A reopening is a remedial action taken to change a final determination or decision that resulted in either an overpayment or an underpayment, even though the determination was correct based on the evidence of the record. Reopenings are separate and distinct from the Medicare appeals process. Section 937 of the Medicare Modernization Act (MMA) required the Centers for Medicare and Medicaid Services (CMS) to establish a process whereby providers, physicians, and suppliers could correct minor error or omissions outside of the appeals process. CMS defines clerical errors (including minor errors or omissions) as human or mechanical errors on the part

I am often asked must physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists (SLPs) in private practice enroll in the Medicare program if they want to treat Medicare beneficiaries? The answer is yes. PTs, OTs and SLPs in private practices do not have the option to opt out if they want to treat Medicare beneficiaries. They must become Medicare providers. This then leads to a second question I am often asked. If PTs, OT’s and SLPs must enroll in the Medicare program, what is this non-participating provider status? Doesn’t this mean I don’t participate with Medicare, hence, I can

UnitedHealthcare has announced they will implement the Medicare outpatient therapy functional limitation reporting effective with dates of service on and after

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

Wisconsin Physician Services (WPS) will host an onsite seminar on May 21, 2014 in Seattle, WA focused on documentation. During this seminar, WPS will review sample documentation and see how it stacks up against medical necessity criteria. This is a must attend session for any clinician hoping to gain additional insight into the medical review process for skilled nursing facilities. For additional information and to register, click HERE.