Gold Members, please log in to read about breaking new information concerning the 2014 therapy cap exception process, payment update for services reimbursed under the Medicare Physician Fee Schedule and breaking news about ICD-10 implementation. Not yet a Gold Member? Join HERE and get access to all the information on the website, monthly electronic member only newsletters, and member only breaking news email updates. On March 31, the United States Senate passed

The Centers for Medicare and Medicaid Services have issued clarification instructions on the use of the skilled nursing facility (SNF) Advance Beneficiary Notice (ABN) of Non-Coverage form pursuant to the Jimmo vs Sebelius settlement. The instructions cover common denial reasons why the extended care items or services are noncovered under Medicare. The SNF may use these denial paragraphs as inserts in the “Because” and “Items or Services” sections of the SNF ABN. Denial paragraphs provided by CMS include, but are not limited to, teaching and training activities – partial denial, teaching and training activities – no skilled services, teaching or

On July 24, 2012, First Coast Service Options activated a prepayment edit for therapy services rendered by specialty 25 (Physical Medicine and Rehabilitation) in Puerto Rico. This was due to medical review findings that revealed this specialty presents an 88 percent error rate. The purpose of the edit is to prevent the payment of non-covered, incorrectly coded, and inappropriately billed services. Also, with medical review assistance, customer service now advises providers in correcting the billing and documentation errors. Data for October 1 through December 31, 2013, show an error rate of 81 percent. A significant amount of this error rate

If Congress does not pass additional legislation either eliminating the therapy cap or extending the exception process prior to April 1, 2014, Medicare beneficiaries will not have coverage for outpatient therapy services once they exceed $1920 PT and SLP combined or a separate $1920 for occupational therapy. If no legislation is passed and no exception process is in place, therapy provided above the $1920 would be considered

Wisconsin Physician Services (WPS) will be hosting several teleconferences in the month of April. The first will occur on April 9, 2014 and will focus on the Advance Beneficiary Notice of Noncoverage. WPS will also be doing a 2-part teleconference titled “Outpatient Therapy Guidelines” with Part 1 occurring on April 22, 2014 and Part 2 on April 24, 2014.

First Coast Service Options, National Government Services (NGS) and Novitas Solutions have announced that claims reporting Outpatient Therapy Functional G-codes and modifier information may be incorrectly receiving errors from the Common Working File (CWF) causing incorrect denials. The issues have been referred to CWF system maintainer for research and resolution. CWF has acknowledged an issue that is causing some of the incorrect denials and they are working on a resolution.  However, CWF is also researching other potential issues related to the G-code processing. Further instructions will be provided once CWF has completed their research and any required system corrections. Even

The Humana health insurance corporation has nearly completed processing refunds owed to practitioners who were incorrectly billed during an “overpayment recovery” process last year. The overpayments were part of Humana’s attempt to implement the multiple procedure payment reduction (MPPR) policy retroactively, and the problems have contributed to a Humana decision to hold off on full MPPR implementation until the system can run more smoothly. Humana will delay MPPR implementation until

Wisconsin Physician Services (WPS), Medicare Administrative Contractor for the states of Iowa, Kansas, Missouri, and Nebraska, will be hosting a variety of teleconferences over the next several months pertinent to inpatient and outpatient therapy as well as required documentation for total joint replacements. To access upcoming teleconferences, click HERE.