On May 22, 2014, the American Medical Association (AMA) and 3 hospitals filed a lawsuit to compel the Department of Health and Human Services (HHS) to meet statutory deadlines for timely review of Medicare claims denials. Currently, Medicare law requires an administrative law judge (ALJ) to hold a hearing and render a decision within 90 days. In December, the HHS’s Office of Medicare Hearings and Appeals imposed a moratorium on ALJ appeals. As of February 2014, there were 480,000 appeals awaiting assignment to an ALJ. To view a copy of the lawsuit, click HERE.

The J15 Part A Medical Review department performed a service-specific probe review on inpatient services relating to hospital admissions which resulted in admission to skilled nursing facilities, bill type 11X, in Kentucky. Based on the results summarized below, this edit was discontinued in Kentucky. To view the results of the probe review, click HERE.

The J15 Part A Medical Review department performed a service-specific probe review on inpatient services relating to hospital admissions which resulted in admission to skilled nursing facilities, bill type 11X, in Ohio. Although results demonstrated that additional medical review efforts may be indicated, due to a change in the medical review strategy, CGS will not advance this probe edit to ongoing complex review at this time. We may conduct additional reviews related to these services in the future. To read the results of the review, click HERE.

The Centers for Medicare and Medicaid Services has issued a special article to clarify the proper use of modifier 59. The article only clarifies existing policy. The article defines the definition of modifier 59 and provides several situations and examples when modifier 59 should be utilized. The article also defines which modifier should be used when a physician bills an E&M code on the same day as a non E&M code such as a physical therapy evaluation being billed incident-to a physician. To read the complete article, click