Reimbursement for Anticoagulation Services

Size: px
Start display at page:

Download "Reimbursement for Anticoagulation Services"

Transcription

1 Journal of Thrombosis and Thrombolysis 12(1), 73 79, # 2002 Kluwer Academic Publishers, Manufactured in The Netherlands. Reimbursement for Anticoagulation Services Paul W. Radensky McDermott, Will & Emery, Miami FL Key Words. reimbursement, anticoagulation services, Medicare The Basics of Reimbursement for Anticoagulation Services: Coverage, Payment, and Coding To determine how anticoagulation services will be paid, one must consider three issues: (1) coverage policy, (2) payment policy, and (3) coding. Coverage policy determines whether anticoagulation services are eligible for payment under the terms of the benefit plan. For public payers (e.g., Medicare and Medicaid), coverage is determined by statute. For private payers, coverage is determined by contract (benefit plan agreements) under requirements set out by state or federal law. Payment policy determines how the allowed payments are determined and what, if any, copayments or coinsurance will apply. Coding is the language providers use to tell payers what they have done and why.* To be eligible for coverage, a service must be included under the scope of benefits and not otherwise excluded. The benefits under most benefit plans are described broadly and include hospital, physician, clinical laboratory, home health, and skilled nursing facility services. The scope of benefits under Medicare is set out in the Social Security Act. Anticoagulation services are not listed specifically under the scope of benefits. Anticoagulation services may include physician services for evaluating a patient on therapy, obtaining blood specimens, and for administration of a low molecular weight heparin; clinical laboratory services for monitoring prothrombin time (PT) levels; hospital services if the patient is evaluated and managed in a hospital setting; skilled nursing facility services if the patient is managed in that setting; and home health agency services if the patient is managed at home. Home prothrombin time (PT) monitors meet the criteria for durable medical equipment (DME), a separately listed item under the scope of benefits. Some, but not all, benefit plans include outpatient prescription drugs. Medicare does not cover outpatient prescription drugs generally. Coverage under Medicare is limited to drugs that are not usually self-administered by the patient. Therefore, a drug like warfarin is not covered under Medicare because it is not included under the scope of benefits. Warfarin may be covered under certain Medicare supplement policies (NAIC standard plans H, I, J). A low molecular weight heparin (LMWH) may be covered under Medicare when administered by a physician or hospital but would not be covered when selfadministered by a patient. Exclusions may apply two ways: (1) to all beneficiaries at all times (that is, the item or service is never covered) or (2) to specific beneficiaries or under specific circumstances. Some items are specifically excluded (e.g., hearing aids). Anticoagulation services are not specifically excluded. Other items may be excluded because the payer considers the item or service to be investigational or experimental. Under these circumstances, the payer will deny coverage whenever the item or service is ordered. For example, the Medicare Durable Medical Equipment Regional Carriers (DMERCs) have denied coverage for home PT testing because the DMERCs believe that the benefits of home testing have not been proved. CMS s Coverage and Analysis Group is reviewing the evidence on this issue and is expected to issue a coverage decision allowing coverage in Items and services that are generally covered also must be considered medically necessary for the specific patient at the specific time. A payer may determine that it is medically necessary to order a PT test every 3 to 4 weeks, for example, but not every 3 to 4 days. The payment policies that apply to covered items and services vary by the setting where the service is provided. Under Medicare, there Address for correspondence: Paul W. Radensky, M.D. 201 South Biscayne Boulevard, 22nd Floor, Miami, FL pradensky@mwe.com * The policies under Medicare are publicly available and directed nationally by the Centers for Medicare and Medicaid Services (CMS). By contrast, the policies among private payers vary widely and also differ among the 50 state Medicaid programs. Therefore, this summary primarily presents information on Medicare policies. 73

2 74 Radensky are several prospective payment systems that define how Medicare sets the payment rate for anticoagulation services. Hospital inpatient services are paid under the per-admission all inclusive Diagnosis Related Group (DRG) rates. Medicare payment is the same, for example, for an admission to manage a patient with deep venous thrombosis whether the patient is treated with unfractionated heparin (UFH) or a low molecular weight heparin (LMWH). Hospital outpatient services, such as emergency department visits or outpatient clinic visits are paid under the Hospital Outpatient Prospective Payment System (HOPPS), which provides a packaged payment for procedures performed in the hospital outpatient setting under Ambulatory Payment Classification (APC) rates. Physician services are paid under the Resource Based Relative Value Scale (RBRVS) fee schedule. Prothrombin time tests are paid under the clinical laboratory fee schedule. Home health agency services are paid under the Home Health Prospective Payment System. DME, such as the home PT testing monitors, are paid under the Durable Medical Equipment, Prosthetics, and Orthotic Supplies (DMEPOS) fee schedule. Several coding systems are used to report services on claim forms. Procedures are generally reported using the American Medical Association s Current Procedural Terminology (CPT) codes. Office visits, PT tests, venipuncture, and administration of injectable drugs are all reported using CPT codes. Injectable drugs, such as LMWHs, and DME are reported using the alpha-numeric HCFA Common Procedure Coding System (HCPCS) codes. Providers report the reason for providing services using the International Classification of Diseases 9th Revision Clinical Modification (ICD-9-CM) codes. Coverage Payment and Coding for Oral Anticoagulation Management Visits Consider a patient who is on chronic oral anticoagulation. The patient will be seen at regular intervals and the following services may be provided: (1) PT testing, (2) specimen collection, and (3) evaluation and management. PT testing performed in the outpatient setting is covered and paid under the Clinical Laboratory Fee Schedule. The test is coded using CPT 85610: Prothrombin time. If the test is performed in a physician office laboratory that has a certificate of waiver under the Clinical Laboratory Improvement Amendments (CLIA), the test must be performed using a waived test device and reported using the QW modifier following the CPTcode for the test. The 2001 Clinical Laboratory Fee Schedule payment for PT testing is $5.43 (national limitation amount). PT testing performed in an inpatient setting would be included in the rate paid to the facility for the admission, with no separate payment made for the test. Specimen collection by venipuncture may be paid separately under HCPCS G0001 routine venipuncture for collection of specimens at a 2001 payment amount of $3.00 (2001 midpoint). Medicare will not pay for fingerstick sample collection. Private payers may pay for venipuncture or fingerstick sample collection under CPT routine venipuncture or finger=heel=ear stick for collection of specimen(s). Evaluation and management office visit services are also covered when medically necessary and the services actually provided meet the intensity of services described by the CPT code for each type of service. Evaluation and management office visit service codes and payment amounts are shown in Table 1 for new patients and in Table 2 for established patients. New patients are those who have not received any face-to-face service by the physician within the past 3 years. For multispecialty groups, if the patient has been seen by a physician in the same specialty within 3 years, the patient is an established patient. For the purposes of determining new versus established patients, simply performing a PT test or interpretation of an ECG is not a face-to-face service that would result in a patient being an established patient. Table 1. Evaluation and Management Office Visit Service Codes and 2001 Medicare Fee Schedule Payments for New Patients Code History Problem Expanded problem Detailed Comprehensive Comprehensive Exam Problem Expanded problem Detailed Comprehensive Comprehensive Medical Decision Straight-forward Straight-forward Low complexity Moderate High complexity Making complexity Problem severity Minor=self-limited Low to moderate Moderate Moderate to high Moderate to high Face-to-face time 10 minutes 20 minutes 30 minutes 45 minutes 60 minutes Payment (Office) 2 $35.58 $61.98 $91.44 $ $167.57

3 Reimbursement 75 Table 2. Evaluation and Management Office Visit Service Codes and 2001 Medicare Fee Schedule Payment Amounts for Established Patients Code History Not defined Problem Expanded problem Detailed Comprehensive Exam Not defined Problem Expanded problem Detailed Comprehensive Medical Not defined Straight-forward Low complexity Moderate High complexity Decisision Making complexity Problem severity Minimal Self-limited or minor Low to moderate Moderate to high Moderate to high Face-to-face time 5 minutes 10 minutes 15 minutes 25 minutes 40 minutes Payment (Office) 2 $19.89 $35.96 $50.50 $78.81 $ Evaluation and management service codes are determined by the comprehensiveness of the history and examination and the complexity of the medical decision-making required to manage the patient. The severity of the presenting problem and the time spent with the patient are also listed as guides, but the selection of appropriate evaluation and management code is not determined by the problem severity or time. For hospital-based anticoagulation management services, the facility would submit a claim for the technical or facility component service. This covers the room, equipment, supplies, and staff, excluding the physician s professional services. The hospital payment amounts are determined under the HOPPS under Ambulatory Payment Classification (APC) groups to which each CPT code is assigned. The payment amounts in the hospital outpatient setting are shown in Table 3. If a physician has a face-to-face encounter with the patient, the physician may also be paid a professional fee. The professional fee in the hospital outpatient setting is lower than the corresponding fee in the physician office setting recognizing that the physician does not bear the cost of overhead and staff in the hospital setting (Table 3). Coverage, Payment, and Coding for Administration of LMWH An outpatient encounter to evaluate a patient with deep venous thrombosis and to administer an LMWH would have the following components: (1) evaluation and management services, (2) injection of the LMWH, and (3) the LMWH drug product itself. These items and services may be provided in the physician office setting, a hospital outpatient clinic, an emergency department, or by a home health agency. In the office setting, we would have evaluation and management services under CPT for new patients and for established patients as shown in Tables 1 and 2. For the injection of an LMWH, the physician may report CPT Therapeutic, prophylactic or diagnostic injection (specify material injected); subcutaneous or intramuscular. The allowance under the 2001 Medicare Fee Schedule for this service is $4.59. Note, however, that payment will be made under this code only if no other fee schedule service is provided on the same day. Therefore, the physician will not be paid for the injection if an evaluation and management service visit is billed Table 3. Evaluation and Management Services in the Hospital Outpatient Department (Medicare 2001 Rates) Code: 1 New pt Hospital payment 3 APC 600 $49.24 APC 600 $49.24 APC 601 $50.24 APC 602 $83.40 APC 602 $83.40 Professional fee 2 $24.49 $47.44 $71.54 $ $ Code: 1 Establ pt Hospital payment 3 APC 600 $49.24 APC 600 $49.24 APC 601 $50.24 APC 602 $83.40 APC 602 $83.40 Professional fee 2 $9.56 $24.49 $35.58 $57.77 $ (accessed 24 June 2001).

4 76 Radensky on the same date. Private payer policies on payment for the injection will vary. Under Medicare, outpatient prescription drugs are generally not covered. However, drugs and biologicals, which are not usually self-administered by the patient, are covered when provided incident-to physician services or hospital services. When administered incident-to a physician s service, the payment is set at 95% of the national average wholesale price (AWP) as published by reference sources, such as Drug Topics Red Book or First Databank. As LMWHs may be self-administered, these agents are only covered when it is medically necessary for the drug to be administered by the provider. For example, physicians may determine that a patient should have the initial injection in the office to show the patient how to self-administer and to assess for any complications with the initial injection. Many local Medicare contractors have policies covering the initial injection of LMWH. In addition, some patients may not be able to self-administer at all because of physical impairment, visual limitations, or cognitive impairment. Under those circumstances, repeat injections in the physician office setting may be medically necessary. In the hospital outpatient setting, the facility may report the same services as the physician s office may report in the office setting. The evaluation and management services would be reported and paid at the rates shown in Table 3. In the hospital outpatient setting, however, APC 0359, to which injection code is assigned, has a payment rate of $ Therefore, in the hospital outpatient setting payment would be nearly identical whether the service is billed as an evaluation and management service or an injection. Under HOPPS, payment for drugs is generally included in the payment for the associated procedure. However, orphan drugs, cancer chemotherapy drugs, radiopharmaceuticals, and drugs not available before 1997 are paid separately from the APC rate for the associated procedure as socalled pass-through agents. Payment for passthrough drugs is set at 95% of the published, national AWP. Among the LMWHs, enoxaparin and dalteparin were introduced before 1997, and tinzaparin was introduced in Therefore, tinzaparin should be eligible for separate reimbursement at 95% of AWP. By contrast, there is no separate payment for either enoxaparin or dalteparin. The pass-through payments will continue through January 2003 or In the emergency department setting, both the hospital and physician would report the facility and professional components services respectively. There would be an evaluation and management service, an injection, and the LMWH. Payments for the evaluation and management services are shown in Table 4. The injection service, if separately billed and payable would fall under APC 0359, as above, and the LMWH would be paid under the pass-through payment rules. When LMWH is provided in the home health setting to homebound patients, payment for the nursing service and supplies is made under the Home Health PPS. If the patient requires 5 or more skilled nursing visits within a 60-day encounter period (e.g., to assist with the administration of the LMWH, to evaluate the leg and assess for clotting or bleeding complications, and to conduct point-of-care testing of prothrombin time for adjunctive warfarin therapy), the payment would fall under one of the Home Health Resource Groups, with payment amounts ranging from $1, to $5, (unadjusted for geographic locality). If the patient requires 4 or fewer visits, the payment would be on a per visit basis under what is called the Low Utilization Payment Adjustment (LUPA). The 2001 LUPA amount for skilled nursing visits is $ Table 4. Evaluation and Management Services in the Emergency Department (Medicare 2001 Rates) E&M Code History Problem Expanded problem Expanded problem Detailed Comprehensive Examination Problem Expanded problem Expanded problem Detailed Comprehensive Med decision making Straight-forward Low complexity Moderate complexity Moderate complexity High complexity Problem severity Self-limited or minor Low to moderate Moderate High High Facility payment 3 APC 610 $67.32 APC 610 $67.32 APC 611 $ APC 612 $ APC 612 $ Physician payment 2 $18.75 $30.61 $64.66 $ $ (accessed 28 June 2001).

5 Reimbursement 77 Incident-to Service Rules Providing high-quality anticoagulation services requires a coordinated effort among many professionals. Many of the services can appropriately be provided by physician office or hospital staff and do not require face-to-face services from the physician. For example, under physician supervision, a nurse may evaluate a patient by asking about changes in medication, diet, concurrent illnesses, or occurrence of any bleeding or clotting events, by conducting a brief examination to look for signs of bleeding or clotting, drawing a specimen to run a PT test, performing a point-of-care test, informing the patient of the results, and instructing the patient on any changes in warfarin dosing. Medicare recognizes that physicians and hospitals can provide services beyond the direct physician face-to-face encounter and these services are covered as incident-to the services of a physician, provided specific rules are followed. In the physician office setting, there are three requirements for coverage of incident-to services: (1) there must be direct personal physician supervision, (2) auxiliary personnel who personally perform services, such as nurses, nonphysician anesthetists, psychologists, technicians, therapists, including physical therapists, and other aides must be employed by the physician, and (3) the services must be furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency which reflect his=her active participation in and management of the course of treatment (Medicare Carriers Manual [MCM] ). Direct physician supervision requires that the physician be present in the office suite and be immediately available to provide assistance and direction throughout the time the non-physician is performing services. The physician need not be present in the same room, however. To meet the employed by the physician requirement, the nonphysician performing an incident-to service may be a part-time, full-time, or leased employee of the supervising physician, physician group practice, or of the legal entity that employs the physician who provides direct personal supervision. A leased employee is a nonphysician working under a written employee leasing agreement which provides that the nonphysician provides services as the leased employee of the physician; and the physician exercises control over all actions of the leased employee regarding the rendering of medical services to the same extent the physician would exercise such control if the leased employee were directly employed by the physician. Services provided by auxiliary personnel not in the employ of the physician are not covered as incident-to a physician s service since the incidental service must represent an expense incurred by the physician. To be eligible for incident-to coverage, the physician who is billing for the services must personally provide an initial service to the patient and must see the patient personally at some routine interval as medically necessary to provide adequate supervision of the patient s management. There are no specific policies as to the frequency at which physicians must personally provide follow up services. In addition to services provided by physicians or by their nonphysician staff incident-to a physician s service, anticoagulation management services may be provided by nurse practitioners, physician assistants or clinical nurse specialists, so-called advanced practice nonphysician practitioners (MCM ). These advanced practice nonphysician practitioners are licensed by the states under various programs to assist or act in the place of the physician. For services of a nonphysician practitioner to be covered as incident-to services of a physician, the services must meet all of the requirements for coverage specified above: direct personal supervision, employment, and occur during the course of treatment by the physician. In addition to providing incident-to physician services, these advanced practice professionals also may provide services directly and not under direct physician supervision. When incident-to services are provided by nonadvanced practice nonphysician professionals, Medicare policy limits the services to the lowest level evaluation and management visit: CPT (MCM 15501G). If the services are provided by advanced practice professionals, however, there is no limitation on the intensity of evaluation and management service provided as long as the services provided are within the advanced practice professional s scope of practice under state law. Payment for services provided incident-to a physician s service are paid at the full Medicare Physician Fee Schedule rate. Payment for services of advanced practice professionals performed independently (i.e., not under direct physician supervision) are paid at 85% of the Medicare Physician Fee Schedule rate. Although physician assistants may perform evaluation and management services without direct physician supervision and their services may be billed as independent services, physician assistant services can only be billed by their employer. Services incident-to physician services may also be covered in the hospital outpatient setting (Medicare Intermediary Manual ). These

6 78 Radensky services must be provided: (1) under physician supervision, (2) by hospital personnel, and (3) on the order of a physician who sees the patient personally during the course of treatment. In the hospital setting, when services are provided on the hospital campus, the physician supervision requirement is generally assumed to be met. The hospital medical staff that supervises the services need not be in the same department as the ordering physician. Physician supervision is not assumed, however, for off-campus facilities. (A discussion of the requirements for off-campus facilities to bill as hospital outpatient departments is beyond the scope of this paper.) Although physician supervision may be assumed for reimbursement purposes in the hospital campus setting, good medical care may require that a physician be physically close to the place where the anticoagulation management services are provided and be ready immediately to handle personally any emergency situations that arise. As discussed above for incident-to services in the physician office setting, in the hospital outpatient setting, the hospital can bill only for services provided by its personnel or personnel the hospital provides under arrangements. A physician cannot bring his or her staff to the hospital and bill under the incident-to rules for services performed by the physician s staff. If the anticoagulation management services are provided by advanced practice professionals, these professionals may bill their professional services independent from the hospital facility fee only if the salary, benefits, and expenses of the advanced practice professionals are excluded from the hospitals cost report to Medicare. As in the physician office setting, the incidentto services provided by the hospital must be during the course of care provided by a physician Table 5. Incident-to Billing in Physician Office Setting Personnel performing service Supervision required Reportable codes Payment amount Physician None (new patient); (esablished patient) Advanced practice professional (independent service) Advanced practice professional (incident-to-service) Non-advanced practice professional * Medicare Fee Schedule (physician services). 100 % MFS* None (new patient); (esablished patient) 85 % MFS* Direct physician supervision % MFS* Direct physician supervision % MFS* Table 6. Incident-to Billing in Hospital Outpatient Setting Personnel performing service Supervision required Reportable codes Hospital payment amount Professional fee Physician None (new patient); (established patient) Advanced practice professional (not included on hospital cost report) Advanced practice professional (included on hospital cost report) Non-advanced practice professional * Medicare Fee Schedule (physician services). APC 600 APC % MFS* None (new patient); (established patient) APC 600 APC % MFS* None APC 600 APC 602 Not eligible to bill for professional fee Physician supervision (assumed on campus; not assumed off-campus) APC 600 Not eligible to bill for professional fee

7 Reimbursement 79 who initially evaluates the patient and sees the patient periodically and sufficiently often to assess the course of treatment and the patient s progress and, where necessary, to change the treatment regimen (MIM ). A hospital service or supply would not be considered incident-to a physician s service if the attending physician merely wrote an order for the services or supplies and referred the patient to the hospital without being involved in the management of that course of treatment. The required nexus between the physician who personally sees the patients and the hospital is not defined in the regulations or policies, but it would appear that the physician referring the patient to the hospital for incident-to services must have staff privileges at the hospital. Although the general framework for considering coverage, payment and coding for incidentto services is presented above, many questions arise from those involved in providing anticoagulation management regarding incident-to services: Who can perform these services? Who can bill for the services? How much will be paid for these services? Two important issues should be considered to answer the question about who can provide incident-to services. First, one must ask whether it is appropriate for the physician to delegate the particular service that is performed by non-physician staff. Second, one must consider whether it is appropriate for the physician to delegate the specific service to the particular non-physician practitioner performing the service. These issues involve State law issues about the scope of medical practice, the scope of practice of the non-physician staff actually performing the service, and the standard of care in the community for providing these services. Of course, physicians have greater freedom to delegate services to advanced practice professionals than non-advanced practice professionals. Among nonadvanced practice professionals, the question about whether a particular service is within the scope of practice may not be clear. Under those circumstances, the physician and the nonphysician practitioner may wish to inquire of the respective licensing authorities (medical board and board of practice for the non-advanced practice staff, if any) about the appropriateness of any physician-delegated services performed under direct physician supervision. Finally, the incident-to coverage, payment, and coding rules are summarized in Tables 5 and 6. The rules, as described above, are more detailed than one easily can summarize in tabular form, however. Conclusion Proper anticoagulation can be life-saving and can avert such serious events as strokes and pulmonary emboli. Providing high quality anticoagulation services involves a coordinated effort among multiple professionals. The rules defining coverage, payment, and coding for these services are complex, but navigating through them properly will assure that anticoagulation service providers receive appropriate revenues for the services provided so they may continue to offer these much-needed services.

Chapter 13 Section 2. Billing And Coding Of Services Under Ambulatory Payment Classifications (APC) Groups

Chapter 13 Section 2. Billing And Coding Of Services Under Ambulatory Payment Classifications (APC) Groups Outpatient Prospective Payment System (OPPS)-Ambulatory Payment Classification (APC) Chapter 13 Section 2 Billing And Coding Of Services Under Ambulatory Payment Classifications (APC) Groups Issue Date:

More information

Chapter 13 Section 2. Billing And Coding Of Services Under Ambulatory Payment Classifications (APC) Groups

Chapter 13 Section 2. Billing And Coding Of Services Under Ambulatory Payment Classifications (APC) Groups Outpatient Prospective Payment System (OPPS)-Ambulatory Payment Classification (APC) Chapter 13 Section 2 Billing And Coding Of Services Under Ambulatory Payment Classifications (APC) Groups Issue Date:

More information

Outpatient Hospital Facilities

Outpatient Hospital Facilities Outpatient Hospital Facilities Chapter 6 Chapter Outline Introduce students to 1. Different outpatient facilities 2. Different departments involved in the reimbursement process 3. The Chargemaster 4. Terminology

More information

Chapter 9 Section 1. Ambulatory Surgical Center (ASC) Reimbursement

Chapter 9 Section 1. Ambulatory Surgical Center (ASC) Reimbursement Ambulatory Surgery Centers (ASCs) Chapter 9 Section 1 Issue Date: August 26, 1985 Authority: 32 CFR 199.14(d) Copyright: CPT only 2006 American Medical Association (or such other date of publication of

More information

Chapter 9 Section 1. Ambulatory Surgical Center (ASC) Reimbursement

Chapter 9 Section 1. Ambulatory Surgical Center (ASC) Reimbursement Ambulatory Surgery Centers (ASCs) Chapter 9 Section 1 Issue Date: August 26, 1985 Authority: 32 CFR 199.14(d) Copyright: CPT only 2006 American Medical Association (or such other date of publication of

More information

Procedure Code Job Aid

Procedure Code Job Aid Procedure Code 99211 Job Aid Definition for 99211: Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually,

More information

Documentation Guidelines. Medication Therapy Management (MTM)

Documentation Guidelines. Medication Therapy Management (MTM) Documentation Guidelines Medication Therapy Management (MTM) Effective Date Revision Letter Applies To: FINAL A UNMMG 1.0 Purpose This document provides guidelines for Pharmacist Clinicians (PhC) and other

More information

Chapter 13 Section 2. Billing And Coding Of Services Under Ambulatory Payment Classifications (APC) Groups

Chapter 13 Section 2. Billing And Coding Of Services Under Ambulatory Payment Classifications (APC) Groups Outpatient Prospective Payment System (OPPS)-Ambulatory Payment Classification (APC) Chapter 13 Section 2 Billing And Coding Of Services Under Ambulatory Payment Classifications (APC) Groups Issue Date:

More information

Corporate Reimbursement Policy

Corporate Reimbursement Policy Corporate Reimbursement Policy Code Bundling Rules Not Addressed in ClaimCheck or Correct File Name: code_bundling_rules_not_addressed_in_claim_check Origination: 6/2004 Last Review: 12/2017 Next Review:

More information

Type of intervention Treatment. Economic study type Cost-effectiveness analysis.

Type of intervention Treatment. Economic study type Cost-effectiveness analysis. Shifting from inpatient to outpatient treatment of deep vein thrombosis in a tertiary care center: a cost-minimization analysis Boucher M, Rodger M, Johnson J A, Tierney M Record Status This is a critical

More information

Medi-Pak Advantage: Reimbursement Methodology

Medi-Pak Advantage: Reimbursement Methodology Medi-Pak Advantage: Reimbursement Methodology The information located on the following pages is intended to summarize the reimbursement methodologies for Medi-Pak Advantage: Medi-Pak Advantage reimburses

More information

TRICARE Reimbursement Manual M, February 1, 2008 Ambulatory Surgery Centers (ASCs) Chapter 9 Section 1

TRICARE Reimbursement Manual M, February 1, 2008 Ambulatory Surgery Centers (ASCs) Chapter 9 Section 1 Ambulatory Surgery Centers (ASCs) Chapter 9 Section 1 Ambulatory Surgical Center (ASC) Reimbursement Prior To Implementation Of Outpatient Prospective Payment (OPPS), And Thereafter, Freestanding ASCs,

More information

Shared and Incident To Billing of E/M Services in Radiation Oncology Updated November 2017

Shared and Incident To Billing of E/M Services in Radiation Oncology Updated November 2017 ASTRO Guidance on Shared and Incident To Billing of Evaluation and Management Services in Radiation Oncology The Centers for Medicare and Medicaid Services (CMS) establishes Medicare policy for the payment

More information

HCPCS - C9716* SI - S APC Short Descriptor - Radiofrequency Energy to Anus

HCPCS - C9716* SI - S APC Short Descriptor - Radiofrequency Energy to Anus HMI Corporation Second Quarter 2004 June 21, 2004 C ODING & B ILLING F OR P ROSPECTIVE P AYMENT S YSTEMS JULY 2004 UPDATE OF THE HOSPITAL OUTPATIENT Inside this Issue: July 2004 Update of the Hospital

More information

Florida Medicaid. Outpatient Hospital Services Coverage Policy. Agency for Health Care Administration. Draft Rule

Florida Medicaid. Outpatient Hospital Services Coverage Policy. Agency for Health Care Administration. Draft Rule Florida Medicaid Agency for Health Care Administration Draft Rule Table of Contents Florida Medicaid 1.0 Introduction... 1 1.1 Description... 1 1.2 Legal Authority... 1 1.3 Definitions... 1 2.0 Eligible

More information

Amy Bassano Centers for Medicare and Medicaid Services June 9, 2009

Amy Bassano Centers for Medicare and Medicaid Services June 9, 2009 Amy Bassano Centers for Medicare and Medicaid Services June 9, 2009 Coverage of Clinical Laboratory Services Lab service must meet all requirements of the Clinical Laboratory Improvement Amendment (CLIA)

More information

Payment Methodology. Acute Care Hospital - Inpatient Services

Payment Methodology. Acute Care Hospital - Inpatient Services Grid Medi-Pak Advantage generally reimburses deemed providers the amount they would have received under Original Medicare for Medicare covered services, minus any amounts paid directly by Original Medicare

More information

Objectives. Observation: Exploring the MOON and Charge Capture. Aurora Health Care 10/11/2016

Objectives. Observation: Exploring the MOON and Charge Capture. Aurora Health Care 10/11/2016 Observation: Exploring the MOON and Charge Capture Lynn Sisler, Senior Director Case Management Manpreet Lehn, Manager Revenue Assurance Objectives Understand the CMS requirements for the Medicare Outpatient

More information

Diabetes Outpatient Clinical Coverage Policy No: 1A-24 Self-Management Education Amended Date: October 1, Table of Contents

Diabetes Outpatient Clinical Coverage Policy No: 1A-24 Self-Management Education Amended Date: October 1, Table of Contents Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 2.0 Eligibility Requirements... 1 2.1 Provisions... 1 2.1.1 General... 1 2.1.2 Specific... 2 2.2 Special

More information

Reimbursement Information for Contrast Enhanced Spectral Mammography (CESM) Services 1

Reimbursement Information for Contrast Enhanced Spectral Mammography (CESM) Services 1 GE Healthcare Reimbursement Information for Contrast Enhanced Spectral Mammography (CESM) Services 1 May 2018 www.gehealthcare.com/reimbursement This advisory addresses Medicare coding, coverage and payment

More information

Anthem Blue Cross and Blue Shield Commercial Professional Reimbursement Policy

Anthem Blue Cross and Blue Shield Commercial Professional Reimbursement Policy Subject: Injection and Infusion Administration and Related Services & Supplies IN, KY, MO, OH, WI Policy: 0015 Effective: 05/01/2017 Coverage is subject to the terms, conditions, and limitations of an

More information

Billing Policies and Procedures WVU Physicians of Charleston

Billing Policies and Procedures WVU Physicians of Charleston Billing Policies and Procedures WVU Physicians of Charleston POLICY/PROCEDURE NO.: B-10 10/1/15 Section: Chapter: Policy: Compliance Billing Teaching Physician Requirements Evaluation and Management (E/M)

More information

Coding Guidelines for Certain Respiratory Care Services January 2018 (updates in red)

Coding Guidelines for Certain Respiratory Care Services January 2018 (updates in red) Coding Guidelines for Certain Respiratory Care Services (updates in red) Overview From time to time the AARC receives inquiries about respiratory-related coding and coverage issues through its Help Line

More information

OBSERVATION CARE EVALUATION AND MANAGEMENT CODES POLICY

OBSERVATION CARE EVALUATION AND MANAGEMENT CODES POLICY OBSERVATION CARE EVALUATION AND MANAGEMENT CODES POLICY UnitedHealthcare Oxford Reimbursement Policy Policy Number: ADMINISTRATIVE 232.10 T0 Effective Date: March 1, 2017 Table of Contents Page INSTRUCTIONS

More information

Telemedicine and Telehealth Services

Telemedicine and Telehealth Services INDIANA HEALTH COVERAGE PROGRAMS PROVIDER REFERENCE M ODULE Telemedicine and Telehealth Services L I B R A R Y R E F E R E N C E N U M B E R : P R O M O D 0 0 0 4 8 P U B L I S H E D : J A N U A R Y 1

More information

Medical, Surgical, and Routine Supplies (including but not limited to 99070)

Medical, Surgical, and Routine Supplies (including but not limited to 99070) Manual: Policy Title: Reimbursement Policy Medical, Surgical, and Routine Supplies (including but not limited to 99070) Section: Administrative Subsection: none Date of Origin: 1/1/2002 Policy Number:

More information

Optima Health Provider Manual

Optima Health Provider Manual Optima Health Provider Manual Supplemental Information For Ohio Facilities and Ancillaries This supplement of the Optima Health Ohio Provider Manual provides information of specific interest to Participating

More information

1:35. NPP April Young Medical Consulting, LLC. Non-Physician Practitioner Coding and Billing. Disclaimer

1:35. NPP April Young Medical Consulting, LLC. Non-Physician Practitioner Coding and Billing. Disclaimer Non-Physician Practitioner Coding and Billing Jill Young - CPC, CEDC, CIMC, East Lansing, Michigan 1 Disclaimer This material is designed to offer basic information for coding and billing. The information

More information

PHYSICIAN FEE SCHEDULE PAYMENT GROUND RULES: A COMPARISON OF THE OMFS AND MEDICARE *

PHYSICIAN FEE SCHEDULE PAYMENT GROUND RULES: A COMPARISON OF THE OMFS AND MEDICARE * PHYSICIAN FEE SCHEDULE PAYMENT GROUND RULES: A COMPARISON OF THE OMFS AND MEDICARE * Ground Rule and/or OVERALL FEE SCHEDULE DESIGN Conversion factor Separate conversion factors for: Evaluation & Management

More information

Core Services Provided in Federally Clinical Coverage Policy No: 1D-4 Qualified Health Centers and Amended Date: October 1, 2015 Rural Health Clinics

Core Services Provided in Federally Clinical Coverage Policy No: 1D-4 Qualified Health Centers and Amended Date: October 1, 2015 Rural Health Clinics Qualified Health Centers and Amended Date: October 1, 2015 Rural Health Clinics Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Federally Qualified Health Centers... 1

More information

Rural Health Clinic Overview

Rural Health Clinic Overview TrailBlazer Health Enterprises Rural Health Clinic Overview Steven W. Mildward Published March 2012 108724 2012 TrailBlazer Health Enterprises /TrailBlazer. All rights reserved. Important The information

More information

TCS FAQ s. How will the implementation of national standard code sets reduce burden on the health care industry?

TCS FAQ s. How will the implementation of national standard code sets reduce burden on the health care industry? TCS FAQ s What is a code set? Under HIPAA, a code set is any set of codes used for encoding data elements, such as tables of terms, medical concepts, medical diagnosis codes, or medical procedure codes.

More information

Medical Fee Schedule (MFS) Frequently Asked Questions (FAQs) General FAQs

Medical Fee Schedule (MFS) Frequently Asked Questions (FAQs) General FAQs Medical Fee Schedule (MFS) Frequently Asked Questions (FAQs) General FAQs 1. What is the Medical Fee Schedule (MFS)? The MFS is the schedule of maximum fees payable for scheduled medical services rendered

More information

Anesthesia Services Policy

Anesthesia Services Policy Anesthesia Services Policy Policy Number Annual Approval Date 3/14/2018 Approved By Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY This policy is applicable to UnitedHealthcare Medicare

More information

EXCLUSIVE CARE SUMMARY OF COVERED BENEFITS Select Medicare Eligible Supplement Plan

EXCLUSIVE CARE SUMMARY OF COVERED BENEFITS Select Medicare Eligible Supplement Plan 2018 EXCLUSIVE CARE SUMMARY OF COVERED BENEFITS Select Medicare Eligible Supplement Plan Summary Table of Benefits Select Medicare Supplement Plan PLAN REIMBURSEMENT METHOD DEDUCTIBLE - Individual Medicare

More information

Chapter 02 Hospital Based Care

Chapter 02 Hospital Based Care Chapter 02 Hospital Based Care MULTICHOICE 1. The physician sends the patient to the hospital for a radiological examination. The patient returns to the physician's office for follow-up of test results.

More information

Billing Policies and Procedures WVU Physicians of Charleston

Billing Policies and Procedures WVU Physicians of Charleston Billing Policies and Procedures WVU Physicians of Charleston POLICY/PROCEDURE NO.: B-10 Date(s) of Revision: 10/10/08 Section: Chapter: Policy: Compliance Billing Teaching Physician Requirements Evaluation

More information

Laboratory Services Policy, Professional

Laboratory Services Policy, Professional Laboratory Services Policy, Professional UnitedHealthcare Medicare Advantage Reimbursement Policy CMS 1500 Reimbursement Policy Policy Number Annual Approval Date 12/13/2017 Approved By Oversight Committee

More information

Article from: Health Section News. April 2000 No. 37

Article from: Health Section News. April 2000 No. 37 Article from: Health Section News April 2000 No. 37 For Professional Recognition of the Health Actuary NUMBER 37 APRIL 2000 Chairperson s Corner by Bernie Rabinowitz APCs - They ll Change Outpatient Hospital

More information

Chronic Care Management. Sharon A. Shover, CPC, CEMC 2650 Eastpoint Parkway, Suite 300 Louisville, Kentucky

Chronic Care Management. Sharon A. Shover, CPC, CEMC 2650 Eastpoint Parkway, Suite 300 Louisville, Kentucky Chronic Care Management Sharon A. Shover, CPC, CEMC 2650 Eastpoint Parkway, Suite 300 Louisville, Kentucky 40223 502.992.3511 sshover@blueandco.com Agenda Chronic Care Management (CCM) History Define Requirements

More information

Services That Require Prior Authorization

Services That Require Prior Authorization Services That Require Prior Authorization Some of the services listed in the Medical Benefits Chart are covered only if your doctor or other network provider gets approval in advance (sometimes called

More information

Florida Medicaid. Ambulatory Surgical Center Services Coverage Policy. Agency for Health Care Administration

Florida Medicaid. Ambulatory Surgical Center Services Coverage Policy. Agency for Health Care Administration Florida Medicaid Ambulatory Surgical Center Services Coverage Policy Agency for Health Care Administration Table of Contents 1.0 Introduction... 1 1.1 Florida Medicaid Policies..1 1.2 Statewide Medicaid

More information

Presented by: Jodie Edmonds VP Medicaid Revenue Consultant Passport Health Communications

Presented by: Jodie Edmonds VP Medicaid Revenue Consultant Passport Health Communications Presented by: Jodie Edmonds VP Medicaid Revenue Consultant Passport Health Communications Complete and correct coding of claims will become more important, and will have an effect on claim payment. The

More information

Long Term Care Hospital Clinical Coverage Policy No: 2A-2 Services (LTCH) Amended Date: October 1, Table of Contents

Long Term Care Hospital Clinical Coverage Policy No: 2A-2 Services (LTCH) Amended Date: October 1, Table of Contents Long Term Care Hospital Clinical Coverage Policy No: 2A-2 Services (LTCH) Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 2.0 Eligibility Requirements...

More information

The ASA defines anesthesiology as the practice of medicine dealing with but not limited to:

The ASA defines anesthesiology as the practice of medicine dealing with but not limited to: 1570 Midway Pl. Menasha, WI 54952 920-720-1300 Procedure 1205- Anesthesia Lines of Business: All Purpose: This guideline describes Network Health s reimbursement of anesthesia services. Procedure: Anesthesia

More information

Reimbursement for Non-Invasive Respiratory Support in Hospital Inpatient, Emergency Department and Other Outpatient Settings 1

Reimbursement for Non-Invasive Respiratory Support in Hospital Inpatient, Emergency Department and Other Outpatient Settings 1 2400 Beacon St., #203, Chestnut Hill, MA 02467 617-645-8452 Reimbursement for Non-Invasive Respiratory Support in Hospital Inpatient, Emergency Department and Other Outpatient Settings 1 The purpose of

More information

Observation Care Evaluation and Management Codes Policy

Observation Care Evaluation and Management Codes Policy Policy Number Observation Care Evaluation and Management Codes Policy 2017R0115A Annual Approval Date 3/8/2017 Approved By Reimbursement Policy Oversight Committee IMPORTANT NOTE ABOUT THIS You are responsible

More information

Chapter 1 Section 16

Chapter 1 Section 16 General Chapter 1 Section 16 Issue Date: August 26, 1985 Authority: 32 CFR 199.4(c)(2)(i), (c)(2)(ii), (c)(3)(i), (c)(3)(iii), and (c)(3)(iv) 1.0 APPLICABILITY Paragraphs 3.1 through 3.7 apply to reimbursement

More information

2018 Biliary Reimbursement Coding Fact Sheet

2018 Biliary Reimbursement Coding Fact Sheet The information contained in this document is provided for informational purposes only and represents no statement, promise, or guarantee by Cordis Corporation concerning levels of reimbursement, payment,

More information

Empire BlueCross BlueShield Professional Commercial Reimbursement Policy

Empire BlueCross BlueShield Professional Commercial Reimbursement Policy Subject: Place of Service NY Policy: 0018 Effective: 12/01/2015 02/21/2016 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria

More information

Cigna Medical Coverage Policy

Cigna Medical Coverage Policy Cigna Medical Coverage Policy Subject Observation Care Table of Contents Coverage Policy... 1 General Background... 2 Coding/Billing Information... 4 References... 5 Effective Date... 10/15/2014 Next Review

More information

Corporate Medical Policy

Corporate Medical Policy Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: skilled_nursing_services 07/2001 2/2018 2/2019 2/2018 Description of Procedure or Service Skilled Nursing

More information

Chapter 13 Section 1

Chapter 13 Section 1 Outpatient Prospective Payment System (OPPS)-Ambulatory Payment Classification (APC) Chapter 13 Section 1 Issue Date: July 27, 2005 Authority: 10 USC 1079(j)(2) and 10 USC 1079(h) 1.0 APPLICABILITY This

More information

Medicare Preventive Services

Medicare Preventive Services Medicare Preventive Services Presented by Part B Provider Outreach & Education December 16, 2015 Event Instructions Today s event is a teleconference Slides will not be advanced during the presentation

More information

Payment Policy: High Complexity Medical Decision-Making Reference Number: CC.PP.051 Product Types: ALL

Payment Policy: High Complexity Medical Decision-Making Reference Number: CC.PP.051 Product Types: ALL Payment Policy: High Complexity Medical Decision-Making Reference Number: CC.PP.051 Product Types: ALL Effective Date: 6/2017 Last Review Date: See Important Reminder at the end of this policy for important

More information

Supply Policy. 11/15/2017 Approved By Reimbursement Policy Oversight Committee

Supply Policy. 11/15/2017 Approved By Reimbursement Policy Oversight Committee Supply Policy Policy Number 2018R0006A Annual Approval Date 11/15/2017 Approved By Reimbursement Policy Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY You are responsible for submission

More information

Chapter 6 Section 3. Hospital Reimbursement - TRICARE DRG-Based Payment System (Basis Of Payment)

Chapter 6 Section 3. Hospital Reimbursement - TRICARE DRG-Based Payment System (Basis Of Payment) Diagnostic Related Groups (DRGs) Chapter 6 Section 3 Hospital Reimbursement - TRICARE DRG-Based Payment System (Basis Of Payment) Issue Date: October 8, 1987 Authority: 32 CFR 199.14(a)(1) 1.0 APPLICABIITY

More information

CHANGE M OCTOBER 23, CHAPTER 5 Section 4, pages 1 and 2 Section 4, pages 1 and 2

CHANGE M OCTOBER 23, CHAPTER 5 Section 4, pages 1 and 2 Section 4, pages 1 and 2 CHANGE 149 6010.58-M OCTOBER 23, 2017 REMOVE PAGE(S) INSERT PAGE(S) CHAPTER 5 Section 4, pages 1 and 2 Section 4, pages 1 and 2 CHAPTER 7 Section 2, pages 3 and 4 Section 2, pages 3 and 4 CHAPTER 13 Section

More information

AHLA. MM OPPS Update. Valerie Rinkle Navigant Consulting Seattle, WA

AHLA. MM OPPS Update. Valerie Rinkle Navigant Consulting Seattle, WA AHLA MM. 2014 OPPS Update Valerie Rinkle Navigant Consulting Seattle, WA Christina Ritter, PhD Center for Medicare Management Centers for Medicare and Medicaid Services Baltimore, MD Institute on Medicare

More information

TO BE RESCINDED Fee-for-service ambulatory health care clinics (AHCCs): end-stage renal disease (ESRD) dialysis clinics.

TO BE RESCINDED Fee-for-service ambulatory health care clinics (AHCCs): end-stage renal disease (ESRD) dialysis clinics. ACTION: Revised DATE: 03/13/2017 1:25 PM TO BE RESCINDED 5160-13-01.9 Fee-for-service ambulatory health care clinics (AHCCs): end-stage renal disease (ESRD) dialysis clinics. Requirements outlined in rule

More information

Procedural andpr Diagnostic Coding. Copyright 2012 Delmar, Cengage Learning. All rights reserved.

Procedural andpr Diagnostic Coding. Copyright 2012 Delmar, Cengage Learning. All rights reserved. Procedural andpr Diagnostic Coding What is Coding? Converting descriptions of disease, injury, procedures, and services into numeric or alphanumeric descriptors Accurate coding maximizes reimbursement

More information

Table of Contents. 1.0 Description of the Procedure, Product, or Service Definitions Hospice Terminal illness...

Table of Contents. 1.0 Description of the Procedure, Product, or Service Definitions Hospice Terminal illness... Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 1.1.1 Hospice... 1 1.1.2 Terminal illness... 1 2.0 Eligibility Requirements... 1 2.1 Provisions... 1 2.1.1

More information

Laboratory Services INDIANA HEALTH COVERAGE PROGRAMS. Copyright 2017 DXC Technology Company. All rights reserved.

Laboratory Services INDIANA HEALTH COVERAGE PROGRAMS. Copyright 2017 DXC Technology Company. All rights reserved. INDIANA HEALTH COVERAGE PROGRAMS PROVIDER REFERENCE M ODULE Laboratory Services L I B R A R Y R E F E R E N C E N U M B E R : P R O M O D 0 0 0 3 6 P U B L I S H E D : J U N E 2 9, 2 0 1 7 P O L I C I

More information

HOW TO SUBMIT OWCP-04 BILLS TO ACS

HOW TO SUBMIT OWCP-04 BILLS TO ACS HOW TO SUBMIT OWCP-04 BILLS TO ACS The following services should be billed on the OWCP-04 Form: General Hospital Hospice Nursing Home Rehabilitation Centers As a provider you have the option of sending

More information

Summary of Benefits Advantra Freedom PEBTF

Summary of Benefits Advantra Freedom PEBTF Advantra Freedom is a Medicare Advantage Private Fee-For-Service (PFFS) Plan. This Summary of Benefits tells you some features of our Plan. It doesn't list every service that we cover or list every limitation

More information

Meet the Presenter. HCPCS Reimbursement Impacts the Bottom Line. Welcome to PMI s Webinar Presentation. On the topic:

Meet the Presenter. HCPCS Reimbursement Impacts the Bottom Line. Welcome to PMI s Webinar Presentation. On the topic: Welcome to PMI s Webinar Presentation Brought to you by: Practice Management Institute pmimd.com Meet the Presenter Rhonda Granja CMC, CMIS, CMOM, CPC, CPM, MCS Faculty Practice Management Institute On

More information

NCD for Routine Costs in Clinical Trials (310.1)

NCD for Routine Costs in Clinical Trials (310.1) NCD for Routine Costs in Clinical Trials (310.1) Publication Number 100-3 Manual Section Number 310.1 Version Number 2 Effective Date of this Version 7/9/2007 Implementation Date 10/9/2007 Benefit Category

More information

Excerpts of the Code of Federal Regulations Referenced in Proposed Rule CMS 1403 P

Excerpts of the Code of Federal Regulations Referenced in Proposed Rule CMS 1403 P Excerpts of the Code of Federal Regulations Referenced in Proposed Rule CMS 1403 P The document below reflects the sections of the regulations currently in effect for Independent Diagnostic Testing Facilities

More information

Care Plan Oversight Services and Physician Services for Certification

Care Plan Oversight Services and Physician Services for Certification Education Makes the Difference Care Plan Oversight Services and Physician Services for Certification and Recertification of Medicare-Covered Home Health Services A CMS CONTRACTED INTERMEDIARY CARRIER The

More information

ALASKA. Official MEDICAL FEE SCHEDULE WORKERS' COMPENSATION

ALASKA. Official MEDICAL FEE SCHEDULE WORKERS' COMPENSATION Official ALASKA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE Effective, 201 STATE OF ALASKA DISCLAIMER This document establishes professional medical fee reimbursement amounts for covered services rendered

More information

Empire BlueCross BlueShield Professional Reimbursement Policy

Empire BlueCross BlueShield Professional Reimbursement Policy Subject: Global Surgery NY Policy: 0012 Effective: 02/01/2014 05/31/2014 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria

More information

AMERICAN INDIAN 638 CLINICS PROVIDER MANUAL Chapter Thirty-nine of the Medicaid Services Manual

AMERICAN INDIAN 638 CLINICS PROVIDER MANUAL Chapter Thirty-nine of the Medicaid Services Manual AMERICAN INDIAN 638 CLINICS PROVIDER MANUAL Chapter Thirty-nine of the Medicaid Services Manual Issued December 1, 2009 Claims/authorizations for dates of service on or after October 1, 2015 must use the

More information

Provider-Based RHC Billing June 8, 2018

Provider-Based RHC Billing June 8, 2018 Provider-Based RHC Billing June 8, 2018 Sharon Shover, CPC, CEMC 502.992.3511 Provider-Based RHC Billing Agenda RHC Encounters Payment for RHC Services Same Day Visits Revenue Codes CG Modifier & QVL Non-RHC

More information

Reimbursement Policy. BadgerCare Plus. Subject: Consultations

Reimbursement Policy. BadgerCare Plus. Subject: Consultations Subject: Reimbursement Policy Effective Date: Committee Approval Obtained: Section: Evaluation and 04/20/18 04/20/18 Management *****The most current version of our reimbursement policies can be found

More information

VIRGINIA WORKERS COMPENSATION MEDICAL FEE SCHEDULES GROUND RULES JUNE 5, 2017

VIRGINIA WORKERS COMPENSATION MEDICAL FEE SCHEDULES GROUND RULES JUNE 5, 2017 VIRGINIA WORKERS COMPENSATION MEDICAL FEE SCHEDULES GROUND RULES JUNE 5, 2017 Contents Introduction... 3 Definitions... 4 General Information... 11 Application of the Medical Fee Schedules... 11 Exclusions

More information

SNF Consolidated Billing Exclusions/Inclusions

SNF Consolidated Billing Exclusions/Inclusions SNF Consolidated Billing Exclusions/Inclusions Under SNF consolidated billing rules, certain Part B services provided to SNF residents are to be billed directly by the SNF. The facility would bill the

More information

Reimbursement guide. IODOSORB/IODOFLEX are Cadexomer Iodine-based products, available in two forms gel or pad.

Reimbursement guide. IODOSORB/IODOFLEX are Cadexomer Iodine-based products, available in two forms gel or pad. Reimbursement guide IODOSORB/IODOFLEX are Cadexomer Iodine-based products, available in two forms gel or pad. IODOSORB/IODOFLEX remove barriers to healing by its dual action antimicrobial and desloughing

More information

MLN Matters Number: MM6699 Related Change Request (CR) #: 6699

MLN Matters Number: MM6699 Related Change Request (CR) #: 6699 News Flash Medicare will cover immunizations for H1N1 influenza also called the "swine flu." There will be no coinsurance or copayment applied to this benefit, and beneficiaries will not have to meet their

More information

Drug Therapy Management

Drug Therapy Management 4/17 Welcome to the Centers of Excellence Assessment Becoming an Anticoagulation Center of Excellence gives your service the chance to work as a multidisciplinary team to evaluate your current safety practices

More information

Protocol Applies To: UW Health Clinics: all adult outpatients with an active order for warfarin

Protocol Applies To: UW Health Clinics: all adult outpatients with an active order for warfarin Protocol Number: 7 Protocol Title: Ambulatory Initiation and Management of Warfarin for Adults Protocol Applies To: UW Health Clinics: all adult outpatients with an active order for warfarin Target Patient

More information

Regulatory Compliance Risks. September 2009

Regulatory Compliance Risks. September 2009 Rehabilitation Regulatory Compliance Risks September 2009 1 Agenda - Rehabilitation Compliance Risks Understand the basic requirements for Inpatient Rehabilitation Facilities (IRFs) and Outpatient Rehabilitation

More information

ADVANCED MONITORING PARAMETERS 2017 QUICK GUIDE TO HOSPITAL CODING, COVERAGE AND PAYMENT

ADVANCED MONITORING PARAMETERS 2017 QUICK GUIDE TO HOSPITAL CODING, COVERAGE AND PAYMENT ADVANCED MONITORING PARAMETERS 2017 QUICK GUIDE TO HOSPITAL CODING, COVERAGE AND Overview: Coding and Payment Systems The procedures described are performed in the hospital setting, usually as an intraoperative

More information

Highlights of the 2018 Medicare Physician Fee Schedule (MPFS) Final Rule

Highlights of the 2018 Medicare Physician Fee Schedule (MPFS) Final Rule Highlights of the 2018 Medicare Physician Fee Schedule (MPFS) Final Rule Physician Payment Update & Misvalued Codes Target The update to payments under the PFS in 2018 will be +0.31 percent. This reflects

More information

Division C: Increasing Choice, Access, and Quality in Health Care for Americans TITLE XV: Provisions Relating to Medicare Part A

Division C: Increasing Choice, Access, and Quality in Health Care for Americans TITLE XV: Provisions Relating to Medicare Part A Division C: Increasing Choice, Access, and Quality in Health Care for Americans TITLE XV: Provisions Relating to Medicare Part A Sec. 15001. Development of Medicare study for HCPCS versions of MS-DRG codes

More information

REVISION DATE: FEBRUARY

REVISION DATE: FEBRUARY Mary Ann Hodorowicz, MBA, RDN CDE, CEC, Owner, Mary Ann Hodorowicz Consulting LLC, Palos Heights, IL Coverage: In-Person Payable Places of Services Excluded Places for Part B Payment Excluded Places: 0

More information

A Revenue Cycle Process Approach

A Revenue Cycle Process Approach A Revenue Cycle Process Approach VALERIUS BAYES NEWBY Education BLOCHOWIAK Preface x Parti Chapter1 WORKING WITH MEDICAL INSURANCE AND BILLING Chapter 3 Introduction to the Revenue Cycle 2 1.1 Working

More information

American Health Lawyers Association Institute on Medicare and Medicaid Payment Issues. History of the Physician Fee Schedule

American Health Lawyers Association Institute on Medicare and Medicaid Payment Issues. History of the Physician Fee Schedule American Health Lawyers Association Institute on Medicare and Medicaid Payment Issues March 20-22, 2013 Baltimore, Maryland Sidney S. Welch, Esq. 1 History of the Physician Fee Schedule Prior to 1992,

More information

NEW PATIENT VISIT POLICY

NEW PATIENT VISIT POLICY NEW PATIENT VISIT POLICY UnitedHealthcare Oxford Reimbursement Policy Policy Number: ADMINISTRATIVE 229.12 T0 Effective Date: November 1, 2017 Table of Contents Page INSTRUCTIONS FOR USE... 1 APPLICABLE

More information

Reimbursement Policy. Subject: Consultations Effective Date: 05/01/05

Reimbursement Policy. Subject: Consultations Effective Date: 05/01/05 Reimbursement Policy Subject: Consultations Effective Date: 05/01/05 Committee Approval Obtained: 06/06/16 Section: Evaluation and Management *****The most current version of the Reimbursement Policies

More information

10 Ancillary Networks

10 Ancillary Networks 10 Ancillary Networks This chapter provides information specific to healthcare providers in our contracted ancillary network. Content Section 1: Overview Section 2: Claims and Billing Section 3: Home Based

More information

601-Audit Plan for Medicare s Shared Visit Rule

601-Audit Plan for Medicare s Shared Visit Rule 601-Audit Plan for Medicare s Shared Visit Rule Elin Baklid-Kunz, MBA, CPC, CCS Health Care Compliance Association 6500 Barrie Road, Suite 250, Minneapolis, MN 55435 888-580-8373 www.hcca-info.org Presentation

More information

Empire BlueCross BlueShield Professional Reimbursement Policy

Empire BlueCross BlueShield Professional Reimbursement Policy Subject: Bundled Services and Supplies NY Policy: 0008 Effective: 02/24/2014 06/30/2014 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and

More information

Reimbursement Policy (EXTERNAL)

Reimbursement Policy (EXTERNAL) Subject: Consultations Reimbursement Policy (EXTERNAL) Effective Date: 01/01/15 Committee Approval Obtained: 06/06/16 Section: E&M/Medicine ***** The most current version of our reimbursement policies

More information

Telehealth. Administrative Process. Coverage. Indications that are covered

Telehealth. Administrative Process. Coverage. Indications that are covered Telehealth These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information

More information

Chapter 8 Section Infusion Drug Therapy Delivered In The Home

Chapter 8 Section Infusion Drug Therapy Delivered In The Home TRICARE Policy Manual 6010.60-M, April 1, 2015 Other Services Chapter 8 Section 20.1 Issue Date: September 7, 2011 Authority: 32 CFR 199.2 and 32 CFR 199.6(f) Copyright: CPT only 2006 American Medical

More information

99 - No response error No Medical records were received.

99 - No response error No Medical records were received. 1 May 2017 HCPCS Code Type Error Error Identified by CERT Anesthesia Services 00140 MISSING: 1) Signature attestation statement or signature log for the illegibly signed Pre-Anesthesia evaluation and illegibly

More information

The presenter has owns Kelly Willenberg, LLC in relation to this educational activity.

The presenter has owns Kelly Willenberg, LLC in relation to this educational activity. Kelly M Willenberg, MBA, BSN, CCRP, CHC, CHRC 1 The presenter has owns Kelly Willenberg, LLC in relation to this educational activity. 2 1 Medical Necessity when you submit claims Coding for qualifying

More information

MEDICAL POLICY No R2 TELEMEDICINE

MEDICAL POLICY No R2 TELEMEDICINE Summary of Changes Clarifications: Page 1, Section I. A 6, additional language added for clarification. Deletions: Additions Page 4, Section IV, Description, additional language added in regards to telemedicine.

More information

Hospital Outpatient Services: New CMS Supervision Requirements Complying With the New Rules to Protect Medicare Reimbursement

Hospital Outpatient Services: New CMS Supervision Requirements Complying With the New Rules to Protect Medicare Reimbursement presents Hospital Outpatient Services: New CMS Supervision Requirements Complying With the New Rules to Protect Medicare Reimbursement A Live 90-Minute Teleconference/Webinar with Interactive Q&A Today's

More information

Home Health & HP Provider Relations

Home Health & HP Provider Relations Home Health & Hospice HP Provider Relations October 2010 Agenda Session Objectives Home Health Benefit Coverage Billing Overhead Multiple Visits Most Common Denials Hospice Benefit Coverage Election/Revocation/Discharge

More information