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CMS rescinds, replaces LCD exception transmittal
On September 25, CMS replaced its previous transmittal on LCD exceptions. It had previously sent out the incorrect version of section 3.12. All other material remains the same.
Effective date: October 13, 2009
Implementation date: October 13, 2009
Editor’s note: Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc., is the author of this week’s note from the instructor.
After CMS issued Transmittal 1803, we have continued to receive questions on the correct way to bill for outpatient services when Condition Code 44 criteria have been met. The next chapter of the story involves determining if and when observation begins.
Click over to the MedicareMentor Blog to read more.
CMS replaces FDG PET transmittals
On September 18, CMS rescinded and replaced two previous transmittals related to FDG PET coverage.
Effective date: April 6, 2009
Implementation date: October 19, 2009
By Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc.
On September 11, CMS published Transmittal 302 that updated the Program Integrity Manual on Local Coverage Determination (LCD) exceptions. When specific authorized contractors conduct a complex medical review, they have the authority (in rare and unusual circumstances) to apply an exception to the “reasonable and necessary” requirements described in an LCD to approve or deny a claim. However, they cannot make exceptions to National Coverage Determinations (NCDs). In addition, and unless otherwise directed by CMS, RACs can only use the exceptions process to not deny a claim. This is a good time to review the difference between a national and a local coverage determination policy.
Click over to the MedicareMentor Blog to read more.
DCS Healthcare has released its first CMS-approved issues for audits in Region A.
The three issues, including one new issue not yet approved in other RAC regions, are applicable to durable medical equipment (DME) suppliers in Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont.
According to the DCS Web site, the issues include the following: Read More→
At this point, thanks to a three-year demonstration project and a plethora of available information available for providers, the healthcare industry generally knows what providers are up against in terms of RAC audits. Not that they’ll be easy to handle, but there’s a lot of information out there for providers to help them manage the process.
Unfortunately, comparatively few providers seem to know what to expect with Medicaid Integrity Program audits—which have already begun in many areas across the nation—and in many cases, information that could help them is lacking.
By Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc.
Last month, I participated in an HCPro audioconference on HINNs. "HINN" stands for hospital-issued notice of non-coverage. It’s the inpatient equivalent of an advanced beneficiary notice (ABN).
Under Medicare’s limitation on liability (LOL) provisions, hospitals are required to provide prior notice, in a prescribed form, when certain outpatient or inpatient services ordered by a physician do not meet Medicare’s medical necessity guidelines for the patient’s condition.
In such cases, the ABN is the prescribed form of prior notice for outpatient services, while the HINN is the prescribed from of prior notice for inpatient services. Although the prior notice requirements for LOL have been in place for a number of years, hospitals continue to struggle to provide timely, appropriate notification, particularly in the inpatient setting.
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