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May 23, 2013
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Industry Resources
Today's health care environment requires physical therapy providers to remain current in the extensive information necessary to assure compliance with the myriad of rules, regulations, standards, and guidelines surrounding the provision of outpatient physical therapy services. Fearon & Levine, as the leading expert in these areas, understands the need for providers to have efficient access to accurate information without spending numerous hours searching countless documents and websites in hopes of finding critical information specific to the outpatient therapy setting.
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Topic:
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About Us
Accountable Care Organizations (ACO)
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Date
Title
5/13/2013
FAQs Therapy Caps and Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131: CMS
Categories:
Beneficiary Notices (ABN, Determination Notices)
,
Practice Management (Administrative Operations)
,
Therapy Cap (Medicare)
In April 2013, the Centers for Medicare and Medicaid Services published a series of frequently asked questions that clarifies the use of the Advance Beneficiary Notice of Noncoverage (ABN) form (CMS-R-131) and the shifting of liability to the provider or supplier as a result of the American Taxpayer Relief Act of 2012.
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Summary:
The American Taxpayer Relief Act (ATRA) of 2012 included provisions that affect the use of the Advance Beneficiary Notice of Noncoverage (ABN) form (CMS-R-131). Prior to the passage of the ATRA, claims that were at or above the therapy cap and did not qualify for an exception were denied and the patient was financially liable. The use of an ABN form was voluntary.
The ATRA changed the liability for services at or above the therapy cap. Beginning January 1, 2013, the provider or supplier must issue a valid ABN to the beneficiary before providing services above the cap when the therapy coverage exceptions process is not applicable. If the ABN isn't issued when it is required and Medicare doesn't pay the claim, the provider or supplier will be liable for the charges. Therapists are required to issue the ABN to original (fee-for-service) Medicare beneficiaries prior to providing therapy that is not medically reasonable and necessary regardless of the therapy cap. Add the-GA modifier to the claim to indicate that an ABN has been issued as required per payer policy.
This document discusses mandatory use of the ABN and voluntary use of the ABN for services that are not covered under the benefit.
For Document Resources:
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5/13/2013
Remittance Advice Remark Codes: Washington Publishing Company
Categories:
Practice Management (Administrative Operations)
,
Therapy Billing & Electronic Claims
This detailed list of Remittance Advice Remark Codes (RARCs) identifies specific, standardized messages that inform providers about claims processing decisions.
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Summary:
Providers who submit claims to third parties will receive Remittance Advice (RA) information that includes specific Remittance Advice Remark Codes (RARCs). These standardized codes may not be fully explained on the RAs. The Washington Publishing Company provides a list of RARCs and an explanation of each code. The Remittance Advice Remark Code List is updated tri-annually in March, July, and November.
RARCs can either be used to explain a claims processing determination or they may be used to alert providers as to an important claims processing issue. The Alert RARCs are not linked to a specific claims adjustment.
For Web Site Resources:
Click Here
5/13/2013
Definition of Customized Durable Medical Equipment (DME) Items: CMS
Categories:
DMEPOS
In April 2013, the Centers for Medicare and Medicaid Services (CMS) clarified the definition of customized Durable Medical Equipment (DME), items that are rarely necessary or furnished under the benefit.
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Summary:
The Centers for Medicare and Medicaid Services (CMS) released a clarification pertaining to coverage of Durable Medical Equipment (DME) in the Medicare Claims Processing Manual, Section 30.3 of Chapter 20. The intent of the clarification is to limit the amount of unnecessary expenditures related to customized DME. CMS states that customized DME, such as a wheelchair, "must be uniquely constructed or substantially modified for a specific beneficiary according to the description and orders of a physician and be so different from another item used for the same purpose that the two items cannot be grouped together for pricing purposes." CMS uses an example of a wheelchair that is specially customized for conjoined twins.
The guidance states:
The item must be uniquely constructed using raw materials or there must be a necessary,
substantial modification to the base equipment (e.g., wheelchair frame) for the item to be considered a customized item; and
The item must be so different from another item used for the same purpose that the two items cannot be grouped together for pricing purposes.
5/13/2013
Services that are Not Reasonable and Necessary: Novitas Solutions (J12)
Categories:
Medical Necessity
,
Medicare Administrative Contractors
,
Medicare Coverage: LCDs/NCDs
Novitas Solutions, the Medicare Administrative Contractor (MAC) for J12, published a Local Coverage Determination (L31686) outlining services that it considers not reasonable and necessary.
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Summary:
Novitas Solutions, the Medicare Administrative Contractor (MAC) for J12 covering Pennsylvania, Maryland, Delaware, New Jersey, and the District of Columbia published a Local Coverage Determination that provides guidance as to services that are considered to be not reasonable and necessary. The Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-08, Chapter 13, Section 13.5.1 defines that in order to be covered under Medicare, a service shall be considered reasonable and necessary, and further, that when appropriate, a contractor shall describe the circumstances under which the service is reasonable and necessary as part of its Local Coverage Determination (LCD) process. This LCD includes services represented by Category III codes that are not considered reasonable and necessary.
The LCD notes that a service that appears to meet the technical requirements for coverage may also be excluded if that service:
is not generally accepted as safe and effective by the medical community
is not supported in peer-reviewed medical literature
is experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000 which meet the requirements of the Clinical Trials NCD are considered reasonable and necessary)
is not medically necessary in a specific case, or for a specific is furnished at a level, duration, dosage or frequency not appropriate for a specific patient or clinical condition
is not furnished in a manner consistent with community standards of care
is not furnished in a setting (place of service) consistent with the patient’s medical needs and condition
is furnished in a manner primarily for patient convenience or provider convenience
is a device not approved for marketing by the FDA and is not included in an FDA approved IDE trial
is a test or service now considered obsolete by the medical community, and replaced by more efficacious services.
The LCD notes that the development of a CPT code or FDA approval for a service does not guarantee coverage by Medicare.
4/28/2013
State Operations Manual – Guidance for Surveyors of Rehabilitation Agencies: CMS
Categories:
Medicare Part B Resources - General
,
Practice Management (Administrative Operations)
,
Rehabilitation Agencies (RA)
The Centers for Medicare and Medicaid Services (CMS) published Transmittal 83 which provides further detailed guidance on Medicare's requirements of participation for rehabilitation agencies. This information will be utilized by surveyors of rehabilitation agencies to ensure compliance with regulations.
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Summary:
Medicare's State Operations Manual (Appendix E) provides surveyors of rehabilitation agencies guidance for participation requirements that must be met. The manual was updated March 15, 2013 with the publication of Transmittal 83. The revised regulations for physical therapy services in section §485.713 include:
The major sources of information where the surveyors can capture practice information includes but is not limited to physician orders, physical therapist documentation, patient care policies, personnel records, staff interviews and observation of the clinic, personnel rosters for each date of service.
"If physical therapy services are being provided at an extension location, clinical records should be carefully reviewed to note whether the therapist is the actual professional conducting the evaluations and reevaluations, and not the physical therapist assistant. Only physical therapists are allowed to conduct evaluations and reevaluations."
"The clinical record is the only document describing the course of treatment and the outcomes for the patient. Poor documentation may reflect a less than adequate therapy program."
"The organization must provide space for treatment, and offer areas of privacy when needed during treatment or when requested by the patient. Screens, curtains, or other methods for ensuring privacy should be available when needed."
Extension locations must be situated within a 30 mile radius of where 90 percent of the rehabilitation agency's primary site's population lives. Existing extension locations are not necessarily in jeopardy if they are not excessively far from the primary location. They must demonstrate that they have adequate administration and effective supervision in place. The final decision of whether to approve or deny the extension location lies with the regional office.
The requirements also include requirements related to administration, policies, care planning and patient care, staffing, emergency care, equipment maintenance, and infection control.
For Document Resources:
Click Here
4/28/2013
HHS Would Increase Rewards for Reporting Fraud to Nearly $10 Million: OIG
Categories:
Federal Register
,
Fraud, Waste, & Abuse
,
Medicare Enrollment (Provider/Supplier)
,
Proposed & Final Rules (CMS, DHHS)
The Secretary of the Department of Health and Human Services (DHHS) released a proposed rule on April 24, 2013 that would increase possible rewards for reporting fraud to nearly $10 million.
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Summary:
On April 24, 2013, the Secretary of the Department of Health and Human Services (DHHS) released a proposed rule that would strengthen the incentives for reporting cases of fraud and abuse to the federal government. The government is proposing to increase the potential reward amount for information that leads to a recovery of Medicare funds from 10 percent to 15 percent of the final amount collected, up to the first $66 million recovered. The possible reward for reporting is nearly $10 million.
The government also proposes to strengthen Medicare's enrollment provisions for providers. The following are proposed:
Add the ability to deny the enrollment of providers, suppliers and owners affiliated with an entity that has unpaid Medicare debt.
Deny enrollment or revoke the billing privileges of a provider or supplier if a managing employee has been convicted of certain felony offenses.
Permit CMS to revoke billing privileges of providers and suppliers that have a pattern or practice of billing for services that do not meet Medicare requirements.
For Document Resources:
Click Here
For Web Site Resources:
Click Here
4/28/2013
Proposed Rule for Electronic Health Records Safe Harbor under the Anti-Kickback Statute: OIG
Categories:
Electronic Medical Records (EMR)/Electronic Health Records (EHR)
,
Office of Inspector General (OIG)
,
Proposed & Final Rules (CMS, DHHS)
April 1, 2013, the Office of Inspector General (OIG) within the Department of Health and Human Services (DHHS) published a proposed rule to amend the safe harbor regulation concerning electronic health records items and services, which defines certain conduct that is protected from liability under the Federal anti-kickback statute in the Social Security Act.
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Summary:
In August 2006, the Department of Health and Human Services (DHHS) is published a final rule that set forth "safe harbors" to the anti-kickback statute. The safe harbors sunset at the end of 2013 and DHHS is required to update the safe harbors based on any industry or technological advances that impact the statute. Because of this requirement, the Office of Inspector General (OIG) of the DHHS published a proposed rule in April 2013 that deals with safe harbors for electronic health records under the anti-kickback statute. The government wants electronic health record interoperability to support data rich, patient-centered information that will assist with the provision of evidence based decisions, care coordination, and optimal outcomes.
The proposed rule proposes the following:
An update to the provision regarding the interoperability of donated electronic health record software for information technology and training services.
Removal of the requirement related to e-prescribing capability under the safe harbor.
Extension of the sunset date of the safe harbor.
The government is using its certification process for electronic health record software as a way to maintain a high level of quality in this area.
For Document Resources:
Click Here
For Web Site Resources:
Click Here
4/8/2013
CMS Contractor Interactive Map: CMS
Categories:
Medicare Administrative Contractors
The Centers for Medicare and Medicaid Services' (CMS) website has a user-friendly scroll over interactive map that provide contractor contact information in all states and US territories.
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Summary:
In an effort to consolidate contractor information for providers and suppliers, the Centers for Medicare and Medicaid Services' (CMS) website now has an interactive map that provides users contact information for all contractors servicing their state or territory. This includes information on Medicare Administrative Contractors (MAC), audit contractors, Durable Medical Equipment contractors, and offices within CMS that provide oversight to the contractors. The contractors' address, website link, and contact information is available. Each page also contains a definition of the types of contractors performing a scope of work for CMS.
For Web Site Resources:
Click Here
4/5/2013
Medicare Provider Quarterly Compliance Newsletter Archive: CMS
Categories:
Audits: Medicare (including CERT, RAC, PSC, ZPIC, etc.)
,
Compliance
,
Fraud, Waste, & Abuse
,
Practice Management (Administrative Operations)
Providers and suppliers have access to an archive of Medicare’s quarterly newsletter publications related to compliance issues.
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Summary:
The Centers for Medicare and Medicaid Services (CMS) publishes a quarterly newsletter pertaining to common compliance issues faced by suppliers and providers in all settings of care. An archive of past newsletters is available as an educational resource for both staff and managers. Common topics include but are not limited to billing errors, durable medical equipment (DME), and findings from Comprehensive Error Rate Testing (CERT) and Recovery Audit Contractors (RACs) are addressed.
There is a link to a key word index. Notably, physical therapy is mentioned in the following issues:
April 2011
April 2012
July 2012
October 2012
January 2013
Occupational therapy and speech language pathology are separately listed in the keyword index.
For Web Site Resources:
Click Here
4/5/2013
Medicare Appeal of Claims Decisions - Medicare Claims Processing Manual (Pub.100-04), Chapter 29: CMS
Categories:
Medicare Denials, Appeals, & Recoupment
,
Medicare Manuals
,
Practice Management (Administrative Operations)
,
Therapy Billing & Electronic Claims
Definitive information on Medicare’s claims appeal process is found in Chapter 29 of the Medicare Claims Processing Manual (Pub. 100-04).
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Summary:
The Medicare claims appeal process is complicated and includes a five stage process. The Medicare Claims Processing Manual (Pub. 100-04), Chapter 29, provides detailed guidance for this process including:
Who can appeal
The appeals process and levels of appeal
Where to appeal
Time limits for appeal
Appointment of representatives
Fraud and Abuse considerations
Glossary of terms pertinent to the appeals process
The five levels of appeal are: Redetermination, Reconsideration, Administrative Law Judge, Departmental Appeals Board (DAB) Review Appeals Council, and Federal Court Review. Every requirement must be met at each level of appeal. Attention to detail is very important. Engaging an attorney who specializes in Medicare appeals is often highly recommended.
This chapter also contains links to all transmittals that have been issued pertaining to information in this chapter.
For Document Resources:
Click Here
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CMS Contractor Interactive Map: CMS
Industry Resources
One of the most sought after features of FearonLevine.com! Designed to assist outpatient therapy providers to locate essential information easily, this section provides the ability to sort through hundreds of resources by dozens of categories, with content being added on a daily basis.
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