90 Days (+2) Major Surgery Global

Per national Correct Coding Initiative (CCI) Chapter 3 guidelines, a procedure with a 90 day global period “is defined as a major surgical procedure.” The 90 day global period actually extends to 92 days, to include one day before the day of the surgery, the day of surgery, and the 90 days immediately following the day of […]

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How do you know how much to charge your patient at the first session?

Benefits verification & reports for each new patient and each patient who changes insurance plans… Our Orthopaedic Health Team take care of this by verifying the benefits with the insurance company. We ask about deductible/status, co-pay, coinsurance, # visits allowed, authorization requirements, allowable CPT codes, network status, and any other special condition of the policy. […]

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Medicare to Crack Down on Medical Necessity Errors with Heightened Claims Scrutiny in 2018

OIG believes that CMS didn’t have the tools to identify medical necessity, several coding errors, and documentation deficiencies-and could have saved nearly 36.7 billion in 2017 by auditing improper payments. As a result, the OIG is directing CMS to: 1. Establish new systems and monitoring to evaluate the appropriateness of claims. 2. Instruct Medicare Administrative […]

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Medicare: Reminder`Don’t balance bill Medicare Beneficiaries (QMB) eligible

Reminder: Don’t balance bill Medicare beneficiaries Under the Qualified Medicare Beneficiary (QMB) program for Medicare beneficiaries, providers can’t charge for cost sharing. State Medicaid programs may pay providers for Medicare deductibles, coinsurance and copayments. But federal law allows states to limit provider reimbursement for Medicare cost sharing under certain conditions. Dually eligible individuals may qualify […]

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Passionate to get Life Moving Again

The rise of Musculoskeletal Disorders (MSDs) is proving to be a dire problem. From older generations to newer ones, MSDs are no longer just threating to the health of our bodies; these common disorders are a threatening our economy—our society—our way of life.  Spanning from minor fractures to the more serious cases such as osteoporosis, […]

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Reworking Denied Claims

Even in the most efficient of offices, claims will still be denied.  The average office will have approximately 5-10% of claims rejected or denied, and the efforts needed to resolve those claims can be a drain on resources.   Follow-up on denied claims is time-consuming.  When questions cannot be answered through the remark coding on […]

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Complete HIPAA Compliance

We all understand how important it is to protect our patients’ privacy.  In an ideal world, every healthcare provider would have such perfect system in place, they wouldn’t need to worry about HIPAA compliance.  However, the fast-paced medical office can sometimes put specific compliance activities on the back burner, which is a mistake.  Below is […]

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Non`compliance with Medicaid’s requirements

Most of New York’s Claims for Federal Reimbursement for Monthly Personal Emergency Response Service Charges Did Not Comply With Medicaid Requirements New York provides Personal Emergency Response Services (PERS) to eligible Medicaid beneficiaries through contracts negotiated between local social services districts (local districts) and PERS providers. Beneficiaries authorized to receive PERS receive electronic communication equipment […]

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TPM aims to improve Medicare claims

The Centers for Medicare and Medicaid Services (CMS) rolled out the Targeted Probe and Educate (TPE) programs for the Medicare Administrative Contractors (MAC) to begin identifying targeted providers and sending out round-one reviews by the end of last year. The TPE process is only used with providers that have high denial rates or unusual billing […]

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UHC Recent Medication Update` Good Time to Brush-up on the changes!

UnitedHealthcare Commercial Product and Sourcing Update for Hyaluronic Acid Product – Durolane® Beginning May 1, 2018, UnitedHealthcare will require that Durolane® be obtained from a designated specialty pharmacy for UnitedHealthcare commercial plan members. This is the same process currently required for Gel-one,® Supartz,® Hyalgan,® Orthovisc,® Gel-Syn,® Gelsyn-3,® Genvisc,® and Hymovis.® These requests also may be […]

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UHC Now Mandates Appending Modifier SA on NPP E/M claims

New Policy – Advanced Practice Health Care Professional Evaluation and Management Procedures Policy Effective for claims with dates of service on or after Sept. 1, 2017, UnitedHealthcare will require physicians reporting evaluation and management (E/M) services on behalf of their employed Advanced Practice Health Care Professionals to report the services with a modifier to denote […]

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Prior Authorization for Knee Braces

Starting June 1, 2018, providers in the BlueCare Tennessee and CoverKids networks who supply or service a knee brace that exceeds $200 will need prior authorization. The No Prior Authorization Required list on bluecare.bcst.com will be updated June 1, 2018 to reflect this change. Providers who are out of network will be required to request […]

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Reject Claims with an Invalid Prefix

Member ID Number Prefix Update.. We want you to know about a recent change we made to our Member ID card prefixes. Effective April 15, 2018, we modified them to allow numeric characters in addition to the traditional alpha-only ones. We made this decision to expand the pool of prefixes needed to support the various […]

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Casting Vs. Surgery?

Foot and ankle —A research letter published in JAMA (March 27) suggests that close contact casting or surgical treatment of unstable ankle fracture may offer equivalent ankle function for older adults. The authors conducted a randomized clinical trial of 428 patients older than 60 years, 206 of whom were treated with casting and 222 of […]

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Timely filing adjustments

Seeing timely filing adjustments can be incredibly frustrating, but sometimes they are unavoidable for reasons outside of the office’s control.  What the office can control, however, is making sure that providers are aware of any time constraints involving addendums or outstanding paperwork that is needed to file a claim.  

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BAD DEBT ADJUSTMENTS…

Although difficult, bad debt can be recovered in some cases.  If you are not already doing so, consider working with a collections agency – some agencies cater to the healthcare profession and are sensitive to the relationship physicians have with their patients.  An option to avoid bad debt is to offer patient loan programs, which […]

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