Thursday, January 26, 2017

What kinds of health problems are linked to excess weight?

Men's Health Week

The week leading up to Father’s Day, June 10-16, is National Men’s Health Awareness Week.  It is a time to focus on getting and/or keeping yourself or the man in your life healthy.  Weight-related diseases are a growing cause of men’s health issues.

What kinds of health problems are linked to excess weight?
•         type 2 diabetes
•         high blood pressure
•         heart disease and strokes
•         certain types of cancer
•         sleep apnea
•         osteoarthritis
•         fatty liver disease
•         kidney disease

The table and graph below illustrate the significant increase in the percentage of overweight males in the 35-44 years category.

*Body mass index (BMI) equals weight in kilograms divided by height in meters squared. 

(Source CDC:  Data are based on measured height, without shoes, and weight of a sample of the civilian non-institutionalized population.)

**Age-adjusted to the year 2000 standard population using five age groups:20-34 years, 35-44 years, 45-54 years, 55-64 years, and 65 years and over

Closely linked to weight issues, is lack of physical activity. 

Recommendations from the CDC are as follows:

Scenarios Aerobic Activity Amount/Week  Muscle Strengthening Frequency/Week

1 Moderate Intensity 2 hours,30 minutes

All major muscle groups 2 or more days

2 Vigorous Intensity 1 hour, 15 minutes
All major muscle groups 2 or more days

3 Combined Intensity Up to 2 hours,30 minutes
All major muscle groups 2 or more days

Proper nutrition also plays an important part in maintaining a healthy weight.  Here are the guidelines for the average adult daily 2000 calorie intake:

•         6 ounces of whole grains,
•         2 and ½ cups of vegetables,
•         2 cups fruit,
•         3 cups low fat dairy, and
•         5 and ½ ounces of lean protein

With diligent efforts to keep active and eat properly any man can optimize his chances for good 

Appealing a Medicare Denial

If you have received a claim denial from your Medicare contractor you do have the right to submit an appeal.  If you do not take assignment on the claim, your appeal rights can be limited.

clerical reopeningSee section at the bottom on Clerical Reopening when an appeal is not indicated.

First level of appeal: Redetermination

A redetermination is an examination of a claim by fiscal intermediary (FI), carrier, or MAC personnel who are different from the personnel who made the initial claim determination. The appellant (the individual filing the appeal) has 120 days from the date of receipt of the initial claim determination to file an appeal. A redetermination must be requested in writing. A minimum monetary threshold is not required to request a redetermination
Second level of appeal: Reconsideration 

A party to the redetermination may request a reconsideration if dissatisfied with the redetermination decision. A qualified independent contractor (QIC) will conduct the reconsideration. The QIC reconsideration process allows for an independent review of medical necessity issues by a panel of physicians or other health care professionals. A minimum monetary threshold is not required to request a reconsideration.

Third level of appeal: Hearing by an administrative law judge (ALJ) 

If at least $140 remains in controversy following the qualified independent contractor's (QIC's) decision, a party to the reconsideration may request an administrative law judge (ALJ) hearing within 60 days of receipt of the reconsideration decision. Appellants must send notice of the ALJ hearing request to all parties to the QIC for reconsideration. ALJ hearings are conducted by the Office of Medicare Hearings and Appeals (OMHA).

OMHABy clicking here you will find information on the OMHA website.

Fourth level of appeal: Review by the Medicare Appeals Council
If a party to an ALJ hearing is dissatisfied with the ALJ's decision, the party may request a review by the Medicare Appeals Council. 

There are no requirements regarding the amount of money in controversy. The request for Medicare Appeals Council review must be submitted in writing within 60 days of receipt of the ALJ's decision, and must specify the issues and findings that are being contested.

Medicare AppealsBy clicking here you will find information on the Medicare Operations Division/Medicare Appeals Council.

Fifth level of appeal: Judicial review

If $1,400 or more is still in controversy following the Medicare Appeals Council's decision, a party may request judicial review before a Federal District Court judge. The appellant must request a Federal District Court hearing within 60 days of receipt of the Medicare Appeals Council's decision.

•The Medicare Appeals Council's decision will contain information about the procedures for requesting judicial review.

Medicare AppealsAdditional resources

Within the CMS websites you will find information related to the five levels in the Part A and Part B appeals process.

• CMS Appeals Web resources
• CMS Appeals process flowchart

CMS resource materials available for download

• MLN - The Medicare Appeals Process Brochure
CMS Internet-only manuals: Publication 100-04
• Chapter 29– Appeals of Claims Decisions
• Chapter 34– Reopening and Revision of Claim Determinations and Decisions

Minor errors or omissions on some Part B claims can be corrected for reprocessing using the clerical reopening process.

Medicare AppealsThere are two ways to initiate this process:

• Telephone reopening requests via the interactive voice response (IVR) allows providers/customers to request telephone re-openings on certain claims.  For the IVR reopening request help sheet, click here
• For reopening requests in writing, use the clerical reopening .

corrected claimCommon clerical errors consist of:

• Mathematical or computational mistakes
• Transposed procedure or diagnostic codes
• Inaccurate data entry
• Misapplication of a fee schedule
• Computer errors
• Denial of claims as duplicates which party believes incorrectly identified as duplicate
• Incorrect data items such as provider number, modifier, date of service.

Wednesday, January 25, 2017

medically unlikely edit (MUE) and Key Medicare Benefits for Men’s Health

Do you know MUE?

Working in medical billing is like being in a bowl of alphabet soup. 

One of the probably less common acronyms is MUE:  Medically Unlikely Edit.

Read below to find out what an MUE is, and why you should care.

what is a medically unlikely edit A medically unlikely edit (MUE) is an automated claim processing edit that compares the number of units submitted for a procedure code against the designated maximum units that are typically reported for that code on the vast majority of appropriately reported claims.

MUE The edit is applied to services billed by a single provider/supplier to a single beneficiary on the same date of service.

Automated claim processing edit

The MUE program was developed by CMS in an effort to reduce the paid claims error rate for Medicare claims that result from various circumstances such as:

• clerical entries
• incorrect coding based on:

o   anatomic considerations
o   procedure code descriptors
o   procedure coding instructions
o   established CMS policies
o   nature of a service/procedure
o   unlikely clinical treatment

MUE CMS does not publish MUE values for some codes. Some MUE values are confidential and may not be published.

CMS fiscal intermediaries 

CMS fiscal intermediaries and Part A/Part B Medicare administrative contractors (A/B MACs) process claims with the fiscal intermediary shared system (FISS).  

They adjudicate MUEs against each line of a claim rather than the entire claim. If a procedure code is reported more than once, each line with that code is separately adjudicated against the MUE. They will deny the entire claim line if the unit of service (UOS) on the claim line exceeds the MUE value for the procedure code listed on the claim line.

MUE For Example CPT Code 77300 is submitted on one service line for 11 units, if the MUE is 10, then all 11 are denied, instead of a just denying the one unit over the limit.

MUe value modifiersWhen there is a need to report medically reasonable and necessary units of service in excess of an MUE value modifiers can be used to report the same code on separate lines of a claim will enable a provider/supplier to report medically reasonable and necessary units of service in excess of an MUE value.

modifiersThe modifiers noted below will accomplish this purpose.

• 76 -- Repeat procedure by same physician
• 77 -- Repeat procedure by another physician
• Anatomic modifiers (e.g., RT, LT, F1, F2, 50)
• When is it appropriate to bill modifier 50?
• 91 -- Repeat clinical diagnostic laboratory test
• 59 -- Distinct procedural service (Note: Modifier 59 should be utilized only if no other modifier describes the service.)

MUE Effective April 1, 2013, CMS converted some claim line MUEs to date of service (DOS) MUEs.  The total units of service (UOS) from all claim lines for a HCPCS/CPT code with the same date of service will be summed and compared to the MUE value.  Claims denied based on DOS MUEs may be appealed usingsimilar processes to claim line MUE denials.  

CMS does not publish which codes have DOS MUEs.  Since all UOS for a HCPCS/CPT code on all claim lines with the same date of service are summed, reporting additional UOS on separate claim lines with a HCPCS/CPT modifier will not result in payment of UOS in excess of the MUE value.

Key Medicare Benefits for Men’s Health

For those providers servicing Medicare beneficiaries, Men’s Health Awareness Week is a good time for you to re-familiarize yourself with the wide range of covered preventive services.  Identifying risk factors and utilizing screening tests for early detection can mean the difference between life and death. 

As demonstrated by the chart below, several of leading causes of death in males age 65 and over in the United States, are routinely linked to preventable and /or highly treatable causes.  This data was reported by Centers for Disease Control and Prevention for 2009.   

The table below lists the covered service detailing eligibility requirements and other useful billing information:

Service : Procedure Code(s) : Coverage : Frequency

Abdominal Aortic Aneurysm Screening

G0389-U/S exam AAA Screening
Any beneficiaries with certain risk factors and a referral resulting from an IPPE visit.
Once in a lifetime
Alcohol Misuse Screening and Counseling
G0442-Annual screening, 15 min.
G0443-Brief face-to-face behavioral counseling for misuse, 15 min.
For screening: all beneficiaries.
For misuse, furnished by PCP: all competent beneficiaries.
G0442-Once annually
G0443-4 times per year

Annual Wellness Visit (AWV)

G0348-Initial Visit
G0349-Subseqeunt Visit
Any beneficiary that has been effective for Part B for at least 1 year.
G0348- Once in a lifetime
G0349- Once annually
Colorectal and Prostate Cancer Screenings
G0104-Flexible Sigmoidoscopy or G0106-Barium Enema
(high risk) or
G0120-Barium Enema
G0121-Colonoscopy (not high risk)
G0328-Fecal Occult Blood Test immunoassay
82270- Fecal Occult Blood Test by peroxidase activity.
Any beneficiary aged 50 or over who are at normal or high risk for developing

Colo-rectal cancer.

G0328/82270-Once annually
G0104-Once every 4 years or 120 months after G0121
G0121-Once every 10 years or 48 months after G0104 or every 24 months for high risk
G0106/G0120-Once every 48 months or 24 months for high risk.

Cardiovascular Disease Screenings

80061-Lipid Panel
Any beneficiaries w/o signs or symptoms of cardiovascular disease
Every 5 years
Depression Screening
G0444-Annual screening, 15 min.
Any beneficiary as furnished by PCP with proper support staff.
Once annually
Diabetes Screening

82947-Blood Glucose; quantitative
82950-Glucose;post-glucose dose
82951-Glucose;3 specimen tolerance test
Any beneficiaries with risk factors or diagnoses with pre-diabetes.
Once annually if no pre-diabetes. 

Twice annually with pre-diabetes.
HIV Screening
G0432-Infectious agent by EIS technique
G0433-Infectious agent by ELISA technique
G0435-Infectious agent by rapid antibody test
Any beneficiaries at increased risk for HIV infection or pregnant.
Annually for high risk beneficiaries. 

Three times per pregnancy.

Immunizations (Seasonal Influenza, Pneumococcal, and Hepatitis B)

90654-90657, 90660-90662, Q2034-Q2039-Influenza Virus Vaccine/ G0008 administration 90669-90670,90732-Pneumococcal Vaccine/


90740,90743-90744, 90746-90747-Hepatitis B Vaccine/G0010 administration

Influenza and Pneumococcal: all beneficiaries.

Hepatitis B:i any beneficiaries at intermediate or high risk for
Influenza- Once per season.
Pneumococcal- Once in a lifetime.
Hepatitis B- Scheduled dosages as required.
Intensive Behavioral Therapy for Cardiovascular Disease
G0446-IBT to reduce cardiovascular disease risk; individual, face-to-face, bi-annual, 15 min.

Furnished by PCP: Male beneficiaries aged 45-79-encouraging aspirin use, adults aged 18 or older- screening for hypertension, adults with risk factors- promoting a healthy diet

Intensive Behavioral Therapy for Obesity

G0447-Behavioral counseling, face-to-face, 15 min.
Beneficiaries with BMI greater than or equal to 30 kg/m2, furnished by PCP.

One visit per week in first month.
One visit every 2 weeks, months 2-6.
One visit per month, months 7-12.
Prostate Cancer Screening
G0102-Digital rectal exam
G0103-Prostate Specific Antigen test
All male beneficiaries aged 50 and older.
Once annually

Tobacco Use Cessation Counseling

G0436-Counseling for the asymptomatic patient; intermediate >3min. up to 10 min.

G043-Couseling for the asymptomatic patient; intensive, > 10 min.
All outpatient and inpatient beneficiaries.

Two cessation attempts per year: attempt =  max of four sessions, up to eight sessions in 12 months.

For More Information:

• MLN Preventive Services Educational Products for Health Professionals
• CMS Prevention website
• CMS Immunizations website
• MLN National Provider Calls and Events website
• Men’s Health Month website

Tuesday, January 24, 2017

Discharge Planning as Part of Community-Based Care Transition Program (CCTP) and Medicare: What is a Duplicate?

CMS encourages Home Health Agencies, Hospices, Hospitals, Inpatient Psychiatric Facilities, Long-Term Care Facilities, and Swing Beds to review the guide on “Discharge Planning”(ICN 908184) found in the Medical Learning Network section of CMS. 

This 20 page publication provides valuable detailed information for any provider of service involved in the patient discharge process.

CMS data suggests almost 20% of hospitalized Medicare patients are readmitted within 30 days of their discharge. This amounts to approximately 2.6 million beneficiaries being affected and costs the Medicare program an estimated $26 billion every year.

Increase medical costs

In an attempt to curb this expense, the CMS Innovation Center established by the Affordable Care Act has created the Community-Based Care Transition Program (CCTP).  The ACA has earmarked up to $500 million for the CCTP that was launched in 2011 and will run for 5 years.

Community-Based Care Transition Program

The program starts with the basic principle that the healthcare community should work together to improve quality of patient care.

Reduced healthcare costs

The goal is to ultimately reduce hospital readmissions by a minimum of 20 % which would translate to a savings of $5.2 billion a year.  This represents a significantly larger amount than the initial cost to CMS for the program.
Data for 2012 suggests the program is already working by preventing an estimated 70,000 readmissions.
Enrolled participants, referred to as Community-based organizations (CBOs) now numbering over 100, will work with hospitals to coordinate patient care transitions.  If you would like to see who is participating in your area, you can select this link to access the CMS interactive map:

Care transition

Care transitions as referred to in this program, relate to hospital inpatients that are being discharged to their home, a nursing home, or other care facility.  CBOs will use care transition services to identify risk factors that produce readmissions and coordinate the necessary actions to lessen the effect of those factors.

patient education

CBOs will be requred to provide:

Care transition services that begin no later than 24 hours prior to discharge

Timely, culturally and linguistically competent post-discharge education to patients

NOTE:This education is crucial so that patients understand potential additional health problems that may develop or a deteriorating condition.

Timely interactions between patients and post-acute and/or outpatient providers

Patient centered self-management support and information specific to the beneficiary’s condition

A comprehensive medication review and management

NOTE:This includes any appropriate counseling and self-management support.                          

The CBOs will be paid an all-inclusive rate per eligible discharge based on the cost of care transition services provided at the patient level and of implementing systemic changes at the hospital level. CBOs will only be paid once per eligible discharge in a 180-day period of time for any given beneficiary.      

Performance and effectiveness of the CBOs will be gauged by the evaluation contractor and the implementation and monitoring contractor.  Quality and utilization measures will consist of 30-day all cause readmission rates, and will also monitor 90-and 180-day readmission rates, mortality rates, observation services, and emergency department visits.  

One major goal of the CCTP is to develop effective approaches to care interventions that will improve the quality of care while decreasing readmissions.  This transparency of the COB’s should ensure accurate evaluations of both successes and shortcomings of this program.

Please follow this link to the CMS site for full details on this program:

Medicare: What is a Duplicate?

Each Medicare claims processing system contains criteria to evaluate all claims received for potential duplication.  The claims can be placed into two categories: exact duplicate or suspect duplicate.  Each category is processed uniquely by the Medicare contractor.

CMSCMS has recently updated the Medicare Claims Processing Manual, Chapter 1, Section 120: “Detection of Duplicate Claims” based on change request (CR) 8121.

Duplicate claims : An exact duplicate claim is denied or rejected, if missing applicable modifiers, automatically by the claims processing system.

 For exact duplicate denials, professional providers do have appeal rights, but institutional and DME providers do not.

suspect duplicateIf a claim is deemed suspect by the initial system review, the claim is suspended for further review by the Medicare contractor.

 If suspect duplicate is denied after review, all providers have right to appeal.

Due to the nature of the service, some claims may only appear to be duplicates.  Proper coding of the service with the applicable condition codes or modifiers will identify the claim as a separate payable service, not a duplicate.  An example could be modifiers “LT” and “RT” for bilateral procedures.

By utilizing an advanced Medical Practice Management Billing Software like Iridium Suite from Medical Business Systems, duplicate claims submissions are easily prevented.  A configurable Claim Scrubber as found in Iridium Suite will check each service entered and alert the user immediately if the same service is already on record. 

This gives the user the opportunity to determine if the service is a true duplicate or if the service qualifies for an appropriate addition of a modifier.

See the information below for details on the process Medicare utilizes to identify duplicate claims.

Provider of Service duplicate claimsExact Duplicate suspect duplicate 

Suspect Duplicate

Institutional institutional claims Claim matches identically on the following data:

1. Health insurance claim (HIC) number 
2. Type of bill 
3. Provider identification number  
4. From date of service 
5. Through date of service
6. Total charges (on the line or on the bill)
7. HCPCS,  CPT-4, or procedure code/modifiers Claim matches on the following data:

1. Beneficiary information
2. Provider identification
3. Same date of service or overlapping dates of service

Professional professional claims

1. HIC number
2. Provider number
3. From date of service
4. Through date of service
5. Type of service
6. Procedure code
7. Place of service
8. Billed amount

The criteria for identifying suspect duplicate claims submitted by physicians and other suppliers vary according to the type of billing entity, type of item or service being billed, and other relevant criteria.

DMEDME supplies Claim matches identically on the following data:

1. HIC number
2. From date of service
3. Through date of service
4. Place of service 22
6. Type of service
7. Billed amount
8. Supplier

The criteria for identifying suspect duplicate claims submitted by physicians and other suppliers vary according to the type of billing entity, type of item or service being billed, and other relevant criteria.

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