United Healthcare - Laboratory Benefit Management Program

As of Oct. 1, 2014, United Healthcare implemented a pilot program in Florida to help manage appropriate utilization for outpatient laboratory services. Physicians/providers are required to use a Physician Decision Support system when ordering tests to obtain prior authorization for certain laboratory services. Currently, this laboratory benefit management program is for all fully insured commercial members in Florida. Members will have a BeaconLBS logo on their ID card. You will be required to Log-on and register to gain access to the system.  For more information, visit www.BeaconLBS.com.

CMS will hold all 2015 Date-of-Service Claims for Services Paid for the first 14 calendar days in Jan. 2015. The hold should have minimal impact on provider cash flow as, under current law, clean electronic claims are not paid sooner than 14 calendar days (29 days for paper claims) after the date of receipt.

Attention Iowa, Kansas, Missouri and Nebraska Providers: The Medicare Administrative Contractor, WPS Medicare, provides updated information on correct coding and required documentation elements for Prolia™ and Xgeva™. Click here for more information. *All providers are encouraged to check their local Medicare Administrative Contractors to determine coding and documentation requirements for these drugs. 

The OIG expects EHR programs to be adequately audited. CMS stated they intend to audit a minimum of 5 percent of all providers who are participating in the EHR Incentive Program and some say that number may be higher. Remember, failure of just one element of an EHR audit could cause the entire year's incentive payment to be returned. Click here for additional information. 

Click here for the CMS-recommended, An Introduction to EHR Incentive Programs for Eligible Professionals: 2014 Clinical Quality Measure (CQM) Electronic Reporting Guide.  

If you're a provider participating in the EHRIncentive Programs, please remember a security risk analysis is required when certified EHR technology is used in the first reporting year. For more information visit the EHR Incentive Programs website or Click here for EHR FAQs. 

Open Payments: Final Rule Changes Related to CE Events The Law and Policy webpage includes details about four revisions made to the Open Payments final rule. The most significant change affects the Open Payments reporting requirements for payments or other transfers of value provided at CE events. These requirements will change starting for data collected in 2016: 1. Fact sheet for the Medicare Physician Fee Schedule; 2. CY 2015 Medicare Physician Fee Schedule final rule 3. Sections of the CY 2015 Medicare Physician Fee Schedule final rule that pertain to Open Payments 4. FAQs 

* Quarterly Update to CCI Edits, effective April 1 Make sure your billing staffs are aware of new changes in Correct Coding Initiative (CCI) edits. Read the complete update.

* Revisions to CMS' Program Integrity Manual, Chapter 15 Most of the changes were editorial to clarify other Medicare manuals being referenced in Chapter 15. Read the complete update.

* Revised: Provider Enrollment Requirements for Writing Prescriptions for Medicare Part D Drugs This rule requires physicians and other eligible professionals who write prescriptions for Part D drugs to be enrolled in an approved status or to have a valid opt-out affidavit on file for their prescriptions to be covered under Part D. Read more.

* New rules to strengthen beneficiary protections include: 1.Denying enrollment to providers affiliated with any entity that has unpaid Medicare debts 2. Denying or revoking the enrollment of a provider if a managing employee has been convicted of a felony offense that CMS determines to be detrimental to Medicare beneficiaries 3. Revoking enrollments of providers engaging in abuse of billing privileges by demonstrating a patter or practice of billing for services that don't meet Medicare requirements. Read the fact sheet, final rule and the CMS press release.

* New time frame for Response to Additional Documentation Requests. This article instructs Medicare Administrative Contractors (MACs) & Zone Program Integrity Contractors (ZPICs) to produce prepayment review Additional Documentation Requests (ADRs) that states providers have 45 days to respond to an ADR issued by a MAC or ZPIC. 

* The Medicare Appeals Process podcast is designed to provide education on the five levels of claim appeals in Original Medicare (Medicare Part A and B). It includes details explaining how the Medicare appeals process applies to providers in addition to including more information on available appeals-related resources.

* Medicare's 2014 and 2015 Costs at a Glance Part B Deductible for 2015 is $147 per year. 

New Coding Requirements related to Modifer 59, beginning Jan. 1.

Proper Use of Modifier 59 from CMS

Q: Is it incorrect to add a modifier 59 or 76 to CPT 76942 when performing multiple UGFNA on multiple nodules?

A: According to Medicare's MUE (Medically Unlikely Edits) CPT code 76942 (Ultrasound guidance for needle placement, imaging supervision and interpretation) should be reported one time per date of service regardless of the number of nodules being aspirated. We encourage physicians to review their commercial contracts to determine if they follow Medicare's NCCI guidelines prior to billing multiple 76942 CPT codes. 

Q: Is there free educational opportunities where I can obtain CME/CEU credit for coding and billing?

A: CMS offers an array of educational opportunities for physicians, non-physicians, coders and billers. Click here for more information.  

Q: Can we submit an appeal if we disagree with a Medially Unlikely Edit denial? 

A: MUE denials do have appeal rights. To appeal in excess of the MUE value, submit a Redetermination: First Level Appeal form with supporting documentation. Because many MUE denials are the result of incorrect billing, research the service to make sure it's correctly coded and counted.  MLN Article MM8853 - Revised Modification to the Medically Unlikely Edit (MUE) Program (PDF, 77 KB)

Q: Can we bill a patient for a service that denied due to MUE? Should we issue an Advance Beneficiary Notice (ABN) to the patient in this case?

A: No, a patient is not liable for a service that was denied for MUE. A denial of services due to an MUE is a coding denial, not a medical necessity denial. Therefore, the presence of an ABN does not shift liability to the beneficiary and ABN issuance based on an MUE is not appropriate.  

Resource: MLN Article MM8853 - Revised Modification to the Medically Unlikely Edit (MUE) Program (PDF, 77 KB)

Submit comments or questions to: [email protected]

New Medscape Resources Offer CME/CE Credits to help small physician practices prepare for ICD-10. If you're a first-time visitor to Medscape, you must create a free account to access these resources.

• ICD-10: Getting from here to there -- Navigating the road ahead: offers providers an overview of ICD-10 and its benefits, the differences between ICD-9 & ICD-10, and the CMS 'Road to 10' Tool.

• ICD-10 and Clinical Documentation: discusses the role of documentation and coding in health care and examines why documentation is important for ICD-10.

• Preparing for ICD-10: Now is the time: A column exploring the effects ICD-10 will have on systems, the coding process, documentation, and quality reporting. Also, provides steps to prepare for implementation.

A Level 1 established patient office visit (CPT� code 99211) should not be billed with CPT� code 96372 (Therapeutic, prophylactic or diagnostic injections; subcutaneous or intramuscular) per Medicare's NCCI edit guidelines. 

Make sure you are billing initial visit evaluations and management visits correctly when using "Incident to" guidelines. Remember, the physician must perform the initial visit. For more information, go to the CMS Internet Only Manual (IOM) Publication 100-02, Chapter 15, Section 60.