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Issue #170 - April 6, 2011
AAPC EdgeBlast
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CMS Proposes Accountable Care Organization Regulations

The Centers for Medicare & Medicaid Services (CMS) issued, March 31, a proposed rule that would establish a new voluntary type of health care entity under the Medicare Shared Savings Program. The Patient Protection and Affordable Care Act (PPACA) requires the Health and Human Services (HHS) secretary to establish the Shared Savings Program by Jan. 1, 2012. This voluntary program is intended to encourage health care providers and suppliers to form groups, called Accountable Care Organizations (ACOs), so that they may better coordinate care for patients with "Original" Medicare (Parts A and B). This coordination of care, CMS says, would reduce duplication and waste and produce an estimated $960 million in Medicare savings.

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Claims and Appeals Reform Held Until Year-end

If you've been waiting for claims appeals reform as outlined in the health reform bill, you'll have to wait until next year.

The U.S. Department of Labor, Health and Human Services, and the Treasury (the Departments) announced via a technical release that enforcement of a key health reform provision will be postponed for a second time, from July 1, 2011 until Jan. 1, 2012 to allow more time for payers and others to comment. Public Health Service Act revisions and related provisions in the Patient Protection and Affordable Care Act (ACA) seek to speed appeals of denied claims while making the decision process more transparent.

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MedPAC Recommends Physician Pay Increase for 2012

If Congress takes up recent recommendations made by the Medicare Payment Advisory Commission (MedPAC), acute care and outpatient hospitals, physicians and other health professionals, ambulatory surgical centers (ASCs), end-stage renal dialysis (ESRD) centers, and hospices should see payment rate increases in 2012. But for long-term care hospitals (LTCHs), skilled nursing facilities (SNFs), home health agencies (HHAs), and inpatient rehabilitation facilities (IRFs), MedPAC paints a different picture in its March 2011 Report to the Congress: Medicare Payment Policy.

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I/OCE April Update: Modifier 33, New APCs for Outpatient Claims

The Centers for Medicare & Medicaid Services (CMS) announced, March 11, the release of the Integrated Outpatient Code Editor (I/OCE) Specifications Version 12.1. The I/OCE routes institutional outpatient claims through a single, integrated OCE. Version 12.1, effective April 1, 2011, includes code, ambulatory payment classification (APC) and status indicator changes, the addition of a new modifier, and more.

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OPPS Update: New Services, Retroactive Payment Corrections

The Centers for Medicare & Medicaid Services (CMS) announced updates for the Hospital Outpatient Prospective Payment System (OPPS), effective April 1. If your facility or ambulatory surgical center (ASC) submits outpatient claims to Medicare, you'll want to know about these changes, which include code additions and deletions, payment status changes and corrections, too.

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Correct Coding Initiative v17.1 Includes Thousands of New Edits

The Centers for Medicare & Medicaid Services (CMS) has released the latest National Correct Coding Initiative (NCCI) update. Version 17.1 is effective April 1, 2011, and contains over 700,000 code pair edits. Among those edits, nearly 12,000 are new to Version 17.1. Approximately 350 code pair edits have been deleted, the majority of which are retroactive to earlier dates of service.

Action point: Retroactive code pair deletions may mean you're eligible for payment on past claims, if those claims were rejected based on the now-deleted code pair edits.

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EHR Attestation Begins April 18

Attestation for the Medicare Electronic Health Record (EHR) Incentive Program begins April 18. To receive your Medicare EHR incentive payment, you must attest through CMS' web-based Medicare and Medicaid EHR Incentive Programs Registration and Attestation System. To successfully attest, you need to understand the required meaningful use criteria.

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NJ BCBS Pays $8 Million for
Holding Claims


A State of New Jersey Department of Banking & Insurance class action suit against Horizon Blue Cross Blue Shield (BCBS) of New Jersey has been settled out of court. The Blues plan has agreed to pay approximately $8 million in restitution for allegedly delaying payment of claims for which the insurer was the secondary payer to Medicare. The state department alleged that Horizon was setting the claims aside until it could ascertain whether a claim stemmed from a preexisting condition.

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Coding Tips

Correctly Report Hepatitis B Vaccine Admin After
April 1

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2011 Update to Therapy Code List
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MLN CLFS Fact Sheet Updated for 2011
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Medical News

CMS Says Provenge is Reasonable and Necessary
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ACOG Updates Ob/Gyn Guidelines
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CMS Opens NCA for Behavioral Therapy for Obesity
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Study Looks For, Can't Find Much Evidence of
E-Health's Benefits

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Shingles Drug Approved for People 50-59 Years
of Age

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FDA Approves New Treatment for Melanoma
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Featured Items
ACO Regulations
Claims & Appeals Reform
Physician Pay Increase
Modifier 33
OPPS Update
Thousands of NCCI Edits
EHR Attestation
NJ BCBS Pays $8 Million
Coding Tips
Medical News
Coding Job Links






























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