On February 18, 2014, the Centers for Medicare and Medicaid Services (CMS) announced they will pause recovery audits since they are in the procurement process for the next round of Recovery Audit Program contracts. This will allow the Recovery Auditors time to complete all outstanding claim reviews and other processes by the end date of the current contracts.  In addition, a pause in operations will allow CMS to continue to refine and improve the Medicare Recovery Audit Program. February 21, 2014 is the last day a Recovery Auditor may send a postpayment Additional Documentation Request (ADR). February 28, 2014 is

National Government Services has issued a draft local coverage determination (LCD) regarding non-covered services. They are proposing to not reimburse for CPT code 97610 – Low frequency, non-contact, non-thermal ultrasound since it is considered investigational due to methodological limitations and small sample size in the published data. Comments on the proposed LCD will be accepted until March 22, 2014 and applies to all states served by NGS. To access the proposed LCD, click HERE.

Cahaba GBA, Medicare Administrative Contractor in the states of Alabama, Georgia, and Tennessee, have developed a tool to assist providers in determining whether they should file an appeal or do a reopening. For non-private practices, click HERE to access the tool. For private practices, click HERE to access the tool.

The Centers for Medicare and Medicaid Services (CMS) has released an article in which CMS creates edits in original Medicare claims processing systems to ensure that certain ‘always therapy’ evaluation and reevaluation codes are reported with the correct modifier. It also makes several clarifications of details in the “Medicare Claims Processing Manual,” Chapter 5 – Part B Outpatient Rehabilitation and Comprehensive Outpatient Rehabilitation Facility (CORF) Services. In the past, occupational therapy evaluation and re-evaluation CPT codes have been reimbursed even though they contained the GP discipline modifier instead of the GO discipline modifier. The same has also occurred when the

The Medical Directors for all 4 DME Medicare Administrative Contractors (MACs) have developed “Dear Physician” letters to help define medical necessity requirements of specific items such as diabetic supplies, oxygen equipment, power wheelchairs and power operated devices, hospital beds, therapeutic shoes for diabetics, nebulizers, etc., for ordering physicians. If the treatment plan includes durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), Medicare requires that suppliers have access to information from the patient’s medical record that addresses the coverage criteria for the items prescribed. Utilization of these “Dear Physician” letters will ensure the required information and documentation are available. Suppliers are

On January 31, 2014, The Centers for Medicare & Medicaid Services extended for six months the partial enforcement delay of its two-midnight policy for inpatient admission and medical review criteria. Under the extension, recovery auditors and other Medicare review contractors will not conduct post-payment patient status reviews of inpatient hospital claims with dates of admission on or after Oct. 1, 2013 through Sept. 30, 2014. However, Medicare Administrative Contractors will continue to conduct pre-payment “probe and educate” audits on select claims for patients admitted between Oct. 1, 2013 and Sept. 30, 2014. For more on the claims review policy, see

On February 3, 2014, WPS Medicare simplified provider contact center phone numbers with a single toll-free number.  All J8 A/B MAC providers will now call (866) 234-7331 when contacting Customer Service, Appeals, Electronic Data Interchange (EDI), Reopenings (Part B) and Provider Enrollment. Please read the following article for examples of the new menu changes.

The Settlement Agreement in Jimmo v. Sebelius provides that Medicare beneficiaries who were previously denied Medicare coverage may have claims re-reviewed under the revised manual provisions.  The process is not automatic: people who wish to take advantage of the re-review process must fill out and submit a form, known as a Request for Re-Review. Per the Medicare Advocacy Organization, a Medicare beneficiary is eligible for a review if he/she 1. Has received skilled nursing or therapy services in a skilled nursing facility, home health setting, or outpatient therapy setting, and 2. Has received a partial or full denial of Medicare