. The directive was part of MLN Matters article MM8109.

This should help practices immeasurably, since inclusion of applicable ICD-10 codes on NCDs could at least offer a window into how Medicare payers will view each new diagnosis code and which codes it deems payable for particular services.

To read the complete MLN Matters article, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8109.pdf.

CMS Podcast Reminds Practices That Phase 2 Of ‘Ordering/Referring’ Edits Is Coming Soon

If a new CMS podcast is any indication, the agency might soon follow through on its longstanding threat to deny claims that fail the ordering/referring provider edits. Although CMS has had this on the horizon for several years now, the agency has never actually formalized a date when the denials would start.

However, a Dec. 13 CMS podcast indicates that CMS "will soon begin denying Part B, DME, and Part A Home Health claims that fail the ordering/referring provider edits." Although CMS notes in the podcast that the agency "does not have a date at this time," it warns providers that once it does, it will offer at least 60 days’ notice before the edits are turned on, so you should prepare now.

Background: Currently, if you submit claims for services or items ordered/referred and the ordering or referring physician’s information is not in the MAC’s claims system or in PECOS, your practice will get an informational message letting you know that the practitioner’s information is missing from the system.

Part B reminder: MACs will take two steps before denying your Part B claims. First, the carrier will check whether the ordering/referring physician is in PECOS. If not, the MAC will try to find the provider in the Claims Processing System Master Provider File. If the physician is in neither system, the claim will be rejected once the edits are turned on.

To listen to the complete podcast, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Multimedia-Items/2012-12-17Phase-2-of-Ordering-Referring-Requirement-Podcast.html.

OIG Quickly Spending Recovery Act Funds

The HHS Office of Inspector General is spending Recovery Act Funds like water, according to the latest monthly report released on Jan. 10. At the end of November 2012 (the most recent totals available), the OIG had spent nearly $17 million of Recovery Act Funds. During fiscal year 2012, the OIG also spent nearly $4.5 million of other funds on Recovery Act activities.

Get Ready For Serious Scrutiny Of Your HIPPS Claims

Palmetto GBA is set to launch medical review edits for high-denial rate codes. Your claims for certain Home Health Insurance Prospective Payment System codes are under review, according to a recent Palmetto announcement. The Jurisdiction 11 A/B Medicare Administrative Contractor’s medical review department will conduct a service-specific prepay complex review on claims billed for the top 20 Home Health HIPPS codes.

Palmetto plans to set service-specific complex targeted medical review edits for the two HIPPS codes found to have the highest claim count denial rates. The edits will apply to four regions within the J11 home health and hospice jurisdiction: Midwest (IL, IN, OH); Southeast (KY, NC, SC, TN); Southwest (AR, LA, NM, OK, TX); and Gulf Coast (AL, FL, GA, MS).

When finalized, the MAC may pay in full or in part or deny the claim. If you receive an Additional Documentation Request, you must submit the requested medical record information to Palmetto within 30 days.