Monday, 16 January 2017


CMS has a number of policies that limit payment when multiple procedures are furnished on the same day. Under the American Taxpayer Relief Act, the multiple procedure payment reduction has been increased to 50 percent for therapy services furnished on or after April 1, 2013.


The time frame in which CMS may recoup over payments made for items and services was lengthened from 3 years to 5. Under this provision, providers are deemed to be “without fault” for any over payments “subsequent to the fifth year following the year in which notice was sent” as to the amount paid.


Two programs specifically for low-income Medicaid beneficiaries have also been extended through 2013. State Medicaid plans will provide assistance to those with dual eligibility in the form of premium support for Part B services for qualifying Medicare beneficiaries that have incomes between 120% and 135% of the poverty level. 

The Transitional Medical Assistance Program provides low-income families with the ability to continue Medicaid coverage on a temporary basis once they become employed and collect earnings that otherwise disqualify them from eligibility. There is an increase in the amount allocated to the program in 2013, with $485 million available for the period from January 1, 2013, to September 30, 2013, and $300 million available for the period from October 1, 2013, to December 31, 2013.


The Medicare Program provides a percentage increase for each payment to certain qualifying low- volume hospitals. Due to the substantially broadened eligibility criteria, many more hospitals qualify for these additional payments.


Medicare-Dependent Hospitals (MDHs) are typically small rural hospitals with a substantial Medicare patient population that rely significantly on Medicare payments. They will continue to receive the increased Medicare payments through October 1, 2013. CMS has indicated that it will issue instructions to hospitals that forfeited or lost this status effective October 1, 2012, on how to regain MDH status.


The Geographic Practice Cost Index (GPCI) floor of “1.0” for the work component of physician payment rates will continue through 2013. Medicare adjusts payments to physicians through the GPCI to reflect the varying cost of delivering physician services in different locations. 

These GPCIs are applied to the three calculation components of a procedure’s relative value unit: work, practice expense, and malpractice. The “floor” of 1.0 for the work component of the formula means that physician payments would not be reduced in a geographic area just because the relative cost of physician work fell below the national average.


There is an annual per-Medicare-beneficiary cap of $1,500 for outpatient therapy services (physical and speech therapy combined, and separately to occupational therapy. In 2006, an exceptions process whereby Medicare beneficiaries can request and be granted an exception to the caps, and receive an unlimited amount of therapy services to the extent deemed medically necessary by Medicare was established. The exceptions process, which effectively suspends the cap has been extended through December 31, 2013.

Additional protection to beneficiaries affected by this cap has been added to protect Medicare beneficiaries from liability for items and services furnished to them if the Medicare beneficiary and the provider did not know, and could not have been reasonably expected to know, that the item or service would be non-covered.

Medical Office Workflow Step 6: Accounts Receivables

If you followed the advice given in the previous articles, you have properly identified the patient benefits, obtained the necessary authorizations, and carefully produced clean claims.  

If you missed the blogs discussing these important steps, follow these links:  Step 2, Step 3, Step 4. clean claimsEach one of these steps is an integral part to keeping a “young” Accounts Receivables (ARs) balance.  They ensure the quickest turn-around time for your claim payments which keeps your cash flow smooth and predictable.

You may wonder why I use the reference “young” when speaking of ARs.  One of the most common ways to evaluate your practice cash flow situation is by analyzing the open balances by their aging.  

The aging is most often broken down into “buckets” of 30 day increments: 0-30 days, 31-60 days, 61-90 days, 91-120 days, 121-150 days and 151 days and over.  As the aging increases, the balances should decrease with the highest amounts, hopefully, always in the 0-60 days’ categories.

Sunday, 15 January 2017

Medicare Appeal Council : Redetermination Levels

First level of appeal: Redetermination

A redetermination is an examination of a claim by fiscal intermediary (FI), carrier, or MAC personnel who are different from the personnel who made the initial claim determination. The appellant (the individual filing the appeal) has 120 days from the date of receipt of the initial claim determination to file an appeal. A redetermination must be requested in writing. A minimum monetary threshold is not required to request a redetermination
Second level of appeal: Reconsideration

A party to the redetermination may request a reconsideration if dissatisfied with the redetermination decision. A qualified independent contractor (QIC) will conduct the reconsideration. The QIC reconsideration process allows for an independent review of medical necessity issues by a panel of physicians or other health care professionals. A minimum monetary threshold is not required to request a reconsideration.

Third level of appeal: Hearing by an administrative law judge (ALJ)

If at least $140 remains in controversy following the qualified independent contractor's (QIC's) decision, a party to the reconsideration may request an administrative law judge (ALJ) hearing within 60 days of receipt of the reconsideration decision. Appellants must send notice of the ALJ hearing request to all parties to the QIC for reconsideration. ALJ hearings are conducted by the Office of Medicare Hearings and Appeals (OMHA).

Fourth level of appeal: Review by the Medicare Appeals Council

If a party to an ALJ hearing is dissatisfied with the ALJ's decision, the party may request a review by the Medicare Appeals Council. There are no requirements regarding the amount of money in controversy. The request for Medicare Appeals Council review must be submitted in writing within 60 days of receipt of the ALJ's decision, and must specify the issues and findings that are being contested.

Medicare AppealsBy clicking here you will find information on the Medicare Operations. Division/Medicare Appeals Council.

Fifth level of appeal: Judicial review

If $1,400 or more is still in controversy following the Medicare Appeals Council's decision, a party may request judicial review before a Federal District Court judge. The appellant must request a Federal District Court hearing within 60 days of receipt of the Medicare Appeals Council's decision.

• The Medicare Appeals Council's decision will contain information about the procedures for requesting judicial review.

Medicare AppealsAdditional resources

Within the CMS websites you will find information related to the five levels in the Part A and Part B appeals process.

• CMS Appeals Web resources
• CMS Appeals process flowchart
CMS resource materials available for download
• MLN - The Medicare Appeals Process Brochure
CMS Internet-only manuals: Publication 100-04
• Chapter 29– Appeals of Claims Decisions
• Chapter 34– Reopening and Revision of Claim Determinations and Decisions

 look hereMinor errors or omissions on some Part B claims can be corrected for reprocessing using the clerical reopening process.

Medicare AppealsThere are two ways to initiate this process:

• Telephone reopening requests via the interactive voice response (IVR) allows providers/customers to request telephone re-openings on certain claims.  For the IVR reopening request help sheet, click here
• For reopening requests in writing, use the clerical reopening . corrected claimCommon clerical errors consist of:
• Mathematical or computational mistakes
• Transposed procedure or diagnostic codes
• Inaccurate data entry
• Misapplication of a fee schedule
• Computer errors
• Denial of claims as duplicates which party believes incorrectly identified as duplicate
• Incorrect data items such as provider number, modifier, date of service

How Does the American Taxpayer Relief Act Affect You?


The Centers for Medicare and Medicaid Services (CMS) will continue to pay physicians at 2012 levels through 2013. Physician payments were scheduled to be cut 26.5 percent.

2013 is the second consecutive year with no inflation increase in physician payments. Medical claims reimbursement for some services will be the same as they were in 2011.

Revisions were made to the reporting requirements under the Physician Quality Reporting System (PQRS) for payment adjustments beginning in 2015 for eligible professionals who report data on quality measures. Under a new provision, a professional will be deemed to meet data submission requirements for the Program, if he or she “satisfactorily participates” in a qualified clinical data registry. Clarification is required by The Secretary of the Department of Health and Human Services on how reporting requirements are to be met and to define a “qualified clinical data registry”.

Saturday, 14 January 2017

What kinds of health problems are linked to excess weight?

What kinds of health problems are linked to excess weight?
  • type 2 diabetes
  • high blood pressure
  • heart disease and strokes
  • certain types of cancer
  • sleep apnea
  • osteoarthritis
  • fatty liver disease
  • kidney disease

The table and graph below illustrate the significant increase in the percentage of overweight males in the 35-44 years category.

*Body mass index (BMI) equals weight in kilograms divided by height in meters squared.

*Age-adjusted to the year 2000 standard population using five age groups:20-34 years,35-44 years, 45-54 years, 55-64 years, and 65 years and over.

Closely linked to weight issues, is lack of physical activity.  
Recommendations from the CDC are as follows:


Scenarios Aerobic Activity Amount/Week

Muscle Strengthening   Frequency/Week

1. Moderate Intensity  - 2 hours,30 minutes - All major muscle groups - 2 or more days

2.Vigorous Intensity - 1 hour, 15 minutes - All major muscle groups - 2 or more days

3. Combined Intensity - Up to 2 hours,30 minutes - All major muscle groups - 2 or more days

Proper nutrition also plays an important part in maintaining a healthy weight.  Here are the guidelines for the average adult daily 2000 calorie intake:
  • 6 ounces of whole grains,
  • 2 and ½ cups of vegetables,
  • 2 cups fruit,
  • 3 cups low fat dairy, and
  • 5 and ½ ounces of lean protein

With diligent efforts to keep active and eat properly any man can optimize his chances for good

Appealing a Medicare Denial

If you have received a claim denial from your Medicare contractor you do have the right to submit an appeal.  If you do not take assignment on the claim, your appeal rights can be limited. Clerical reopeningSee section at the bottom on Clerical Reopening when an appeal is not indicated.

• MLN Preventive Services Educational Products for Health Professionals
• CMS Prevention website
• CMS Immunizations website
• MLN National Provider Calls and Events website
• Men’s Health Month website

Men's Health Week

The week leading up to Father’s Day, June 10-16, is National Men’s Health Awareness Week.  It is a time to focus on getting and/or keeping yourself or the man in your life healthy.  Weight-related diseases are a growing cause of men’s health issues.

Friday, 13 January 2017

CMS MUE : Automated claim processing

The MUE program was developed by CMS in an effort to reduce the paid claims error rate for Medicare claims that result from various circumstances such as:

· clerical entries
· incorrect coding based on:

o   anatomic considerations
o   procedure code descriptors
o   procedure coding instructions
o   established CMS policies
o   nature of a service/procedure
o   unlikely clinical treatment

MUE CMS does not publish MUE values for some codes. Some MUE values are confidential and may not be published.

CMS fiscal intermediaries

CMS fiscal intermediaries and Part A/Part B Medicare administrative contractors (A/B MACs) process claims with the fiscal intermediary shared system (FISS).  They adjudicate MUEs against each line of a claim rather than the entire claim. If a procedure code is reported more than once, each line with that code is separately adjudicated against the MUE. They will deny the entire claim line if the unit of service (UOS) on the claim line exceeds the MUE value for the procedure code listed on the claim line.

MUE For Example CPT Code 77300 is submitted on one service line for 11 units, if the MUE is 10, then all 11 are denied, instead of a just denying the one unit over the limit.

MUE value modifiersWhen there is a need to report medically reasonable and necessary units of service in excess of an MUE value modifiers can be used to report the same code on separate lines of a claim will enable a provider/supplier to report medically reasonable and necessary units of service in excess of an MUE value.

modifiersThe modifiers noted below will accomplish this purpose.

• 76 -- Repeat procedure by same physician
• 77 -- Repeat procedure by another physician
• Anatomic modifiers (e.g., RT, LT, F1, F2, 50)
• When is it appropriate to bill modifier 50?
• 91 -- Repeat clinical diagnostic laboratory test
• 59 -- Distinct procedural service 

(Note: Modifier 59 should be utilized only if no other modifier describes the service.)

MUE Effective April 1, 2013, CMS converted some claim line MUEs to date of service (DOS) MUEs.  The total units of service (UOS) from all claim lines for a HCPCS/CPT code with the same date of service will be summed and compared to the MUE value.  Claims denied based on DOS MUEs may be appealed usingsimilar processes to claim line MUE denials.  CMS does not publish which codes have DOS MUEs.  

Since all UOS for a HCPCS/CPT code on all claim lines with the same date of service are summed, reporting additional UOS on separate claim lines with a HCPCS/CPT modifier will not result in payment of UOS in excess of the MUE value.

Key Medicare Benefits for Men’s Health

For those providers servicing Medicare beneficiaries, Men’s Health Awareness Week is a good time for you to re-familiarize yourself with the wide range of covered preventive services.  Identifying risk factors and utilizing screening tests for early detection can mean the difference between life and death.

As demonstrated by the chart below, several of leading causes of death in males age 65 and over in the United States, are routinely linked to preventable and /or highly treatable causes.  This data was reported by Centers for Disease Control and Prevention for 2009.  

The table below lists the covered service detailing eligibility requirements and other useful billing information:
  • Service
  • Procedure Code(s)
  • Coverage
  • Frequency
  • Abdominal Aortic Aneurysm Screening
  • G0389-U/S exam AAA Screening

Any beneficiaries with certain risk factors and a referral resulting from an IPPE visit.
  • Once in a lifetime
  • Alcohol Misuse Screening and Counseling
  • G0442-Annual screening, 15 min.
  • G0443-Brief face-to-face behavioral counseling for misuse, 15 min.
  • For screening: all beneficiaries.
  • For misuse, furnished by PCP: all competent beneficiaries.
  • G0442-Once annually
  • G0443-4 times per year
  • Annual Wellness Visit (AWV)

 G0348-Initial Visit

G0349-Subseqeunt Visit

Any beneficiary that has been effective for Part B for at least 1 year.
  • G0348- Once in a lifetime
  • G0349- Once annually
  • Colorectal and Prostate Cancer Screenings
  • G0104-Flexible Sigmoidoscopy or G0106-Barium Enema
  • G0105-Colonoscopy (high risk) or
  • G0120-Barium Enema
  • G0121-Colonoscopy (not high risk)
  • G0328-Fecal Occult Blood Test immunoassay
  • 82270- Fecal Occult Blood Test by peroxidase activity.

Any beneficiary aged 50 or over who are at normal or high risk for developing
  • Colo-rectal cancer.
  • G0328/82270-Once annually
  • G0104-Once every 4 years or 120 months after G0121
  • G0121-Once every 10 years or 48 months after G0104 or every 24 months for high risk
  • G0106/G0120-Once every 48 months or 24 months for high risk.

 Cardiovascular Disease Screenings
  • 80061-Lipid Panel
  • 82465-Cholesterol
  • 83718-Lipoprotein
  • 84478-Triglycerides

Diabetes Screening
  • 82947-Blood Glucose; quantitative
  • 82950-Glucose;post-glucose dose
  • 82951-Glucose;3 specimen tolerance test

Any beneficiaries with risk factors or diagnoses with pre-diabetes.
Once annually if no pre-diabetes.
Twice annually with pre-diabetes.

HIV Screening
  • G0432-Infectious agent by EIS technique
  • G0433-Infectious agent by ELISA technique
  • G0435-Infectious agent by rapid antibody test

Any beneficiaries at increased risk for HIV infection or pregnant.
Annually for high risk beneficiaries.

Three times per pregnancy.

Immunizations (Seasonal Influenza, Pneumococcal, and Hepatitis B)

90654-90657, 90660-90662, 
Q2034-Q2039-Influenza Virus Vaccine/ G0008 administration
90669-90670,90732-Pneumococcal Vaccine/
90740,90743-90744, 90746-90747-Hepatitis B Vaccine/G0010 administration
Influenza and Pneumococcal: all beneficiaries.
Hepatitis B:i any beneficiaries at intermediate or high risk for
Influenza- Once per season.
Pneumococcal- Once in a lifetime.
Hepatitis B- Scheduled dosages as required.

Intensive Behavioral Therapy for Cardiovascular Disease

G0446-IBT to reduce cardiovascular disease risk; individual, face-to-face, bi-annual, 15 min.

Furnished by PCP: Male beneficiaries aged 45-79-encouraging aspirin use, adults aged 18 or older- screening for hypertension, adults with risk factors- promoting a healthy diet once annually

Intensive Behavioral Therapy for Obesity

G0447-Behavioral counseling, face-to-face, 15 min.
Beneficiaries with BMI greater than or equal to 30 kg/m2, furnished by PCP.

One visit per week in first month.
One visit every 2 weeks, months 2-6.
One visit per month, months 7-12.
Prostate Cancer Screening
G0102-Digital rectal exam
G0103-Prostate Specific Antigen test

All male beneficiaries aged 50 and older.
Once annually

Tobacco Use Cessation Counseling

G0436-Counseling for the asymptomatic patient; intermediate >3min. up to 10 min.
G043-Couseling for the asymptomatic patient; intensive, > 10 min.
All outpatient and inpatient beneficiaries.

Two cessation attempts per year: attempt =  max of four sessions, up to eight sessions in 12 months.

Thursday, 12 January 2017

Medicare: What is a Duplicate?

Each Medicare claims processing system contains criteria to evaluate all claims received for potential duplication.  The claims can be placed into two categories: exact duplicate or suspect duplicate.  Each category is processed uniquely by the Medicare contractor.


CMS has recently updated the Medicare Claims Processing Manual, Chapter 1, Section 120: “Detection of Duplicate Claims” based on change request (CR) 8121.

duplicate claimsAn exact duplicate claim is denied or rejected, if missing applicable modifiers, automatically by the claims processing system.

For exact duplicate denials, professional providers do have appeal rights, but institutional and DME providers do not.

Suspect duplicate

If a claim is deemed suspect by the initial system review, the claim is suspended for further review by the Medicare contractor.

If suspect duplicate is denied after review, all providers have right to appeal.

Due to the nature of the service, some claims may only appear to be duplicates.  Proper coding of the service with the applicable condition codes or modifiers will identify the claim as a separate payable service, not a duplicate.  An example could be modifiers “LT” and “RT” for bilateral procedures.

By utilizing an advanced Medical Practice Management Billing Software like Iridium Suite from Medical Business Systems, duplicate claims submissions are easily prevented.  A configurable Claim Scrubber as found in Iridium Suite will check each service entered and alert the user immediately if the same service is already on record.  

This gives the user the opportunity to determine if the service is a true duplicate or if the service qualifies for an appropriate addition of a modifier.

See the information below for details on the process Medicare utilizes to identify duplicate claims.

Provider of Service duplicate claims

Exact Duplicate suspect duplicate

Suspect Duplicate

Institutional institutional claims Claim matches identically on the following data:

1. Health insurance claim (HIC) number
2. Type of bill
3. Provider identification number 
4. From date of service
5. Through date of service
6. Total charges (on the line or on the bill)
7. HCPCS,  CPT-4, or procedure code/modifiers  Claim matches on the following data:

1. Beneficiary information
2. Provider identification
3. Same date of service or overlapping dates of service Professional

Professional claims Claim matches identically on the following data:

1. HIC number
2. Provider number
3. From date of service
4. Through date of service
5. Type of service
6. Procedure code
7. Place of service
8. Billed amount

The criteria for identifying suspect duplicate claims submitted by physicians and other suppliers vary according to the type of billing entity, type of item or service being billed, and other relevant criteria.

DMEDME supplies

Claim matches identically on the following data:

1. HIC number
2. From date of service
3. Through date of service
4. Place of service 22
6. Type of service
7. Billed amount
8. Supplier

The criteria for identifying suspect duplicate claims submitted by physicians and other suppliers vary according to the type of billing entity, type of item or service being billed, and other relevant criteria.

Do you know MUE?

Working in medical billing is like being in a bowl of alphabet soup.

One of the probably less common acronyms is MUE:  Medically Unlikely Edit.

Read below to find out what an MUE is, and why you should care.

what is a medically unlikely edit ? 

A medically unlikely edit (MUE) is an automated claim processing edit that compares the number of units submitted for a procedure code against the designated maximum units that are typically reported for that code on the vast majority of appropriately reported claims.

MUE : The edit is applied to services billed by a single provider/supplier to a single beneficiary on the same date of service.

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