Medical Billing

Claims Part A – Skilled Nursing Facility (SNF) Providers There has been an increase in overlap claim situations due to Skilled Nursing Facility (SNF) providers not submitting their discharge claims correctly.   There are two situations that force a discharge from a SNF: 1) the beneficiary’s admission as an inpatient to a Medicare participating hospital or Critical Access Hospital (CAH), or 2) the beneficiary’s transfer to another SNF for inpatient services. A beneficiary cannot be an inpatient in more than one facility at a time. Consequently, the SNF must submit a discharge bill if either of these events occur.  It is inappropriate to add a 74 span code in lieu of a discharge status.  Reference IOM 100-04, Chapter 6, Section 40.3.4   SNF providers shall submit no-payment claims for beneficiaries that previously dropped to non-skilled care and continue to reside in the Medicare-certified area of the facility. The provider must only submit ...

Difference Between ICD 9 - ICD 10 Basic Information about ICD 9: The United States Implemented ICD 9 in 1979. But most of the countries moved to ICD 10 several years ago, it’s time for United States medical history to reflect modern Medical terms.  Difference between ICD 9 – ICD 10 Code set differences ICD-9-CM codes are very different than ICD-10-CM/PCS code sets: There are nearly 19 times as many procedure codes in ICD-10-PCS than in ICD-9-CM volume 3 There are nearly 5 times as many diagnosis codes in ICD-10-CM than in ICD-9-CM ICD-10 has alphanumeric categories instead of numeric ones The order of some chapters have changed, some titles have been renamed, and conditions have been grouped differently ICD-9-CM Diagnosis Codes ICD-10-CM Diagnosis Codes No Laterality Laterality – Right or Left account for >40% of codes 3-5 digits First digit is alpha (E or V) ...

When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for services that are related to the treatment and management of his terminal illness during the period his hospice benefit election is in force, except for professional services of an “attending physician” who is not an employee of the designated hospice and does not receive compensation from the hospice for those services. Professional services of an “attending physician” are submitted with the GV modifier if all conditions are met (description below). Any services provided to a patient enrolled in hospice that are not related to the treatment and management of the patient’s terminal illness are submitted with the GW modifier (description below). For purposes of administering the hospice benefit provisions an “attending physician” is defined as follows (must meet all requirements): An individual who is a doctor of medicine, doctor of osteopathy or a nurse practitioner. Is identi...

Recently, Novitas Solutions has received numerous requests to provide pre-authorization for surgery scheduled to occur within days. Traditional Medicare does not provide pre-certification or pre-authorization of a surgery. Medically necessary services should not be withheld or delayed. Medically necessary services that have been provided to the patient are billed to Medicare for consideration and processing. If a service is denied, the provider and the patient have a right to request a redetermination of the denial. Title XVIII of the Social Security Act, Section 1862(a)(1)(A) allows coverage and payment for items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. Section 1862(a)(1)(A) of the Social Security Act is the basis for denying payment for types of care, specific items, services, or procedures, not excluded by any other statutory clause, meet all technical requiremen...

Medicare Novitas is currently receiving a high volume of duplicate certifications/signatures for Internet-based PECOS (Provider Enrollment, Chain and Ownership System) CMS-855  submissions.  This is a result of customers submitting both an electronic signature and a hardcopy/paper certification.  When submitting an application via Internet-based PECOS, please elect only one method of submitting your signature; electronic OR hardcopy.  For additional details, please review Novitas educational article titled “Internet-based PECOS Signature Submissions” on our website in the Enrollment Center.   When submitting an application via Internet-based PECOS, please elect one form of signature submission. 1. Electronic Signature: Internet-based PECOS allows for the provider or Authorized/Delegated Official to electronically sign the application submission. Utilizing the electronic signature process will ensure faster application submission, resulting...

DME is equipment that can withstand repeated use, is primarily used for a medical purpose, and is not generally used in the absence of illness or injury. Examples include hospital beds, wheelchairs, and oxygen delivery systems. Medicare will cover medical supplies that are necessary for the effective use of DME, as well as surgical dressings, catheters, and ostomy bags. However, Medicare will only cover DME and supplies that have been ordered or prescribed by a physician. The order or prescription must be personally signed and dated by the patient's treating physician.  DME suppliers that submit bills to Medicare are required to maintain the physician's original written order or prescription in their files. The order or prescription must include:  o the beneficiary's name and full address; o the physician's signature; o the date the physician signed the prescription or order; o a description of the items needed; o the start date of the order (if ap...

September 1 st 2014 is the US labor day, The Department of Labor's Unemployment Insurance (UI) programs provide unemployment benefits to eligible workers who become unemployed through no fault of their own, and meet certain other eligibility requirements. In the United States unemployment benefits generally pay eligible workers between 40-50% of their previous pay. Benefits are generally paid by state governments, funded in large part by state and federal payroll taxes levied against employers, to workers who have become unemployed through no fault of their own. This compensation is classified as a type of social welfare benefit. Eligibility : In order to receive benefits, a person must have worked for at least one quarter in the previous year and have been laid-off by an employer. Workers who were temporary or were paid under the table are not eligible for unemployment insurance. If a worker quits or is fired they are not eligible for UI benefits. There are five...