Medicare Compliance & Reimbursement

CMS Knows You’re Confused About POS Rules

When the Centers for Medicare & Medicaid Services (CMS) issued Transmittal 2679 on April 1, the agency was aiming to clarify place of service coding instruction. However, the change request (numbered 7631) only created confusion about how to report the place of service (POS) in certain scenarios, and CMS decided to take action.

"The place of service change request 7631 that went into effect on April 1 prompted a lot of questions, so we posted some frequently-asked questions on the CMS website," said CMS’s Chris Ritter during a June 4 Open Door Forum.

The FAQs, although nine pages long (available at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQs-CR7631-4-25-13.pdf), unfortunately don’t answer all queries that practices have, and many callers to the forum expressed frustration with the vague answers on the document.

For example, the FAQs pose the common question of how to bill the technical component of an IDTF service in a state that’s different from where the professional component was furnished, and the answer on the document states that local MACs should give advice on this topic, but that "CMS is developing national enrollment requirements for situations where telehealth, teleradiology, and other services cross MAC jurisdictions."

This answer was disappointing for a number of practices who are seeking firm national guidance on this topic, and one of them said as much on the call. After the caller asked whether CMS has a timeline of when this national policy will materialize, a CMS rep said that the agency hopes to have it ready within the next few months, but that it’s currently in process with the agency.

This MAC Denied 31 Percent of Hospice Claims

Make sure your physician’s terminal illness documentation is up to snuff for hospice claims, or you may lose your rightful reimbursement. In a recent probe, Medicare Administrative Contractor NHIC conducted probes of hospice claims in their first, second, and third benefit periods. Reviewers denied 31 percent of claims for the first and second period, and 27 percent of claims in the third period.

Results: Lack of valid physician certification was the top denial reason (43 percent) for first period claims, timely physician cert/recert was second (20 percent), and terminal prognosis was third (19 percent). In second and third periods, terminal prognosis moved to the top denial reason spot (41and 50 percent, respectively). Lack of valid physician certification moved to the second spot (31 and 33 percent, respectively). Untimely physician cert/recert dropped sharply to 3 and 8 percent, respectively.

You can read the complete article at www.medicarenhic.com/providers/articles/RHHIProbe061313.pdf.

Don’t Attempt To Adjust Re-Determined Claims

Keep your claims processing timeline straight to stay away from prohibited actions. That’s the word from Medicare Administrative Contractor Palmetto GBA, which recently posted a corresponding note on its website. "We have seen an increase in the number of providers trying to make an adjustment to a claim after it has gone through the Redetermination process," Palmetto says. "Providers cannot adjust anything on a claim after it has had a line adjusted through the Redetermination process, regardless of whether they are attempting to adjust the previously medically denied line or another line on the claim."

Bottom line: "All needed adjustments to the claim must occur prior to the Redetermination process," Palmetto reminds providers.