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Issue #155 - August 18, 2010
AAPC EdgeBlast

New Rules for Health Plan Appeals Processes
Health plans newly created or significantly amended after Sept. 22 will have to adhere to a new federal appeals process that allows consumers to challenge initial claims denials/rescissions. The U.S. Departments of Health and Human Services (HHS), Labor, and the Treasury issued an interim final rule July 23 for group health plans and health insurance issuers under the Patient and Affordable Care Act.

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HHS Offers States $51 Million to Establish HIEs
The U.S. Department of Health and Human Services (HHS) announced July 29 that states may now apply for their share of $51 million in grant money to establish health insurance exchanges (HIEs). HHS also is requesting public comment as the agency develops the rules and standards HIEs should be required to meet.

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Medicaid Receives Aid, Added Scrutiny
The Centers for Medicare & Medicaid Services (CMS) issued Aug. 10 a final regulation to implement Payment Error Rate Measurement (PERM) improvements for Medicaid and Children's Health Insurance Program (CHIP); and legislation signed by President Barack Obama Aug. 10 to extend the enhanced federal Medicaid assistance percentage (FMAP) through mid-2011.

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Survey Says: Cut Consult Codes Undermine Care
When the news was first released that Medicare would no longer cover CPT® consultation codes beginning Jan. 1, the Centers for Medicare & Medicaid Services (CMS) predicted that no specialty would see Medicare revenues decline by more than 3 percent due to the change. Industry stakeholders, however, feared the policy change would force physicians to implement cost-cutting measures that would ultimately undermine care. Now, nearly nine months later, a recent survey supports those fears.

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Wanted: Comments on Value-based Purchasing
The Centers for Medicare & Medicaid Services (CMS) will hold a listening session in September regarding confidential feedback reports and the implementation of a value-based payment modifier for physicians. Physicians, physician associations, and all others interested in the use of confidential feedback reports as one means of enhancing quality and efficiency are encouraged to participate in person or by calling the teleconference. The Patient Protection and Affordable Care Act requires the secretary of the U.S. Department of Health and Human Services (HHS), beginning in 2012, to provide reports comparing patterns of resource use of individual physicians to other physicians, and to apply a budget-neutral payment modifier to the fee-for-service physician fee schedule beginning in 2015.

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OIG Review Finds Erroneous Capped Rental DME Claims
From 2006 to 2008, Medicare erroneously allowed millions of dollars for routine maintenance and servicing and repairs of capped rental durable medical equipment (DME), and supplier practices adversely affected some beneficiaries with high-cost repairs, according to an Office of Inspector General (OIG) report released this month. From 2006 to 2008, Medicare erroneously allowed nearly $4.4 million for repairs of beneficiary-rented capped rental DME. The costs of repairs of beneficiary-rented capped rental DME are included in the monthly rental payments to suppliers and, therefore, not separately payable by Medicare.

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Medicare Solvency Tied to Pay Cuts and Tax Increases
The Patient Protection and Affordable Care Act, as amended by the Health Care and Reconciliation Act of 2010, has served to "substantially improve" the financial outlook for both major trust funds supporting Medicare, say Medicare trustees in an annual report. To ensure the financial integrity of Medicare's Hospital Insurance (HI) and to reduce the growth rate in Medicare costs, however, "additional policy initiatives are needed."

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Coding Tips

AMA Updates CPT Category III
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New Law Effects IPPS Billing Policy for Outpatient Services
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RACs Begin Medical Necessity Reviews
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COLA Withdraws From Pathology Specialty
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Get Kidney Transplant Donor Claims Paid
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5010 Implementation Expands I-9 Reporting
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When Not to Use Modifiers 52, 53
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Study Shows the Benefits of Working Remotely
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Health Reform Expected to Expand Job Opportunities
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Medical News

ACIP Updates Influenza Vaccine Recommendations
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New Alzheimer's Criteria Encourages Early Detection
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Test Yourself Online
The Test Yourself questions can be accessed online at www.aapc.com/testyourself/. Once you go there and take the test, you can automatically grade your answers, correct any mistakes, and have your CEUs automatically added to your CEU Tracker for submission.

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Featured Items
New Rules for Appeals
HHS Offers States $51M
Medicaid Receives Scrutiny
Consult Code Aftermath
Value-based Purchasing
DME Fraud
Medicare Solvency
Coding Tips
Medical News
Test Yourself Online
Coding Job Links

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