Tuesday, December 27, 2011


The Office of Inspector General (OlG) has released its Work Plan for 2012.  The OIG sets forth various projects to be addressed during the fiscal year by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General. The Work Plan includes projects planned in each of the Department's major entities including CMS.

The OIG plans to initiate the following NEW activities related to physician services:
1)     High Cumulative Part B Payments – The OIG will review high cumulative Part B payments to determine if they are reasonable and necessary, adequately documented, and provided consistent with Federal Regulations.
2)     Incident-to-Services – The OIG will review whether “incident to” billing has a higher error rate than that for non-incident-to-services.
3)     E/M Services: Use of Modifiers during Global Surgery Period – The OIG will review the appropriateness of the use of certain claims modifier codes during the global surgery period to determine if Medicare payments were in accordance with Medicare requirements.

To avoid potential penalties in 2012, be sure that all providers in your practice are documenting exactly what they are billing out to Medicare.  Remember, if it isn't documented, it didnt happen!!!

For more information on this topic, visit http://oig.hhs.gov/reports-and-publications/workplan/index.asp

Thursday, December 8, 2011


Beginning on January 1, 2012, a federal mandate requires providers, health plans, and clearinghouses to use new standards when electronically conducting certain health care transactions.  Included are claims, remittances, eligibility, and claim status requests and responses.  As of March 31, 2011, claims submitted using the current HIPAA 4010 standards will start being denied by CMS.  Commercial insurance carriers may deny claims as soon as January 1, 2012.
As the deadline approaches, providers and health care organizations need to upgrade and test their claims management systems to ensure that they are prepared to accommodate 5010.  The required upgrade to 5010 was prompted by the need for a comprehensive electronic data exchange for the expanded ICD-10 code set mandated for compliance by October 1, 2013.

For more information on this topic, visit www.cms.gov/Versions5010andD0/

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