Highmark Medicare
Services Releases Guidance on Ordering/Referring Physician PECOS
Issue
Medicare Consultation Issue
Synopsis
Empire Blue Cross Blue Shield
Introduces New Claim Research Template Tool
CMS Develops Medically Unlikely Edits (MUE)
Highmark
Medicare Services Releases Guidance on Ordering/Referring
Physician PECOS Issue
Even though the Ordering/Referring Physician PECOS policy has
been delayed until January 2011, it is important that physicians
check to see their status (or lack thereof) in the PECOS system.
As a result, Highmark Medicare Services (HMS) has released an
article that provides guidance to physicians and non-physician
practitioners in determining whether or not they have a current
enrollment record in the PECOS.
To read more, go to the link here:
https://www.highmarkmedicareservices.com/enrollment/pecos/determine.html
For guidance on this issue, contact us through the Third Party
Insurance Help Program.
Medicare Consultation Issue
Synopsis
The Center for Medicare and Medicaid Services (CMS) instructs
that any physician who sees a patient in the office or other
outpatient setting will need to select either a new or
established outpatient evaluation and management code
(99201-99215 or 99381-99397) rather than a consultation code for
Medicare claims.
CMS states that a physician who sees a patient in the hospital
should bill an "initial hospital care" code (99221-99223) for
the first visit for Medicare claims. The admitting physician
will add modifier AI to his/her initial hospital service
allowing the Medicare Administrative Contractor (MAC) to
differentiate between the admitting physician and other
physicians providing care. All physicians should use the
subsequent hospital care codes (99231-99233) for their follow-up
care.
Likewise, CMS states that a physician who sees a patient in a
skilled nursing facility should bill an "initial nursing
facility care" code (99304-99306) for the first visit for
Medicare claims. The admitting physician will add modifier AI to
his/her initial nursing facility care service, allowing the MAC
to identify the physician as the admitting physician of record
who is overseeing the patient's care. All physicians should use
the subsequent nursing facility care codes (99307-99310) for
their follow-up care.
CPT codes 99241-99245 and CPT 99251-99255 have a status
indicator of "I" in the January 2010 National Physician Fee
Schedule. The status indicator of "I" is defined as:
"I" = Not valid for Medicare purposes. Medicare uses another
code for reporting of, and payment for, these services.
For guidance on this issue, contact us through the Third Party
Insurance Help Program.
Empire Blue Cross Blue
Shield Introduces New Claim Research Template Tool
On March 1, 2010, Empire introduced a new tool called the Claim
Research Template (CRT).
EBCBS has indicated that their Physician Network Management team
consists of consultants that focus on ensuring that network
physicians and practitioners understand the processes, policies
and procedures. In addition, this team focuses on informally
researching claim concerns.
As a result, the CRT has been created to ensure that Consultants
have the necessary information to complete informal research on
your claim concerns.
Please note that the CRT does NOT replace the standard claims
grievance process.
It is to be used when physicians and practitioners have concerns
impacting multiple claims and will help facilitate the
collection of certain information so that Empire may conduct
further research, and seek to informally resolve claim issues
raised by providers.
For conditions and other important information, read more at the
link below.
http://www.empireblue.com/wps/portal/ehpprovider?content_path=provider/noapplication/f1/s0/t0/pw_b142772.htm&label=Introducing
a new tool and process to help us better address your claim
questions
CMS Develops Medically Unlikely Edits
(MUE)
The Centers for Medicare & Medicaid Services (CMS) has developed
Medically Unlikely Edits (MUEs) to reduce the paid claims
error rate for Part B (outpatient) claims.
An MUE for a Healthcare Common Procedure Coding System (HCPCS)/current
procedural terminology (CPT) code is the maximum units of
service that a provider would report under most circumstances
for a single beneficiary on a single date of service.
All HCPCS/CPT codes do not have an MUE. Although CMS will
publish most MUE values on their Web site, other MUE values are
confidential and are for CMS and CMS Contractors’ use only.
To view the MUE edits, go to:
http://www.cms.hhs.gov/NationalCorrectCodInitEd/08_MUE.asp
If a physician, healthcare organization, or other interested
party believes that an MUE value should be modified, it may
write Correct Coding solutions, LLC at the address below. The
party should include its rationale and any supporting
documentation.
However, it is generally recommended that the party contact the
national healthcare organization whose members perform the
procedure prior to writing to Correct Coding Solutions, LLC. The
national healthcare organization may be able to clarify the
reporting of the code in question. If the national healthcare
organization agrees that the MUE value should be modified, its
support and assistance may be helpful in requesting the
modification of an MUE value.
Requests for modification of an MUE value should be sent to the
following:
National Correct Coding Initiative
Correct Coding Solutions, LLC
P.O. Box 907
Carmel, IN 46082-0907
FAX: 317-571-1745
For guidance on this issue, contact us through the Third Party
Insurance Help Program.
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