The Centers for Medicare and Medicaid Services is proposing to implement a Medicare demonstration project, which they believe will help assist in developing improved procedures for the identification, investigation, and prosecution of Medicare fraud occurring among Home Health Agencies (HHAs) providing services to Medicare beneficiaries. This demonstration would help assure that payments for home health services are appropriate before the claims are paid, thereby preventing fraud, waste, and abuse. As part of this demonstration, CMS proposes performing prior authorization before processing claims for home health services in: Florida, Texas, Illinois, Michigan, and Massachusetts. CMS would establish a prior authorization procedure

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), signed into law on April 16, 2015, extended the therapy cap exception process through December 31, 2017 and modified the requirement for manual medical review for services over the $3,700 therapy thresholds. MACRA eliminated the requirement for manual medical review of all claims exceeding the thresholds and instead allows a targeted review process. MACRA also prohibits the use of Recovery Auditors to conduct the reviews. CMS has tasked Strategic Health Solutions as the Supplemental Medical Review Contractor (SMRC) with performing this medical review on a post-payment basis. The SMRC will

I receive many questions at my in-person seminars and via email that begin something like “I know we can’t have 2 Medicare patient’s being treated at the same time, but how about 2 patient’s with private insurance”? Or, “I know I need to be one-on-one with Medicare patient’s, but that does not apply to patient’s with private insurance, right”? Lastly, “I know if I have 2 Medicare patient’s in my facility for one hour during the same time period, I have to split the time between them, but if the 2 patient’s had private insurance, I could bill each for

The Centers for Medicare and Medicaid Services has a booklet on Medicare Advance Beneficiary Notices. The booklet includes information on the following topics: Types of ABNs Prohibitions and Frequency Limits Completing the ABN Collecting Payment from the Beneficiary Financial Liability and the ABN Claim Reporting Modifiers Resources To access the complete booklet, click

On December 29, 2015, the Centers for Medicare and Medicaid Services (CMS) issued the final rule that establishes a prior authorization process for certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items that are frequently subject to unnecessary utilization. This process assures that all Medicare coverage, coding, and clinical documentation requirements are met before the item is furnished to the beneficiary and before the claim is submitted for payment. CMS has released a frequently asked question document concerning the prior authorization for certain DMEPOS as well as a master list of DMEPOS items subject to frequent unnecessary utilization for

As more and more therapists are getting trained in dry needling, I receive more questions on what CPT code do I bill for the dry needling techniques? According to APTA, “Dry needling is a skilled intervention that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular, and connective tissues for the management of neuromusculoskeletal pain and movement impairments. It is a technique used to treat dysfunctions in skeletal muscle, fascia, and connective tissue, and to diminish persistent peripheral nociceptive input, and reduce or restore impairments in body structure and function, leading to improved

The recently released U.S. News & World Report Best Jobs 2016 list ranks 100 of the best jobs. Good jobs are those that pay well, challenge us, are a good match for our talents and skills, aren’t too stressful, offer room to advance and provide a satisfying work-life balance. Even though there is no one best job that suits each of us, U.S. News’ list of the 100 Best Jobs of 2016 are ranked according to their ability to offer this mix of qualities. Also, the best careers are ones that are hiring. In the top 100 jobs for 2016, physical therapists rank

In the CY 2015 Outpatient Prospective Payment System Final Rule, the Centers for Medicare and Medicaid Services (CMS) created a HCPCS modifier for hospital claims that is to be reported with every code for outpatient hospital items and services furnished in an off-campus provider-based department (PBD) of a hospital. Reporting of this new modifier was voluntary for CY 2015, with reporting required beginning on January 1, 2016. I am often asked must off-campus therapy locations that are hospital based departments (i.e. billing under the hospital NPI number) use the PO modifier on all CPT codes submitted on the UB-04 claim