How important is proper documentation in the medical record to support a claim?

Buried in documentation?  Looking to save yourself time and trouble?  Rather than cutting corners and skipping paperwork, you’ll actually save time and significant risks if you commit to full and proper documentation in the medical record to support each submitted claim.   If the records do not substantiate the service reported and show [...]

Coding Updates Announced for July 2018

CPT and HCPCS codes are updated quarterly. On May 11, 2018, CMS released Transmittal 4025, which describes HCPCS coding changes effective July 1, 2018. The following new HCPCS codes will be established: Q9991 Injection, buprenorphine extended-release (sublocade), less than or equal to 100 mg Q9992 Injection, buprenorphine extended-release [...]

Why Should You Search State Exclusion Databases?

You know the OIG (Office of Inspector General) LEIE (List of Excluded Individuals/Entities) is the federal database for all Medicaid sanctions. However, did you know that many states maintain separate sanction/exclusion databases as well? These are investigations conducted by the state Medicaid offices, which do not always include [...]

Why Choose to Search NPDB?

There are approximately 14,300 medical malpractice payments each year. Most of these are never revealed publicly, and rarely do they reach the level of a medical board disciplinary review. So these practitioners often go unnoticed, leaving your organization vulnerable to claims of negligent credentialing. However, all settlements and court [...]

How long does an exclusion last?

How long does an exclusion last? The length of any given exclusion will depend on the circumstance and basis of the particular exclusion. Some exclusion periods, such as for violations for licensure requirements, is indefinite. The minimum term for a mandatory exclusion is five years. Reinstatement at the conclusion of an exclusion term is not [...]

What’s the difference between a mandatory exclusion and a permissive exclusion?

What is the difference between mandatory exclusion and permissive exclusion? Mandatory Exclusion – ​The OIG is required to automatically exclude individuals and entities that are convicted of a program related crime or a crime of patient abuse or neglect. Other mandated exclusions include when an individual or entity is convicted of a [...]

What is the difference between a line item, MUE edit and a date of service edit?

What do the different MUE Adjudication Indicators (MAI) for service lines and service dates mean on the Medically Unlikely Edits (MUE)? In 2013, CMS introduced an additional element to the Medically Unlikely Edits, the MUE Adjudication Indicator (MAI). There are two types of MUE edits. The first type (indicator value “1”)is a quantity of [...]

Why would I get a rejection for a “Covered” code?

Why am I receiving a rejection on claims for this Dx/HCPCS combination? The code is 62311, with theDx being M48.07. The LCD module shows this to be covered.   This particular code is found in the list of diagnoses considered medically necessary, but there is additional language restricting the number of injections, which could be […]

What is a retired coverage policy?

What happens when a Local Coverage Determination (‘LCD”) is retired? When a policy is retired, it means that the specific diagnosis and coverage requirements of the policy are no longer in effect. Therefore claims will not be denied based on the policy provisions after the retirement date. For example, a policy might have restricted knee […]

Advanced Beneficiary Notice (ABN)

What is an ABN? An Advanced Beneficiary Notice of Noncoverage (CMS-R-131) is issued to Medicare patients by a medical provider when the care planned for a patient is not expected to be covered by Medicare. The ABN allows a patient to make an informed decision about whether to proceed with the item or service and […]