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New Values for Incomplete Colonoscopies Billed with Modifier 53


An incomplete colonoscopy, e.g., the inability to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, is billed and paid using colonoscopy through stoma code 44388, colonoscopy code 45378, and screening colonoscopy codes G0105 and G0121 with modifier “-53.” (Code 44388 is valid with modifier 53 beginning January 1, 2016.) The Medicare physician fee schedule database has specific values for codes 44388-53, 45378-53, G0105-53 and G0121-53. An incomplete colonoscopy performed prior to January 1, 2016, is paid at the same rate as a sigmoidoscopy. Beginning January 1, 2016,

Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.

Reference: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9317.pdf

Showing Patient Payments in CMS 1500 form


Most of the practices would collect copayments from the patient at the time service. Although it's not a violation for participating providers to accept payment prior to rendering services, there are specific guidelines to follow, especially when reporting these payments.

Additionally, some providers who accept assignment have a concern that Medicare issues partial checks to beneficiaries. Such checks are generally issued because of a patient paid amount in item 29 of the CMS-1500 (02/12) claim form.

Here are a few guidelines to follow;

Medicare Part B recommends not to collect copay amounts prior to a claim being submitted to Medicare since it is difficult to predict when deductible/coinsurance amounts will be applicable (and over-collection is considered program abuse). So, it is recommended that providers not to do so until Medicare Part B payment is received.

If you believe you can accurately predict the coinsurance amount and wish to collect it before Medicare Part B payment is received, note the amount collected for coinsurance on your claim form. It is recommended that providers do not collect the deductible prior to receiving payment from Medicare Part B because, as noted above, over-collection is considered program abuse. In addition, this practice can cause a portion of the provider's check to be issued to beneficiaries on assigned claims. 

Do not collect money from the patient for the preventive services for which copayment and coinsurance are waived. Please refer Preventive Services covered by Medicare.

Do not show any amounts collected from patients if the service is never covered by Medicare Part B or you believe, in a particular case, the service will be denied payment. Where patient paid amounts are shown for services that are denied payment, a portion of the provider's check may go to the beneficiary.

There is no need to show a patient paid amount in item 29 of form CMS-1500 (or electronic equivalent) when assignment is not accepted.

Reference: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c26.pdf

Medicare will hold HCPCS codes G0477 through G0483 till April 04, 2016


CMS discovered systems errors affecting claims with new drug testing laboratory codes (HCPCS codes G0477 through G0483) with dates of service on or after January 1, 2016. Your Medicare Administrative Contractor (MAC) will be holding these claims until April 4, 2016. No provider action is required. However, should you wish to avoid your claims from being held, you can remove codes G0477 through G0483 and submit the rest of the services on the claim. When the system is updated in April, you can submit an adjustment claim to add these HCPCS codes. Your MAC will correct any claims previously returned to you in error with these codes and reason code W7006 after the system is updated


2016 - New CPT codes for Arthrocentesis


20604 Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); with ultrasound guidance, with permanent recording and reporting
(Do not report 20600, 20604 in conjunction with 76942) (If fluoroscopic, CT, or MRI guidance is performed, see 77002, 77012, 77021)

20606 Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting

20611 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting (Do not report 20610, 20611 in conjunction with 27370, 76942) (If fluoroscopic, CT, or MRI guidance is performed, see 77002, 77012, 77021)

The above three new codes (20604, 20606 and 20611) describe ultrasound imaging guidance as an inclusive component of arthrocentesis, aspiration and/or injection of a joint or bursa. Fluoroscopicguided arthrocentesis will remain component coded. Revisions were made to 20605 and 20610 to denote the procedures are performed without ultrasound guidance.

2015 MU Attestation Deadline Approaching


If you are an eligible professional participating in the Medicare EHR Incentive Program, you have until 11:59 p.m. ET on February 29, 2016 to attest Meaningful Use for 2015 EHR reporting period. 

If you are participating in the Medicaid EHR Incentive Program, please refer to your state's website for attestation information.

If you are a Medicaid participant who is subject to Medicare penalties and you’re attesting for the first time in 2015, you can demonstrate Meaningful Use on the Medicare attestation portal by February 29th to avoid penalties in 2016 and 2017. You will still need to submit a Medicaid attestation with your state to earn incentives. If you are a returning Medicaid MU participant who is eligible for Medicare penalties but unable to meet the 30% patient volume threshold, then also you can demonstrate Meaningful Use on the Medicare attestation portal by February 29th to avoid 2017 penalties.

Medicare Attestation Portal: https://ehrincentives.cms.gov/hitech/login.action

Inpatient Hospital Payment Rate Impacted by the Consolidated Appropriations Act, 2016


CMS is currently revising the Inpatient Prospective Payment System (IPPS) FY 2016 Pricer to reflect the new payment calculation requirement.  The amount of the payment with respect to the operating costs of inpatient hospital services of a subsection (d) Puerto Rico hospital for inpatient hospital discharges on or after January 1, 2016, will be based on 0 percent of the applicable Puerto Rico percentage and 100 percent of the applicable Federal percentage. In addition, the IPPS FY 2016 Pricer will include conforming changes to certain FY 2016 IPPS operating rates and factors that result from the application of the new Puerto Rico hospital payment calculation requirement, which are applicable to all IPPS hospital discharges on or after January 1, 2016. We will also incorporate the revised IPPS rates into the Long-Term Care Hospital (LTCH) Pricer, as they are used for certain LTCH claims payments.

To allow sufficient time to develop and test, CMS will implement the IPPS and LTCH Pricers on April 4, 2016. Medicare Administrative Contractors (MACs) will reprocess IPPS inpatient claims from Puerto Rico and all other IPPS hospitals with a discharge date on or after January 1, 2016. The MACs will also reprocess LTCH claims with a discharge date on or after January 1, 2016, due to the impact of this change.  Puerto Rico hospitals (as well as all other IPPS and LTCH hospitals) do not need to take any action. We expect to reprocess claims no later than June 30, 2016.

Clinical laboratory fee schedule on travel allowances and specimen collection fees


The Centers for Medicare & Medicaid Services (CMS) updated payment rates for travel allowances and specimen collection fees when billed on a per mileage basis using Health Care Common Procedure Coding System (HCPCS) code P9603 and when billed on a flat rate basis using HCPCS code P9604 for 2016.

Payment of the travel allowance is made only if a specimen collection fee is also payable. The travel allowance is intended to cover the estimated travel costs of collecting a specimen including the laboratory technician’s salary and travel expenses. The per mile travel allowance is to be used in situations where the average trip to the patients’ homes is longer than 20 miles round trip.

The per flat-rate trip basis travel allowance is $9.90

Reference: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9485.pdf

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