Tagged with ICD-10 Diagnosis Coding
On February 5, CMS released Part II of the Calendar Year (CY) 2021 Advance Notice of Methodological Changes for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies. In the CY 2021 Advance Notice, the agency is proposing updates and changes to the methodologies used to pay MA plans, Programs of All-Inclusive Care for the Elderly (PACE) organizations, and Part D sponsors.
On January 28, the FDA issued six final guidances on gene therapy manufacturing and clinical development of products, as well as a draft guidance, describing the agency’s proposed approach to determining sameness of gene therapy products for orphan drug designation and exclusivity purposes.
CMS, on January 30, published the Fiscal Year (FY) 2022 Skilled Nursing Facility (SNF) Annual Payment Update (APU) table, indicating the data elements the agency will use for FY 2022 SNF Quality Reporting Program APU determinations.
By Marie Franklin, MBA, National Director of Coding, Education, and Audit The proposed new rules for 2021 will focus on medical decision-making or time as the determining factor when selecting the appropriate level for service rendered for all physicians for evaluation and management. Currently, Medicare has not made Medical Decision Making (MDM) as one of…
The American College of Radiology (ACR) is seeking help in its efforts to urge Congress to stop CMS from implementing proposed changes to the Evaluation and Management (E/M) Codes that could result in severe cuts to radiology.
Aetna has issued a notice, informing providers that, at the end of this year, the insurer will adjust payment for multiple endoscopy procedures in the same family.
Humana has published its latest medical claims payment policy updates, including its reimbursement policy for ambulance transportation, requirements for billing and documentation of observation services, as well as a new policy for obstetric billing, including antepartum, delivery and postpartum care.
UnitedHealthcare Expands Prior Auth Requirements and Site-of-Service Medical Necessity Reviews for Certain Surgeries
UnitedHealthcare has expanded prior authorization requirements and site of service medical necessity reviews for certain surgeries in an effort to shift surgical procedures to less expensive locations.
The president, on October 3, signed an executive order directing the Department of Health and Human Services to increase efforts to provide more insurance plan options under Medicare Advantage and to remove regulations that are considered burdensome to health care providers. The order is intended to protect traditional Medicare and private Medicare Advantage while ramping up alternative payment models, time spent with patients, access to innovative technology and reducing the regulatory burdens on providers.
By Joe Laden, Vice President of Client Management All billing companies and in-house billing operations provide a package of standard reports. They are generally financial reports designed to report cash flow and illustrate the performance of the billing entity However, data collected for billing can provide a wealth of information for the practice beyond the…
In a recent report, the Office of Inspector General (OIG) determined that payments for outpatient Intensity Modulated Radiation Therapy (IMRT) did not comply with Medicare billing requirements. Specifically, hospitals billed separately for complex stimulations when they were performed as part of IMRT planning. Overpayments occurred because hospitals are unfamiliar with or misinterpreted CMS guidance.
Anthem BCBS has posted its recent Clinical, Medical, and Coding Updates, including revisions to Gene Therapy for Spinal Muscular Atrophy guidelines and changes to Positron Emission Tomography (PET) guidelines.
Cigna has made several additions and removals to its precertification list, as well as updates to its Preventive Care Services Policy.
Effective October 1, 2019, Optum will make changes to and start managing prior authorization requests and processes for certain medical benefit injectable medications for UnitedHealthcare (UHC) commercial plan members.
Effective October 1, an affiliate company of UnitedHealthcare (UHC), will begin managing the insurer’s prior authorization requests for outpatient injectable chemotherapy and related cancer therapies for (UHC) Community Plan members in New Jersey.
Anthem is introducing a new program to reduce the administrative burden associated with current prior authorization (PA) processes for providers who are contracted with Anthem in Connecticut. The Prior Auth Pass Program allows providers who meet program requirements to waive prior authorization for select outpatient medical procedures that generally have high rates of PA requests and approvals.
Effective July 1, Aetna will require prior authorization for certain procedures under its Enhanced Clinical Review Program with eviCore healthcare.
UnitedHealthcare (UHC) Washington has released a notice detailing which procedure codes will require prior authorization for UnitedHealthcare Community Plan of Washington, effective for dates of service on or after October 1.
Effective September 1, UnitedHealthcare (UHC) will add a new policy for molecular pathology and will make changes to its procedure to modifier policy.
Cigna has published a number of clinical, reimbursement, and administrative policy updates, including its reimbursement policy for spinal fusion related services, venous angioplasty, and orthotic prescriptions.