Awareness : Newsletter Articles

Outpatient Therapy

On February 9, 2018, President Trump signed into law the Bipartisan Budget Act of 2018. This new law includes several provisions related to Medicare payment.

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Published in the March 2018 (2018Q1) UHealth Compliance Newsletter

Condition Code 44

Should a facility use condition code 44 on a claim if the admitting physician decides the patient should be in observation rather than an inpatient setting, without prompting by the utilization review (UR) committee or case management and prior to the discharge of the patient/submission of the claim?

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Published in the March 2018 (2018Q1) UHealth Compliance Newsletter

Physician Payment Update and Relative Value Unit (RVU) Changes

CMS set the 2018 Medicare PFS conversion factor at $35.9996, which includes a 0.5% update as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

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Published in the March 2018 (2018Q1) UHealth Compliance Newsletter

Pathology and Laboratory New Waived Tests

Below, is an update of The Clinical Laboratory Improvement Amendments of 1988 (CLIA) waived tests.

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Published in the March 2018 (2018Q1) UHealth Compliance Newsletter

Major Joint Replacement (Hip and Knee) Revision to the Part A and Part B LCD

The local coverage determination (LCD) for major joint replacement (hip and knee) was revised to add ICD-10-CM diagnosis code Z47.32 to the “ICD-10-CM Diagnosis Codes for Total Hip Arthroplasty” section of the LCD and ICD-10-CM diagnosis code Z47.33 to the “ICD-10-CM Diagnosis Codes for Total Knee Arthroplasty” section of the LCD. Also, the “Sources of Information and Basis for Decision” section of the LCD was updated.

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Published in the March 2018 (2018Q1) UHealth Compliance Newsletter

Codes Subject to and Excluded From CLIA Edits

The Clinical Laboratory Improvement Amendments (CLIA) regulations require a facility to be appropriately certified for each test performed. To ensure that Medicare only pays for laboratory tests performed in certified facilities claims considered a CLIA laboratory test are currently edited at the CLIA-certificate level.

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Published in the March 2018 (2018Q1) UHealth Compliance Newsletter

Supervision Requirements Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests

When providing the technical component of diagnostics tests for a patient who is not a hospital inpatient or outpatient, levels of physician supervision are required.

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Published in the March 2018 (2018Q1) UHealth Compliance Newsletter

Cochlear Devices Replaced Without Cost: Bill Correctly — Reminder

the Office of the Inspector General (OIG) reported that hospitals did not always comply with Medicare requirements for reporting cochlear devices replaced without cost to the hospital or beneficiary. Medicare Administrative Contractors use this information to adjust payment; incorrect billing led to Medicare overpayments of $2.7 million.

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Published in the March 2018 (2018Q1) UHealth Compliance Newsletter

2018 Anesthesia Conversion Factors for Florida

The conversion factors for use in calculating payment for anesthesia services (procedure codes 00100 through 01999) for service dates January 1 through December 31, 2018, are as follows:

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Published in the March 2018 (2018Q1) UHealth Compliance Newsletter

Use of Modifier “FY”

As stated in the CY 2018 OPPS/ASC final rule, section 502 of Division O, title V of the Consolidated Appropriations Act, 2016 (Pub. L. 114-113), which was enacted on December 18, 2015, contains provisions to incentivize the transition from traditional X-ray imaging to digital radiography. As permitted by section 1833(t)(16)(F)(iv) of the Social Security Act (the Act), CMS implemented modifier “FY” (X-ray taken using computed radiography technology/cassette-based imaging) to enable providers under the OPPS to appropriately report computed radiography services.

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Published in the March 2018 (2018Q1) UHealth Compliance Newsletter

Fraud, Waste and Abuse UHealth Compliance 2017

It’s that time of the year again when we wall must complete our annual compliance and fraud, waste, and abuse training.

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Published in the November 2017 UHealth Compliance Newsletter

Documentation Requirements to Bill Under the Anesthesia Medical Direction Rules

Seven steps required documentation criteria…

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Published in the November 2017 UHealth Compliance Newsletter

Selective Debridement (97597 and 97598)

Selective Debridement (97597 and 97598) CPT codes 97597 and 97598 are used for the removal of specific, targeted areas of devitalized or necrotic tissue from a wound along the margin of viable tissue. Occasional bleeding and pain may occur.

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Published in the November 2017 UHealth Compliance Newsletter

How to Use Modifiers to Indicate the Status of an ABN

If a provider or supplier expects that the service or item furnished to the beneficiary may be considered unreasonable and/or medically unnecessary by Medicare, an advanced beneficiary notice (ABN) may be used to inform the beneficiary of his or her financial liability, appeal rights, and protections under the fee-for-service (FFS) Medicare program.

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Published in the November 2017 UHealth Compliance Newsletter

Use of Condition Code 44

Should a facility use condition code 44 on a claim if the admitting physician decides the patient should be in observation rather than an inpatient setting, without prompting by the utilization review (UR) committee or case management and prior to the discharge of the patient/submission of the claim?

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Published in the November 2017 UHealth Compliance Newsletter

Reporting Place of Service (POS) Codes

Physicians are required to report the place of service (POS) on all health insurance claims they submit to Medicare Part B contractors. The POS code is used to identify where the procedure is furnished. Physicians are paid for services according to the Medicare physician fee schedule (MPFS). This schedule is based on a payment system that includes three major categories, which drive the reimbursement for physician services:

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Published in the November 2017 UHealth Newsletter

When Is It Appropriate to Bill Modifier 50?

Modifier 50 is used to report bilateral procedures performed during the same operative session as a single line item. Do not use modifiers RT and LT when modifier 50 applies. Do not submit two line items to report a bilateral procedure using modifier 50.

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Published in the November 2017 UHealth Compliance Newsletter

Centers for Medicare & Medicaid Services (CMS) Approval to First Coast Service Options for TAVR/TMVR

A hospital must make sure that all orders, including verbal orders, are dated, timed and authenticated promptly. Verbal orders are orders for medications, treatments, interventions or other care that are transmitted as oral, spoken communications between senders and receivers, delivered either face-to-face or via telephone

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Published in the November 2017 UHealth Compliance Newsletter

Requirements for Inpatient Services of Inpatient Psychiatric Facilities

Requirements for certification and recertification: General considerations. Certification begins with the order for inpatient admission.

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Published in the November 2017 UHealth Compliance Newsletter

Repayment Delay Triggers False Claims Act Settlement for Double Damages

A cardiovascular group recently agreed to pay over $440,000 to settle false claims allegations that they failed to timely report and return $175,000 in overpayments owed to federal healthcare programs.

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Published in the November 2017 UHealth Compliance Newsletter

Condition of Participation: Surgical Services

Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice.

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Published in the November 2017 UHealth Compliance Newsletter

Compliance & Ethics Week

In celebration of Compliance & Ethics Week, the university community is invited to come learn about our various compliance, ethics and risk initiatives. It is our commitment to support a culture reflecting our D-I-R-E-C-C-T values.

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Largest Health Care Fraud Take Down in History

In July 2017, the Office of Inspector General announced $1.3 billion in false claims to Medicare and Medicaid. More than 400 defendants in 41 federal districts were charged for their alleged participation in schemes involving false claims to the vital health care program.

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Published in the August 2017 UHealth Compliance Newsletter

Fredericksburg Hospitalist Group Pays $4.2 Million to Settle Civil Fraud Case

Fredericksburg Hospitalist Group, P.C. (FHG), and 14 of its member shareholders have agreed to pay approximately $4.2 million.
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Published in the August 2017 UHealth Compliance Newsletter

Results of First Coast Widespread Probe for CPT 99214

First Coast Service Options Inc. conducted a widespread post payment probe review for CPT® code 99214 for the top three provider specialties billing this code: Cardiology, Internal Medicine, and Family Practice.
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Published in the August 2017 UHealth Compliance Newsletter

New Advance Beneficiary Notice (ABN) Required for Use by August 21

The new Advance Beneficiary Notice of Noncoverage (ABN) Form CMS-R-131 will be implemented as of August 21, 2017
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Published in the August 2017 UHealth Compliance Newsletter

Processing Services Not Authorized by the Veterans Administration in a Non-VA Facility

For inpatient claims where the Veterans Administration (VA) is the payer, the covered services are exclusions to the Medicare program per Section 1862 of the Social Security Act. Change request (CR) 9818 provides clarification to address the following:
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Published in the August 2017 UHealth Compliance Newsletter

Bendamustine Hydrochloride (Treanda®, Bendeka™)-Revision to Part A and Part B LCD

Effective for services rendered on or after July 06 2017, the local determination (LCD) for bendamustine hydrochloride has been revised.
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Published in the August 2017 UHealth Compliance Newsletter

Modifier 74

Facilities use modifier 74 to indicate that a surgical or diagnostic procedure requiring anesthesia is terminated
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Published in the August 2017 UHealth Compliance Newsletter

Ranibizumab (Lucentis®) – Revision to Part A and Part B LCD”

Based on a reconsideration request, the local coverage determination (LCD) for ranibizumab (Lucentis®) was revised to add two new indications approved by the Food and Drug Administration (FDA) (Myopic Choroidal Neovascularization and Diabetic Retinopathy) to the “Indications and Limitations of Coverage and/or Medical Necessity” section of the LCD.
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Published in the August 2017 UHealth Compliance Newsletter

Revision To Local Coverage Determination (LCD): Vitamin D; 25 Hydroxy, Includes Fraction(s)

Vitamin D; 25 hydroxy, includes fraction(s), if performed –revision to the Part A and Part B LCD
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Published in the August 2017 UHealth Compliance Newsletter

Medicare Overpayments

A Medicare overpayment is a payment you receive in excess of amounts properly payable under Medicare and regulations. After Medicare identifies an overpayment, the overpayment amount becomes a debt you owe the Federal government. Federal law requires the Centers for Medicare and Medicaid Services (CMS) to try to recover all identified overpayments.

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Published in the April 17, 2017 OBS Newsletter

CMS Guidelines vs AMA CPT Definition of Co-Surgery (Two Surgeons) Modifier 62

For certain procedures, co-surgeons could be paid by submitting the required supportive documentation to establish the medical necessity of two surgeons for the procedure.
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Published in the April 2017 OBC Newsletter

Endoscopic Procedures: Be Aware of the Summary of “Family Codes”

Special rules for multiple endoscopic procedures apply if a procedure is billed with another endoscopy in the same family (i.e., another endoscopy that has the same base procedure).
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Published in the January 2017 OBC Newsletter

Abdominal Aortic Aneurysm Screening CPT Code Update

A new CPT code (76706) was established to bill abdominal aortic aneurysm (AAA) screening.
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Published in the April 2017 OBC Newsletter

G Codes For Mammography

CMS has introduced new codes for mammography procedures, both diagnostic and screening.
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Published in the April 2017 OBC Newsletter

Fraud, Waste and Abuse UHealth Compliance 2016

Thank you for being an integral part of the UHEALTH compliance effort! As with all strong programs, it starts with communication and training. All University of Miami UHealth/Miller School of Medicine faculty and employees are required to complete the mandatory UHealth Fraud, Waste and Abuse 2016 (FWA) Training. Read More


Published in the January 2017 OBC Newsletter

Medicare Finalizes New Physician Payment System

The Centers for Medicare & Medicaid Services (CMS) released a final rule implementing a new Medicare physician payment system. Beginning in 2017, physician practices can choose between two payment options…
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Published in the January 2017 OBC Newsletter

Observation Services

Outpatient observation services are not to be used as a substitute for medically necessary inpatient admissions. Additionally, there must be medical necessity for observation beyond the usual recovery period (4 to 6 hours).
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Published in the January 2017 OBC Newsletter

New Physician Specialty Code for Hospitalist

Effective April 1, 2017, a new physician specialty code for hospitalist will be implemented.
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Published in the January 2017 OBC Newsletter

2017 Hospital Outpatient and ASC Prospective Payment System Highlights

On November 1, 2016, CMS released its final 2017 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System rule.
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Published in the January 2017 OBC Newsletter

Moderate Sedation and Endoscopic Services

For CY 2017, CMS unbundled moderate sedation for some endoscopic services and will require sedation to be separately billed using designated CPT code(s), when provided.
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Published in the January 2017 OBC Newsletter

2017 Office of Inspector General Work Plan Hospital Initiatives

The Department of Health and Human Services Office of Inspector General publishes its Work Plan for the upcoming fiscal year.
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Published in the January 2017 OBC Newsletter

2017 ICD-10 Changes

The 2017 update to the ICD-10-CM diagnosis coding structure is effective for services rendered on or after October 1, 2016.
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Published in the January 2017 OBC Newsletter

2017 Medicare Physician Fee Schedule (MPFS)

Select from the links below to view the disclosure report for your locality
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Published in the January 2017 OBC Newsletter

The Importance of the Medicare Coverage Analysis in Clinical Trials

To ensure appropriate reimbursement for the services provided to a patient in a clinical trial, research sites must develop a budget for each trial.
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Published in the January 2017 OBC Newsletter

False Claims Act Settlement

South Miami Hospital, has agreed to pay the United States approximately $12 million to settle False Claims Act allegations .
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Published in the January 2017 OBC Newsletter

What Is The Minimum Required Documentation When Billing For A Split/Shared Visit?

The physician provides a medically necessary face-to-face portion of the E/M encounter …
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Published in the January 2017 OBC Newsletter

Patient Admission Orders

An inpatient admission is appropriate for payment under Medicare Part A when the admitting physician expects the patient to require hospital care that crosses two midnights.

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Published in the April 2017 OBC Newsletter

2017 Physical Therapy Payment Caps

Starting on January 1, 2017 the limit on incurred expenses for physical therapy will be $1,980 for physical therapy and speech-language pathology services combined.

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Published in the April 2017 OBC Newsletter

Myocardial Perfusion Imaging

When a Myocardial Perfusion Imaging (MPI) is performed, the current procedural terminology (CPT) code that should be used is 78452.
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Published in the April 2017 OBC Newsletter

Authenticating Orders

A hospital must make sure that all orders, including verbal orders, are dated, timed and authenticated promptly. Verbal orders are orders for medications, treatments, interventions or other care that are transmitted as oral, spoken communications between senders and receivers, delivered either face-to-face or via telephone

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Newsletter Tip for April 2017

Clinical Research Participant Enrollment and Tracking In Velos

All participants enrolled in clinical research protocols must be registered in the Velos clinical trial management system within 48 hours of obtaining informed consent.
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UMMG Interaction with Health Industry Entities Policy

UM Interaction with Health Industry Entities