Advisory Opinion 11-10

http://oig.hhs.gov/fraud/docs/advisoryopinions/2011/AdvOpn11-10.pdf

Dallas L Alford IV, CPA is a licensed Certified Public Accountant in the state of North Carolina and owner of Atlantic Financial Consulting, a consulting firm that provides comprehensive medical billing services, practice management consulting, coding audits, Medicare compliance, Medicare RAC support and other general medical practice consulting services.

To learn more about Atlantic Financial Consulting you may visit their website at

http://atlanticfinancial.us  or contact Dallas L Alford IV, CPA directly at 1 888-428-2555, Ext. 200.

Last Chance to Register for the National Provider Call on “ICD-10 Implementation Strategies for Physicians”

Join Us:
Wednesday, August 3, 2011 from 1 to 3 p.m. ET

Is your office preparing for a smooth transition to ICD-10 on October 1, 2013? The Centers for Medicare & Medicaid Services (CMS) will host a National Provider Call on "ICD-10 Implementation Strategies for Physicians." CMS subject matter experts will discuss ways that clinicians can prepare for the change to ICD-10 for medical diagnosis and inpatient procedure coding. In addition to this presentation for Medicare fee-for-service (FFS) providers, there will also be an update on national ICD-10 implementation issues affecting all providers. A question and answer session will follow the presentations.

The call will cover the following topics:
ICD-10 requirements and resources overview
Implementation strategies for provider offices
Update on coverage conversion activities
National ICD-10 implementation issues
Update on bill processing, including claims that span the implementation date
Update on Home Health Agency Home Health Resource Grouper
This call is appropriate for physicians, clinicians, provider office staff, provider billing staff, medical coders, health records staff, vendors, educators, system maintainers, laboratories, and Medicare FFS providers. 

Registration:
To register for this informative session, please go to the Registration Page on the CMS website. Please register early. Registration will close on Tuesday, August 2 at 1 p.m. ET or when available space has been filled. No exceptions will be made.
Keep Up to Date on Version 5010 and ICD-10.
Please visit www.cms.gov/ICD10 for the latest news and resources to help you prepare!

Testimony of Daniel R. Levinson, Inspector General

http://oig.hhs.gov/testimony/docs/2011/levinson_testimony_07282011.pdf

Dallas L Alford IV, CPA is a licensed Certified Public Accountant in the state of North Carolina and owner of Atlantic Financial Consulting, a consulting firm that provides comprehensive medical billing services, practice management consulting, coding audits, Medicare compliance, Medicare RAC support and other general medical practice consulting services.

To learn more about Atlantic Financial Consulting you may visit their website at

http://atlanticfinancial.us  or contact Dallas L Alford IV, CPA directly at 1 888-428-2555, Ext. 200.

Medicaid Alert - Attention: All Providers Termination of Inactive Medicaid Provider Notices

An announcement was made in the July general bulletin regarding the termination of inactive Medicaid providers. The article stated, effective July 1, 2011, once a provider is terminated due to billing inactivity within the previous 12 months, a new application and agreement to re-enroll must be submitted. A letter dated July 1, 2011, was mailed to providers notifying them of the August 1, 2011 termination date. Providers should disregard this letter because providers will not be terminated on August 1st and do not need to re-enroll in the Medicaid Program. DMA Provider Services
919-855-4050

Dallas L Alford IV, CPA is a licensed Certified Public Accountant in the state of North Carolina and owner of Atlantic Financial Consulting, a consulting firm that provides comprehensive medical billing services, practice management consulting, coding audits, Medicare compliance, Medicare RAC support and other general medical practice consulting services.

To learn more about Atlantic Financial Consulting you may visit their website at

http://atlanticfinancial.us  or contact Dallas L Alford IV, CPA directly at 1 888-428-2555, Ext. 200.

Healthcare Reform - Health Insurance Exchanges

Uploaded by Benefitfocus on May 11, 2010


Dallas L Alford IV, CPA is a licensed Certified Public Accountant in the state of North Carolina and owner of Atlantic Financial Consulting, a consulting firm that provides comprehensive medical billing services, practice management consulting, coding audits, Medicare compliance, Medicare RAC support and other general medical practice consulting services.
To learn more about Atlantic Financial Consulting you may visit their website at
http://atlanticfinancial.us/ or contact Dallas L Alford IV, CPA directly at 1 888-428-2555, Ext. 200.

Medicaid Alert - Attention: All Providers Implementation of Additional Correct Coding Edits: Global Surgery and Evaluation and Management Codes

As previously announced in the May bulletin, DMA will begin implementing additional correct coding guidelines. These new correct coding guidelines and edits will be nationally sourced by organizations such as the Centers for Medicare and Medicaid Services (CMS) and The American Medical Association (AMA). These edits will identify any inconsistencies with CPT, HCPCS, AMA, CMS and/or DMA policies and will deny the claim line. Additional correct coding edits for Global Surgery Package (GSP) and Evaluation and Management (E&M) codes will be implemented on August 1, 2011 for dates of service on or after August 1, 2011.Global Surgery Package (GSP)

GSP edits are defined by CMS as the specific time periods during which certain services related to a surgical procedure, furnished by the physician who performed the surgery, are to be included in the payment of the surgical procedure code. The GSP has two main subcategories:Evaluation and Management services billed on the same day as the surgical procedure or during the defined global period for the surgical procedure will be denied by the GSP Surgery/E&M editing if not submitted with an appropriate modifier to indicate a separate unrelated service. The following are examples of Global Surgery E & M Edits:Procedure Code DescriptionGlobalAnalysis

45385Colonoscopy with polypectomy0 DaysDeny E&M day of surgery
36571Peripheral insertion of central VAD with port10 DaysDeny E&M day of surgery and 10 days after
44970Appendectomy90 DaysDeny E&M day before, day of surgery and 90 days after

The GSP edits also contain logic that detects additional surgeries or procedures billed within the global period of a previously billed surgery. These edits will deny the subsequent surgery according to DMA Clinical Policy. The use of an appropriate modifier for a separate unrelated surgical service can be appended to the surgery code and will override a GSP Surgery/Surgery edit when appropriate. The following are examples of GSP Surgery/Surgery Edits: Procedure DescriptionDate of Service Analysis

33510Coronary artery bypass, vein only, single vessel01/30/2011Allow (has 90 day global period)
93510Left heart catheterization03/01/2011Deny
27275Manipulation hip joint requiring general anesthesia02/01/2011Allow (has 10 day global period)
27025Fasciotomy, hip or thigh, any type02/07/2011Deny

Evaluation and Management (E&M)

Evaluation and Management (E&M) codes are used to describe the intensity and work associated with a medical encounter as measured by the risks and complexities associated with the history, physical examination, and medical decision-making. The more detailed these components are the higher the level of the E&M service. Correct coding of E&M services stipulates only one E&M code may be reported per day for the same patient/provider. The appropriate use of modifiers complying with DMA policies will allow for appropriate reimbursement. The E & M edits ensure proper coding of these services.For more information about each group of edits, see “Descriptions of Planned Additional Correct Coding Edits” link on DMA's Correct Coding web page (http://www.ncdhhs.gov/dma/provider/ncci.htm). Providers are encouraged to frequently visit DMA’s Correct Coding web page and to review published bulletin articles for information on the project status. HP Enterprise Services
1-800-688-6696 or 919-851-8888

Dallas L Alford IV, CPA is a licensed Certified Public Accountant in the state of North Carolina and owner of Atlantic Financial Consulting, a consulting firm that provides comprehensive medical billing services, practice management consulting, coding audits, Medicare compliance, Medicare RAC support and other general medical practice consulting services.

To learn more about Atlantic Financial Consulting you may visit their website at

http://atlanticfinancial.us  or contact Dallas L Alford IV, CPA directly at 1 888-428-2555, Ext. 200.

CMS implements payment, policy changes for Inpatient Rehabilitation Facilities

Final rule adopts measures for new IRF Quality Reporting Program


The Centers for Medicare & Medicaid Services (CMS) today issued a final rule that updates Medicare payment policies and rates for more than 1,200 freestanding and hospital-based inpatient rehabilitation facilities (IRFs) in Fiscal Year (FY) 2012. The final rule increases IRF payment rates under the IRF Prospective Payment System (PPS) by 2.2 percent and establishes a new quality reporting system authorized by the Affordable Care Act. CMS projects that total payments under the IRF PPS will increase by $150 million in FY 2012.

“The final rule extends to the Inpatient Rehabilitation Facility payment system a quality reporting program designed to encourage these facilities to adopt practices that will better protect patient safety and prevent hospital-acquired conditions, which is an essential part of providing well-coordinated patient-and-family-centered care,” said CMS Administrator Dr. Donald Berwick.”

Initially, IRFs will submit data on two quality measures, a urinary catheter-associated urinary tract infection measure and a measure for new or worsening pressure ulcers, with a third measure—“30-day Comprehensive All Cause Risk Standardized Readmission”--under development. IRFs that do not submit performance data will see their payments reduced by two percentage points beginning in FY 2014. CMS anticipates adding measures for reporting in the future through rulemaking and establishing a process for making the data available to the public. As with other data on the CMS website, the IRFs would have an opportunity to review the data for accuracy before it becomes public.

The final rule will affect payments to more than 200 freestanding rehabilitation hospitals and more than 1,000 IRF units in acute care hospitals and critical access hospitals, beginning with discharges on or after Oct. 1, 2011. Under the IRF PPS, the Medicare payment to an IRF increases after the IRF’s costs for treating a beneficiary exceed an outlier threshold amount. The threshold is set for FY 2012 at an amount that is projected to maintain outlier payments at three percent of total payments under the IRF PPS.

The final rule also:

· Updates the case-mix group (CMG) relative weights using FY 2010 IRF claims and FY 2009 IRF cost report data;

· Uses the final FY 2011 pre-reclassified and pre-floor hospital wage data to determine the FY 2012 rates;

· Freezes the facility-level adjustment factors for FY 2012 at FY 2011 levels for one additional year while the agency explores ways to improve upon the accuracy and consistency of the current methodology used to calculate the facility-level adjustment factors;

· Allows IRFs to receive temporary adjustments to their FTE intern and resident caps if they take on interns and residents who are unable to complete their training because the IRF that had originally been their assigned training site either closed or ended its resident training program; and

· Allows IRF and inpatient psychiatric facility units to expand in the middle of a cost reporting period, rather than restricting such expansions to the start of a cost reporting period.
“The final rule we are announcing today will help ensure that Medicare beneficiaries who require rehabilitation in an inpatient setting, continue to have access to high quality care that will help them meet their rehabilitation goals during the difficult work of recovery,” said Dr. Berwick.

The final rule went on display on July 29, 2011 at the Office of the Federal Register’s Public Inspection Desk and will be available under “Special Filings” at:http://www.ofr.gov/OFRUpload/OFRData/2011-19516_PI.pdf and http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1 

It will appear in the Aug. 5, 2011 Federal Register.

For more information, please see: www.cms.hhs.gov/InpatientRehabFacPPS/

And the CMS Fact Sheet: https://www.cms.gov/apps/media/press/factsheet.asp?Counter=4033

Dallas L Alford IV, CPA is a licensed Certified Public Accountant in the state of North Carolina and owner of Atlantic Financial Consulting, a consulting firm that provides comprehensive medical billing services, practice management consulting, coding audits, Medicare compliance, Medicare RAC support and other general medical practice consulting services.

To learn more about Atlantic Financial Consulting you may visit their website at

http://atlanticfinancial.us  or contact Dallas L Alford IV, CPA directly at 1 888-428-2555, Ext. 200.