03/05/18 | Total knee arthroplasty (27447) removed from Inpatient only list – causing confusion

You may have been experiencing feedback from a facility when trying to schedule your total knee replacements as inpatients. 

Total knee arthroplasty (27447) removed from Inpatient only list – causing confusion
07/10/17 | New Category III codes effective Jan 1st, 2018

You will want to update your bone marrow aspiration coding for 2018 as well as some adipose-derived cell therapy for hands

New Category III codes effective Jan 1st, 2018
07/10/17 | Spinal surgery

If you do any spinal surgery you want to be aware of the Medicare changes that are taking place regarding number of levels, number of cages as well as diagnosis issues.

Spinal surgery
06/10/16 | CMS starting to list ICD-10s not covered
  Unspecified ICD-10 codes be careful
CMS starting to list ICD-10s not covered
07/09/15 | Total joint issues from CMS
  Total joint issues from CMS
Total joint issues from CMS
12/31/14 | Holding claims and fee schedule issues for 2015
  Medicare wants claims held starting Jan 1, 2015
Holding claims and fee schedule issues for 2015
08/20/14 | Medicare finally catching on that modifier 59 is not enough
Medicare finally catching on that modifier 59 is not enough
07/22/14 | Keep an eye on your private payer contracts..
Keep an eye on your private payer contracts..
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Did You Know:

For years I have been saying that CMS would come up with a modifier relating to 'incident to' - it looks like it is on the table from the OIG
This just out from the OIG OIG today posts six new reports to the website. 
Prevalence and Qualifications of Nonphysicians Who Performed Medicare Physician Services  (OEI-09-06-00430)

In the first 3 months of 2007, when Medicare allowed physicians more than 24 hours of services in a day, nonphysicians performed half of the services and unqualified nonphysicians performed 21 percent of these services.  Medicare Part B pays for services that are billed by physicians but are performed by nonphysicians under the "incident to" rule.  Little is known about these services because physicians are not required to identify them on their Medicare claims.

To identify the services not personally performed by physicians, we sampled claims from physicians for whom Medicare allowed more than 24 hours of services in a single day in the first 3 months of 2007.  Some of the services that were performed by unqualified nonphysicians were invasive services, involving entry into the body by incision or insertion of an instrument.  These services, in particular, may represent a risk to Medicare beneficiaries when they are performed by unqualified individuals.  We are concerned that the problem of Medicare services performed by unqualified nonphysicians may be more widespread
than we can report at this time.

We recommend that CMS seek revisions to the "incident to" rule.  The rule should require that physicians who do not personally perform the services they bill to Medicare ensure that no persons except:  (1) licensed physicians personally perform the services or (2) nonphysicians who have the necessary training, certification, and/or licensure, pursuant to State laws, State regulations, and Medicare regulations, personally perform the services under the direct supervision of a licensed physician.  Further, CMS should require that physicians who bill services to Medicare that they do not personally perform to identify the services on their Medicare claims by using a service code modifier.  The modifier would enable CMS to monitor claims to ensure that physicians are billing for services performed by nonphysicians with appropriate qualifications.  Finally, CMS should take appropriate action to address the claims for services that we detected that (1) were billed by physicians and performed by nonphysicians that were, by definition,
not "incident to" services and (2) were for rehabilitation therapy services performed by nonphysicians who did not have the training of a therapist.

In comments on the draft report, CMS concurred with two of our three recommendations.  CMS did not concur with our recommendation to create a service code modifier to identify physicians' claims for services that physicians do not personally perform.  We continue to recommend that CMS have the ability to identify and monitor these claims.  CMS stated it would study the operational issues involved in implementing the recommendation.  We look forward to learning the specific steps CMS plans to take with respect to this issue.

Medicare Fraud Strike Force Widens Scope

December 31st, 2009

The Department of Justice (DOJ) and Health and Human Services (HHS) announced Dec. 15, 2009 expansion of Medicare Fraud Strike Force operations to Brooklyn, Tampa, and Baton Rouge.

“Along with teams already operating in Miami, Los Angeles, Houston and Detroit,” said HHS Secretary Kathleen Sebelius, “these Strike Force operations will allow us to concentrate our agents and resources on the criminal hubs where we know a significant share of fraud occurs.”

On the same day, 30 people were charged in Miami, Detroit, and Brooklyn for their alleged roles in schemes to submit more than $61 million in false Medicare claims. And Strike Force agents executed four search warrants at businesses and homes in Coconut Creek, Fla., Miami, and Brooklyn.

Since operations began in March 2007, the Strike Force has obtained indictments of more than 460 individuals and organizations that collectively have falsely billed the Medicare program for more than $1 billion.

Source: HHS press release -  http://www.hhs.gov/news/press/2009pres/12/20091215a.html

; DOJ press release-http://www.hhs.gov/news/press/2009pres/12/20091215a.html

Charging for Copying of Medical Records

Here is a great URL that will give you the information per State:


Like Alabama


Section 12-21-6.1 Alabama Code Reproduction

The reasonable costs of reproducing copies of written or typed documents, or reports shall not be more than:

  • One dollar ($1) for each page of the first 25 pages
  • Not more than 50 cents ($.50) for each page in excess of 25 pages
  • A search fee of five dollars ($5)
  • If the medical records are mailed to the person making the request, reasonable costs shall include the actual costs of mailing the medical records
  • A person may charge in addition to the above fees, the actual cost of reproducing X-rays and other special medical records


WAC 246-08-400
  • No more than ninety-six cents per page for the first thirty pages
  • No more than seventy-three cents per page for all other pages
  • The provider can charge a twenty-two dollar clerical fee for searching and handling records
  • If the provider personally edits confidential information from the record, as required by statute, the provider can charge the usual fee for a basic office visit
  • UPDATE: July 2009 through June 2011


South Dakota Administrative Rules

Reimbursement for copies. The maximum reimbursement for copies of provider records is ten dollars for the first ten pages, and thirty-three cents for each additional page.

Military and Debt collections:

Before you take collection actions regarding members of the Armed Services you will want to check out this article published in the Debt3 Commercial Law League of America  http://www.debt3online.com/index.html?page=article&article_id=13. This is a great written article and helps offices understand what they can and cannot do in their efforts to collect debts.


Don't jump to neoplasm codes, when the provider does not state 'neoplasm'

ICD-9 Coding Clinic Vol 23 No 1, 1st Qtr 2006
"When coding a diagnosis documented as a MASS of a particular site and that site is not listed under the main term “MASS,” is it appropriate to look under the term “LESION,” and if not found under “LESION” should we refer to the site in the Table of Neoplasms?

It is incorrect to select a code from the neoplasm table when only the terms “MASS” or “LESION” are used. The coder should follow the cross-references under the main term representing the documented diagnosis. If a final diagnosis is documented as “lump” and there is no index entry for the affected organ or site under “lump” in the index, look up the main term “MASS,” as directed by the “see also” note under the main term “lump.” If there is no index entry for the specific site under “MASS,” look up the main term “disease.” The index directs you to see Disease of specified organ or site for “MASS, specified organ NEC.”

If a final diagnosis is documented as “LESION” and there is no index entry for the specified organ or site under the main term “LESION,” look up the main term “Disease.” The index directs you to see Disease by site for “LESION, organ or site NEC.”

UHC agrees to close Ingenix "reasonable and customary" databases

Private payers' methods of determining "reasonable and customary" payment rates for out-of-network services are destined to change, thanks to a fraud settlement struck by the New York Attorney General's office and UnitedHealthCare.

Specifically, UHC has agreed to close two Ingenix databases widely used by private insurance companies to set their "reasonable and customary" pay rates for out-of-network care. The company will then pay $50 million to open a new, wholly independent non-profit database.

Insurers often promise to cover as much as 80 percent of "reasonable and customary" rates for claims from providers outside their network, according to the attorney general's office. But the investigation found the rate of underpayment by insurers ranged from 10 to 28% for various medical services across the state.

The settlement caps a year-long investigation into Ingenix's operation of the databases, which Attorney General Andrew Cuomo says were rife with conflict of interest. Cuomo's office looked into allegations that the
Ingenix database intentionally skewed "usual and customary" rates downward through faulty data collection, poor pooling procedures, and the lack of audits

According to Cuomo's office, the attorney general "found that having a health insurer determine the 'usual and customary' rate - a large portion of which the insurer then reimburses - creates an incentive for the insurer to manipulate the rate downward."

UnitedHealth officials noted that Ingenix provides data for insurers but does not calculate reimbursement rates. They also said that information is just one tool insurers can use to calculate out-of-network reimbursement. Others include Medicare-based reimbursement rates.

UnitedHealth regrets that conflicts of interest "were inherent" in the databases, said Mitch Zamoff, general counsel for its subsidiary UnitedHealthcare. He said the agreement will "finally and decisively" resolve questions about independence.

The new database will include a Web site that allows consumers to learn in advance how much they may be reimbursed for common out-of-network services in their area.

Cuomo said he hopes to have the new database running in six months, but he concedes that may be an optimistic time frame. Until then, insurers will continue to use Ingenix.

For more information, visit:


OIG today adds a new section to the website on State False Claims Act Reviews. 

As enacted by section 6031 of the Deficit Reduction Act of 2005, section 1909 of the Social Security Act (Act) provides a financial incentive for States to enact false claims acts that establish liability to the State for the submission of false or fraudulent claims to the State's Medicaid program.  If a State false claims act is determined to meet certain enumerated requirements, the State is entitled to an increase of 10 percentage points in its share of any amounts recovered under a State action brought under such a law. 

On August 21, 2006, OIG published a notice in the Federal Register (71 FR 48552 PDF) that sets forth OIG's guidelines for reviewing State false claims acts.  The guidelines invited States to request OIG's review of State laws to determine if the laws meet the requirements of section 1909(b) of the Act. 

So far, OIG has reviewed State laws from California, Florida, Illinois, Indiana, Louisiana, Massachusetts, Michigan, Nevada, Tennessee, and Texas.

For more background information, and links to specific State reviews, go here:


If you own your MRI unit and self refer patients remember you must give then a choice of facilities and you must let them know that you own or are part owner in the MRI facility.

Maryland Ortho Group is being brought to task on this issue:

AAOS files amicus brief on MRI issue in Maryland.

The American Association of Orthopaedic Surgeons (AAOS) has filed an amicus brief in a case involving the Maryland Self Referral Law. The case, Potomac Valley Orthopaedic Associates et al. v. Maryland State Board of Physicians, is an appeal of a declaratory ruling of the Maryland State Board of Physicians (Board). In 2006, 13 years after passage of the Self Referral Law, the Board ruled that physicians could not refer patients for tests to be conducted on magnetic resonance imaging (MRI) equipment that the physician owned or leased. Insurance carriers have since indicated that they will seek refunds from physicians who were paid for such tests conducted in violation of the Self Referral Law. The AAOS argues that the ruling is unnecessary and contrary to a federal policy determination and medical community views. The Board's response is expected in 30 days. A PDF file of the ruling can be viewed at:


Here is what the OIG Compliance Program States:
"III. Limitations on Certain Physician Referrals (‘‘Stark Laws’’) (42 U.S.C. 1395nn) Description of Unlawful Conduct Physicians (and immediate family members) who have an ownership, investment or compensation relationship with an entity providing ‘‘designated health services’’ are prohibited from referring patients for these services where payment may be made by a Federal health care program unless a statutory or regulatory exception applies. An entity providing a designated health service is prohibited from billing for the provision of a service that was provided based on a prohibited referral. Designated health services include: clinical laboratory services; physical therapy services; occupational therapy services; radiology services, including magnetic resonance imaging, axial tomography scans, and ultrasound services; radiation therapy services and supplies; durable medical equipment and supplies; parenteral and enteral nutrients, equipment and supplies; prosthetics, orthotics, prosthetic devices and supplies; home health services; outpatient prescription drugs; and inpatient and outpatient hospital services. New regulations clarifying the exceptions to the Stark Laws are expected to be issued by HCFA shortly. Current exceptions articulated within the Stark Laws include the following, provided all conditions of each exception as set forth in the statute and regulations are satisfied. Exceptions for Ownership or Compensation Arrangements • physician’s services; • in-office ancillary services; and • prepaid plans. Exceptions for Ownership or Investment in Publicly Traded Securities and Mutual Funds • ownership of investment securities which may be purchased on terms generally available to the public; • ownership of shares in a regulated investment company as defined by Federal law, if such company had, at the end of the company’s most recent fiscal year, or on average, during the previous 3 fiscal years, total assets exceeding $75,000,000; • hospital in Puerto Rico; • rural provider; and • hospital ownership (whole hospital exception).
Exceptions Relating to Other Compensation Arrangements • rental of office space and rental of equipment; • bona fide employment relationship; • personal service arrangement; • remuneration unrelated to the provision of designated health services; • physician recruitment; • isolated transactions; • certain group practice arrangements with a hospital (pre-1989); and • payments by a physician for items and services.
Penalty for Unlawful Conduct Violations of the statute subject the billing entity to denial of payment for the designated health services, refund of amounts collected from improperly submitted claims, and a civil monetary penalty of up to $15,000 for each improper claim submitted. Physicians who violate the statute may also be subject to additional fines per prohibited referral. In addition, providers that enter into an arrangement that they know or should know circumvents the referral restriction law may be subject to a civil monetary penalty of up to $100,000 per arrangement. Examples 1. Dr. A worked in a medical clinic located in a major city. She also owned a free standing laboratory located in a major city. Dr. A referred all orders for laboratory tests on her patients to the laboratory she owned. 2. Dr. X agreed to serve as the Medical Director of Home Health Agency, HHA, for which he was paid a sum substantially above the fair market value for his services. In return, Dr. X routinely referred his Medicare and Medicaid patients to HHA for home health services. 3. Dr. Y received a monthly stipend of $500 from a local hospital to assist him in meeting practice expenses. Dr. Y performed no specific service for the stipend and had no obligation to repay the hospital. Dr. Y referred patients to the hospital for in-patient surgery."

For Immediate release Contact: CMS Office of Media Affairs

January 15, 2009 (202) 690-6145



The Centers for Medicare & Medicaid Services (CMS) announced today three national coverage determinations (NCDs) to establish uniform national policies that will prevent Medicare from paying for certain serious, preventable errors in medical care.

The following errors, called “never events,” covered in these NCDs are identified in the National Quality Forum’s (NQF) list of Serious Reportable Events:

                        Wrong surgical or other invasive procedures performed on a patient;

                        Surgical or other invasive procedures performed on the wrong body part; and

                        Surgical or other invasive procedures performed on the wrong patient.

In addition, consistent with current policy for non-covered services, Medicare does not cover any services related to these non-covered services.

“The national coverage policies for certain types of surgical errors are important steps for Medicare in working to reduce or eliminate their occurrence and their associated payments.” said CMS Acting Administrator Kerry Weems. “These policies have the potential to reduce causes of serious illness or deaths to beneficiaries and reduce unnecessary costs to Medicare.”

In 2002, prompted in part by the release of the 1999 Institute of Medicine report titled, “To Err is Human: Building a Safer Health System,” the NQF created a list of 27 never events, which was expanded to 28 events in 2006.


As part of the ongoing implementation of Section 5001(c) of the Deficit Reduction Act (DRA) of 2005, CMS has addressed some of the NQF never events through the Hospital-Acquired Conditions (HACs) provisions in the Inpatient Prospective Payment System (IPPS) final rule for fiscal years (FY) 2008 and 2009.


For discharges occurring on or after Oct. 1, 2008, Medicare will no longer pay a hospital at a higher rate for an inpatient hospital stay if the sole reason for the enhanced payment is one of the selected HACs, and the condition was acquired during the hospital stay. CMS is exploring the feasibility of adapting this policy to its other payment systems.

In the IPPS FY 2008 final rule, CMS selected eight categories of conditions for the HAC list, a number of which were among the 28 never events listed by the NQF and include retained foreign object after surgery, air embolism, blood incompatibility, stage III & IV pressure ulcers, and injuries related to falls and traumatic events such as electric shock and burns.

In the IPPS FY 2009 final rule, CMS added manifestations of poor glycemic control, including hypoglycemic coma, to the list. Hypoglycemic coma is closely related to NQF’s listing of death or serious disability associated with hypoglycemia.

CMS determined that not all conditions included on the NQF list of Never Events should be addressed by the HAC payment provision and therefore determined that the NCD process was appropriate to address coverage for the three types of surgical errors cited above. Unlike the HAC provisions, which affect only payments to hospitals for inpatient stays, these NCDs may affect payment to hospitals, physicians, and any other health care providers and suppliers involved in the erroneous surgeries.

These NCDs are effective immediately, however; implementation instructions for processing such claims will occur at a later date. To view the NCDs, visit:


Wrong body part: www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=222

Wrong patient: www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=221

Wrong surgery performed on a patient: www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=223

CMS offers PQRI PowerPoint.  

CMS has made available a PowerPoint presentation explaining the Physician Quality Reporting Initiative (PQRI), which authorizes a financial incentive for physicians to participate in a voluntary quality reporting program. AAOS worked closely with the AMA Physician’s Consortium for Performance Improvement and the National Quality Forum to develop some of the measures that are included in the program. Eligible professionals who choose to participate and successfully report on a designated set of quality measures for services provided between July 1, 2007 and Dec. 31, 2007 and paid under the Medicare Physician Fee Schedule may earn a bonus of 1.5 percent of their charges during that period, subject to a cap. The PowerPoint presentation and a complete description of the program can be accessed at:


Survey: Physicians find P4P attractive, but doubts remain strong.

According to Government Health IT, a study published in the April/May issue of the journal Health Affairs finds that more than 75 percent of primary care physicians are in favor of pay-for-performance (P4P) programs if quality measures are accurately implemented, yet a majority of doctors have little confidence that they would be. In a survey of 1,168 general internists, only 32 percent supported the public reporting of individual quality scores, and 45 percent supported public reporting of group scores. Many of those surveyed commented that they feared unintended consequences of P4P, stating that a poorly designed program could result in certain undesirable patients being refused care. For more information:


 The abstract of the survey can be viewed at:


House subcommittee holds hearing on Medicare fraud.

The U.S. House Ways and Means Oversight and Health subcommittees held a joint hearing last week on Medicare fraud. Lawmakers estimated that up to 50 percent of $10.8 billion in Medicare overpayments last year may be the result of fraud. One U.S. Attorney recommends that prosecutors pursue both criminal and civil charges in Medicare fraud cases, saying that some perpetrators consider penalties to be a minor “cost of doing business.” Initial testimony is currently available; a hearing transcript will be posted soon. For more information:

http://www.kaisernetwork.org/daily_reports/print_report.cfm?DR_ID=43477&dr_cat=3 and


Must support number of Xray views

Jan 2007 CPT Assistant:
"Besides specifying the involved anatomy, the descriptor nomenclature of the radiology codes includes references to the number (eg, 73140) and/or type of views (eg, 74010) performed. In order to assign and report appropriate CPT code(s), the documentation should reflect the number or type of views taken and the method of examination performed and interpreted.


If the number of views is not mentioned in the report, the coder should not assume the procedure performed. Instead, the coder should work closely with the interpreting physician to clarify and obtain the appropriate information. This will help ensure that all pertinent information has been captured, allowing for submission of the correct procedural CPT code, which reflects the level of work performed. It is the radiologist who should decide ultimately the number of views performed to answer the clinical question at hand.


Please note that policy from the Centers for Medicare and Medicaid Services supports this statement. Medicare Carriers Manual, Section 15021 (E)(1), explains, “Unless specified in the order, the interpreting physician may determine, without notifying the treating physician/practitioner, the parameters of the diagnostic test (eg, number of radiographic views obtained, thickness of tomographic sections acquired, use or non-use of contrast media) [emphasis added].”