Awareness : OBC Tips

National Clinical Trial (NCT) Identifier Numbers on Medicare Claims

Do all services to a patient who is in a clinical trial need to be submitted with the NCT number, or only specifically those services that are part of the trial?
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Research Billing Compliance Tip for November 2017

Use of Scribes

Individuals can only create a scribe note in an EHR if they have their own password/access to the EHR for the scribe role.

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Professional Compliance Tip for November 2017

Use of Modifier 59

Medicare Billing requires to use modifier 59 which indicates separate procedures distinct from each other.

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Hospital Compliance Tip for November 2017

Enroll Clinical Research Protocols within 48 Hours

A hospital must make sure that all orders, including verbal orders, are dated, timed and authenticated promptly.

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Research Billing Compliance Tip for October 2017

Steps to Avoid Electronic Health Record Compliance Risks

A hospital must make sure that all orders, including verbal orders, are dated, timed and authenticated promptly.

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Professional Billing Compliance Tip for October 2017

Outpatient Observation Services

A hospital must make sure that all orders, including verbal orders, are dated, timed and authenticated promptly.

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Hospital Billing Compliance Tip for October 2017

Admission Order Requirement for Inpatient Hospital Stays

Medicare law requires admission orders be completed by a Physician or Practitioner with admitting privileges and knowledge of the patient’s condition(s).
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Regulatory Compliance Tip for Septmeber 2017

Correct Date of Service for Specific Services

Physicians and non-physician practitioners need to identify the correct date of service (DOS) for the services they provide to a Medicare patient.

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Professional Billing Compliance Tip For September 2017

Managing Funds in a Clinical Trial and Billing for Services

There are some pitfalls to avoid when billing for services and managing funds in a clinical trial.
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Research Billing Compliance Tip for September 2017

National Coverage Determination (NCD) for Hyperbaric Oxygen Therapy (20.29)

The use of HBO therapy is covered as adjunctive therapy only after there are no measurable signs of healing for at least 30 days of treatment.
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Hospital Billing Compliance Tip for August 2017

Post-Operative Evaluation and Management (CPT 99024)

Reporting is required for all eligible practitioners in a practice furnishing post-operative visits, including the global period.

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Research Billing Compliance Tip For August 2017

Administration Charges

Hospitals must report all outpatient drug administration procedures that are not integral to another separately reportable procedure.
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Hospital Billing Compliance Tip for July 2017

Qualifying Clinical Trial Requirements

The purpose of the trial must be the evaluation of an item or service that falls within a Medicare benefits.

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Research Billing Compliance Tip For July 2017

Assistant At Surgery (Modifier 82)

It is critical to appropriately document the role of each physician, as well as the medical necessity of the second surgeon/assistant.
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Hospital Billing Compliance Tip for July 2017

Billing Critical Care Services

When it comes to Medicare Part B physician services which are paid under the physician fee schedule, critical care is not a service that is paid on a “shift” basis or a “per day” basis.
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Professional Billing Compliance Tip for June 2017

Admissions Involving Chemotherapy, Immunotherapy and Radiation Therapy

What code should be assigned during a neoplasm treatment?
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Hospital Billing Compliance Tip for June 2017

Diagnosis Codes on Requisitions

Recommendations apply to all order entry mechanisms whether they are hard-copy requisitions or electronic/web-based systems.
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Laboratory Billing Compliance Tip for June 2017

Ophthalmic Diagnostic Tests

What is meant by the phrase “with interpretation and report” found in the description of most ophthalmic diagnostic tests?
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Professional Billing Compliance Tip for May 2017

Same Day Diagnostic Cardiac Catheterization and PCI

The diagnostic cardiac catheterization may be performed at any time prior to the PCI.
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Hospital Billing Compliance Tip for May 2017

Proper Use of Medicare Coverage Analysis (MCA)

Medicare Coverage Analysis as a general guideline for use in determining which items and services are billable to Medicare.
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Research Billing Compliance Tip for May 2017

Reducing Improper Medicare Payments

Insufficient documentation means that something is missing from the medical record.
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Professional Billing Compliance Tip for April 2017

Research Modifiers Q1 And Q0

Modifier Q1 must be used to identify any routine clinical services which are provided to a study participant of an approved clinical research study. Modifier Q0 must be used to identify any investigational clinical services which are provided to a research study participant during an approved clinical research study.
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Research Billing Compliance Tip for April 2017

How Does an Advanced Beneficiary Notice (ABN) Influence A Medicare Payment

If a patient does not receive a written notice of non-coverage (ABN) prior to services that are usually paid for by Medicare Part A and B, however they may not be paid for a particular service(s).
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Hospital Billing Compliance Tip for April 2017

Payors Are Watching Electronic Medical Record (EMR) Documentation

Once you sign your note, you are responsible for its content.
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Professional Billing Compliance Tip for March 2017

Billing Acute Respiratory Failure (ARF) As A Primary Diagnosis

When should Acute Respiratory Failure (ARF) be blled as primary diagnosis?
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Hospital Billing Compliance Tip for March 2017

Timeliness of Documentation

There are several provisions that may affect “timeliness” when talking about documentation.
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Professional Billing Compliance Tip for February 2017

Billing for Hospital Services

The hospital may bill only for services provided.
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Hospital Billing Compliance Tip for February 2017

Using TIME as a Determining Factor to Code a Visit

Time shall be considered for coding an E/M in lieu of H-E-MDM when > 50% of the total billable practitioner visit time is counseling/coordination of care.
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Professional Billing Compliance Tip for January 2017

Diagnosis Related Group (DRG) Payment When The Patient Is Transferred To A Post-Acute Care Setting

If a qualifying claim is submitted with a discharge status code 01 (Discharge to home of self-care (Routine Discharge)), Medicare’s overpayment edit will look for…
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Hospital Billing Compliance Tip for January 2017

Clinical Research Billing Compliance Risks

Clinical Research Billing Compliance Risks Include…
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Research Billing Compliance Tip for January 2017

Notes on the Documentation of History

You may list the CC, ROS, and PFSH as separate elements of history or you may include them in the description of the HPI….
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Professional Billing Compliance Tip for December 2016

Written Notice of Potential Financial Liability for Hospital Services

Medicare regulations require hospitals to provide patients with a written notice of their potential financial liability….
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Hospital Billing Compliance Tip for December 2016

How to Avoid Double Billing

When a research site takes money for a clinical service from the sponsor…
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Research Billing Compliance Tip for December 2016

Use the “Copy Forward” Functionality with Caution

Use the “copy forward” functionality with caution…

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Professional Billing Compliance Tip for October 2016

Observation Services Tip

There must be medical necessity of observation services…
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Hospital Billing Compliance Tip for October 2016

Medicare Coverage of Clinical Trials, Prospective Studies, and Registries

Medicare Coverage of Clinical Trials, Prospective Studies, and Registries
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Research Billing Compliance Tip for October 2016

Documentation of Physician’s Presence in the Operating Room

OPTIME, effective June 27, 2016 at UMHC/SCCC and BPEI
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Professional Billing Compliance Tip for September 2016

Dose of a Drug Versus Units Billed for a Drug

Drugs are billed based on units…
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Hospital Billing Compliance Tip for September 2016

Tips To Avoid Clinical Research Billing Errors

Tips to avoid clinical research billing errors…
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Research Billing Compliance Tip for September 2016

CMS: CT Scans

CMS Provider Minute: CT Scans Video includes pointers to properly submit claims.

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Professional Billing Compliance Tip for August 2016

Discharge Care and Acute Care Transfer

What is the difference between a discharge and an acute care transfer?

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Hospital Billing Compliance Tip for August 2016

Informed Consent Form (ICF)

Before billing insurance or patient review the informed consent form (ICF).

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Research Billing Compliance Tip for August 2016

Anesthesia Medical Direction Rules

The anesthesiologist must document that he/she examined the patient and his/her individual assessment….

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Professional Billing Compliance Tip for July 2016

Off-Campus Provider-Based Department (PBD)

Off-campus provider-based department (PBD) of a hospital, should the PO modifier be applied?

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Hospital and Professional Billing Compliance Tip for July 2016

Research Billing:“Reasonable and Necessary”

Do not bill insurance for anything that is not “reasonable and necessary.”

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Research Billing Compliance Tip for July 2016

Medicare Part B and DMEPOS Beneficiary Services

Only certain specialty type of physician/NPPs may order/refer for Medicare Part B and DMEPOS

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Professional Billing Compliance Tip for June 2016

JW Modifier

JW modifier: Drug amount discarded/not administered to any patient…

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Hospital Billing Compliance Tip for June 2016

What is a Coverage Analysis

What is a Coverage Analysis? A Coverage analysis is a tool that consists of two parts:

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Research Billing Compliance Tip for June 2016

Services Not Included in the Global Surgery Fee:

Please click on the Read More button to view a list of services not included in the Global Surgery Fee.

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Professional Billing Compliance Tip for May 2016

Hospital Billing Observation Services

Observation billing is addressed in the online Medicare Claims Processing Manual…

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Hospital Billing Compliance Tip for May 2016

Avoid Clinical Research Billing Errors

Tips to avoid clinical research billing errors for services related to Qualified Clinical Trials

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Research Billing Compliance Tip for May 2016

2016 Inpatient Only List

Inpatient-only procedures are those that CMS has determined providers must perform on an inpatient basis because they are invasive and require at least 24 hours of…
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Observation Services Are Covered Only When:

Observation services are covered only when provided by the order of a physician or another individual authorized by State licensure law and hospital staff bylaws to admit patients to the hospital or to order outpatient tests.
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Teaching Physicians Who Seek Reimbursement

Teaching Physicians who seek reimbursement for oversight of patient care by a resident must personally supervise all services performed by the resident.
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Medicare Coverage Analysis

CMS Clinical Trials Policy allows for payment of routine services provided as part of a clinical trial.
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Submission of Diagnoses and Prohibited Practices for Clinical Laboratories

Unlike pathologists and radiologists, clinical laboratories may not alter the diagnosis based on the findings of the test or procedure.
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Revised Exceptions to “Two-Midnight Rule”

The “Two-Midnight Rule,” created in 2013, calls for Medicare’s payment and audit contractors to assume a hospital admission was legitimate if it spans two midnights.
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Teaching Physician Attestations

To bill for services in which a resident/fellow participates, the Teaching Physician must be physically present and personally document that he/she was present during the key or critical portions of the service when performed by the resident/fellow: Read More

Process for Obtaining Child Assent and/or Parental/Guardian Permission

The process for obtaining oral and/or written consent for children and minors is similar to that of obtaining consent for adults.
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Hospital Admitting Diagnosis

The admission diagnosis (or admitting diagnosis) is the initial diagnosis documented by the patient’s provider who determined that inpatient care was necessary…
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Advanced Care Planning Codes 99497 and 99498

Beginning in calendar year (CY) 2016, CPT codes 99497 and 99498 used to describe Advance Care Planning (ACP) will be separately billable.
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Two New E/M Codes in 2016 for Prolonged Services

Two New E/M Codes in 2016 for Prolonged Services provided by the Clinical Staff supervised by the Physician or NPP in an Office Setting (POS 11)
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What Does the Z00.6 Diagnosis Code Tell the Payor and When is it Required?  What is Condition Code 3

The Z00.6 diagnosis code reports that the service involved “Encounter for examination for normal comparison and control in clinical research program
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Acute Hospital Readmissions without Condition Code B4 or 42

An improper payment occurs when two separate acute hospital claims are paid for a Medicare patient who is discharged and re-admitted…
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Several Provisions “Timeliness” When Talking About Documentation.

There are several provisions that may affect “timeliness” when talking about documentation..
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Observation Services Tip

Outpatient observation services require monitoring by a physician and other ancillary staff, which are reasonable and necessary to evaluate the patient’s condition.
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Coding Tip: Evaluation and Management Services

You DO NOT need to re-record a Review of Systems (ROS) if there is an earlier version available in the chart…
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Enroll Clinical Research Protocols within 48 Hours

Clinical research protocols must be registered in the Velos clinical trial system…
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Admission Order Requirement for Inpatient Hospital Stays

Medicare law requires admission orders be completed by a Physician or Practitioner with admitting privileges and knowledge of the patient’s condition(s).
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Teaching Physicians Must Add Their Documentation

Teaching Physicians Must Add Their Documentation
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More Volume of Documentation is Not Always Better

Ensure the billed code is reflective of the actual service provided…
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The Use of an FDA-Approved Drug or Biological is Covered if:

The use of an FDA-approved drug or biological is covered if:
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Research Modifiers

Research Modifiers Q1 and Q0
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Off Campus Medicare Outpatient Coinsurance Notice

Medicare regulations require a notice be given to Medicare patients of potential financial liability for services provided in any off campus hospital-based entity.
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Banish the Words ‘Routine’ or ‘Here for Follow-Up’

Physicians/Providers should avoid the word “routine” or only “here for follow-up”, when documenting a patient’s chief complaint, in the medical record.
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Proper Claims for Clinical Trials

Avoid submitting improper claims related to clinical research
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Present on Admission (POA)

For each diagnosis, Physicians need to identify whether or not it was Present On Admission (POA)
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How to Use Modifiers to Indicate the Status of an ABN

Providers and suppliers should use the appropriate modifier when submitting such claims to indicate whether they have or do not have an ABN signed by the patient.
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Principal Investigator (PI) Responsibilities

The principal investigator (PI) is responsible for assuring that all required approvals are obtained prior to the initiation of the clinical trial.
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Dose of a Drug Versus Units Billed for a Drug

Drugs are billed based on units, not the total number of milligrams.
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Evaluation and Management (E/M) Coding: Volume of Documentation Versus Medical Necessity

Evaluation and Management (E/M) Coding: Volume of Documentation versus Medical Necessity
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Qualified Clinical Trial Cost Types That Are Not Billable to Subjects or Insurance

The following qualified clinical trial cost types cannot be billed to subjects or insurance…
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Importance of Physician Orders

Physician’s orders provide directions to the healthcare team…
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Medicare Inpatient-Only Procedure

Medicare has devised a set of procedures that can only be paid if performed in an inpatient setting.
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Overlapping Surgical Procedures

When the teaching surgeon is involved in two overlapping surgeries…
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Scribes:

Joint Commission guidelines help to regulate the use of scribes:
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Billing for services and Managing Funds in a Clinical Trial

Clinical Research Billing Compliance:Billing for services and managing funds in a clinical trial
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Electronic Health Records (EHR) Cloning of Documentation

Documentation is considered cloned when each entry in the medical record a is worded exactly like or similar to the previous entries. Read More

Medicare Rule for Teaching Physicians

If a resident participates in a service provided in a teaching setting, an attestation is required.

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When to Issue an ABN

Issue an Advanced Beneficiary Notice (ABN) of non-coverage to patients when:

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Qualified Clinical Trial Cost Types Not Billable to Patients or Insurance

Qualified Clinical Trial Cost Types Not Billable or Insurance
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Tips for Documenting Medical Records

Tips for documenting medical records
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