You might not get paid for properly billed claims for the new annual wellness visit (AWV) until mid-to- late March, according to at least one Medicare Administrative Contractor (MAC). Remember: The first wave of AWVs billed in 2011 were incorrectly and automatically denied by at least three different MACs (PBN 1/24/11).

You are now required to provide additional documentation to home health agencies when ordering home health care for patients. A new CMS requirement greatly impacts the bottom line of your peers in home health, but requires additional work from you. The rules state a home health agency must have documentation of a face-to-face encounter between a patient and the patient’s physician or non-physician practitioner (NPP).

Utilize two timely claims filing extensions when CMS corrects an error or creates a retroactive entitlement benefit for a patient. CMS has revised its 12-month timely claims filing requirement (PBN 4/15/10). Transmittal 2140 carves out exceptions and provides additional information about the rule requiring you to submit a claim within 12-months from the date of service. A claim submitted more than 12 months after the date of service will be denied.

Most physicians and non-physician practitioners (NPPs) at your practice will be subject to “limited” screening when enrolling in the Medicare program. But CMS has lumped physical therapy providers and physical therapy groups into a category with more intense screening measures.

These charts offer a rare look at the success of appeals within Medicare Advantage (MA) plans, which do not often share their claims or appeals data with the public, unlike CMS. The first graph shows the percent of reconsiderations (second-level appeals) in which the MA plan’s decision was overturned (either partially or completely) or upheld (this also includes appeals that were dismissed). NOTE: All data comes from Maximus Federal Services Inc., a private contractor selected by CMS to act as the national independent review entity with oversight on MA denials. NOTE: Maximus only processes second-level appeals and does not have code-level data, a company official tells Part B News. The second graph shows the dollar amounts involved; all the data is from 2009.
 

We are a gastroenterology office and at times bill the tobacco cessation counseling visit code (99406). We don’t want to step on the primary care’s toes with respect to billing for tobacco counseling. Is it typically paid once per year for any physician? One time per patient, period?

A new CMS article explains how the agency’s auditors decide whether inpatient status was justified. CMS released the article as a response to provider concerns over how CMS, its carriers and various auditing groups utilize screening criteria to analyze documentation and make medical necessity determinations.