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 When a policy is retired, it means that the specific diagnosis and coverage requirements of the policy are no longer in effect.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 […]

2018 CPT Updates

A list of the new deleted and changed CPT codes effective January 1, 2018 Topics Discussed New Codes New Category III Codes Deleted Codes Deleted Category III Codes 2018 CPT Updates Download Jump to Section   New Codes   02/01/17 05/01/17 07/01/17 08/01/17 10/01/17 01/01/18   New Category III Codes   07/01/17 01/01/18 [...]

2018 HCPCS Updates

A list of the new, deleted, and changed HCPCS codes effective January 1, 2018 Topics Discussed New Codes Deleted Codes 2018 HCPCS Updates Downloads Jump to Section   New Codes   04/01/17 07/01/17 10/01/17 01/01/18   Deleted Codes   New Codes * Denotes recycled code + Denotes code that was added and deleted in the […]

2018 ICD-10-PCS Updates

A list of the new, deleted, and changed ICD-10 procedure codes effective October 1, 2017 Topics Discussed New Codes Codes with Revised Descriptors Deleted Codes 2018 ICD-10-PCS Updates Download

2018 ICD-10-CM Updates

A list of the new, deleted, and changed ICD-10 diagnosis codes effective October 1, 2017​ ​1,​ ​2017 Topics Discussed New Codes Newly Truncated Codes Codes with Revised Descriptors Deleted Codes 2018 ICD-10-CM Updates Download