Recent News

CMS to Cover Transcatheter Mitral Valve Repair Under CED

The Centers for Medicare & Medicaid Services announced August 7 in a decision memo for coverage of transcatheter mitral valve repair (TMVR) that “there is promising but inconclusive evidence whether TMVR improves health outcomes for a defined subset of the Medicare population.”

In light of a national coverage analysis, initiated November 2013, CMS will cover TMVR under Coverage of Evidence (CED) for the treatment of significant symptomatic degenerative MR when furnished according to FDA-approved indications and several other conditions are met (please see the decision memo for details).

MR, according to the decision memo, is the most common type of heart valve insufficiency in the United States. The mitral valve comprises two valve leaflets. MR occurs when these leaflets do not close properly, allowing blood to flow from the left ventricle back into the left atrium. This causes the heart to work harder to pump blood through the body, slowly increasing the size of the left ventricle, and potentially leading to heart failure.

Symptoms can include shortness of breath, fatigue, lightheadedness, cough, heart palpitations, swollen feet or ankles, and excessive urination.

Treatment for TMVR involves reducing MR by clipping together a portion of the mitral valve leaflets. To date, the only U.S. Food and Drug Administration (FDA) approved device is the Abbott Vascular’s MitraClip®.

CMS received 83 comments during the 30-day comment period following the May 15 proposed decision memo. In general, CMS said commenters support coverage of TMVR with CED for FDA-approved indications with specific conditions, and also support coverage of TMVR for non-FDA-approved indications in a clinical study.

Stay tuned for further coding and billing education.

August 11th, 2014

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What To Do When Your Patient Is a “Poor Historian”

Clear and comprehensive documentation is a critical element in getting claims paid. You hear that advice day in and day out. So what do you do when the provider is unable to obtain a critical component of documentation from a patient? The answer isn’t as tricky as you might think.

When a provider is unable to obtain certain medical information, he or she should clearly document in the record:

  • The components that were unobtainable (for example, the history of present illness (HPI); and
  • Circumstances that precluded obtaining the specific documentation. For example, “The patient was unconscious.” Or, “The patient was a ‘poor historian’ due to advanced dementia.”

Before giving up the ship, however, the provider should attempt to obtain the information from another source, such as a family member, spouse, medical record, etc. If these sources were unable to supply the missing information, the attempt should be documented as well. For example:

  • “A family member was contacted, but unable to provide additional information.” Or,
  • “The medical record did not contain the needed information.”

If, at a later time, the patient or some other source is able to supply the missing information, the provider may add an addendum to the record to fill in the missing blanks that support medical necessity for the provided services.

Resource: The Centers for Medicare & Medicaid Services 1995 and 1997 Documentation Guidelines for Evaluation and Management Services

August 8th, 2014

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Don’t Be Caught Unprepared: How to Respond to a Search Warrant

Advance preparation, including an action plan should government agents serve your practice or facility with a search warrant, is the most important thing you can do to respond to government investigations. When possible, designate a single individual within the organization to coordinate your response, in such circumstances. Specific steps you should take, if served with a search warrant, are:

  • Immediately contact your attorney.
  • Avoid any action that might be misconstrued as obstructing a search. Be aware, however, that there is a limit to the cooperation you must provide.
  • Ask for a copy of the search warrant and give it to your lawyer and verify the scope of the subpoena or search warrant. The scope of an agent’s search or seizure is limited to the scope declared in the subpoena or warrant.
  • You cannot refuse to cooperate with a subpoena or warrant, but do not volunteer any document or information that is not specified in the subpoena or search warrant.
  • Make it known throughout your internal policies and procedures that an employee is not authorized to provide confidential documents of the facility to anyone, including a law enforcement officer, without a valid subpoena, search warrant, or court order.
  • A search warrant is for documents (hard copies and electronic copies), not for testimonial evidence. Although a search warrant can be used to seize documents or other items, it cannot be used to force employees to participate in an interrogation.
  • Alert the agent’s if searched items or areas are not listed specifically in warrant. An agent is not allowed to access any document or property other than those described in the subpoena or warrant.
  • Identify Potentially Privileged Materials. A search warrant does not authorize the seizure of privileged materials, including attorney-client privileged materials.
  • As the search is taking place, maintain an inventory of all that is being seized.
  • Request copies of the medical records (or other documents) being seized, to provide for continued patient care.

The above list is not all-inclusive, but provides a starting point for preparation. Be sure to consult your healthcare attorney for further guidance.

August 7th, 2014

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Best Practice for Speeding Up Claims Payment

You can improve the turnaround time it takes to get claims paid by avoiding this common billing taboo: Don’t report the same procedure code on multiple lines to account for units of service.

There’s a more efficient billing method that will help your correctly coded claims sail through adjudication. The keys to success are Medically Unlikely Units (MUE) and modifiers.

MUEs indicate what the Centers for Medicare & Medicaid Services (CMS) considers the maximum units of service that a provider would report under most circumstances for a single beneficary on a single date of service. And modifiers identify extenuating circumstances.

When you take MUEs and modifiers into account, you can report a procedure code on one line with multiple units (up to the MUE limit), and report subsequent units on additional lines using the appropriate modifier.

For example, if you were billing for a pathology exam on three breast biopsy specimens, you would report on one line CPT® code 88305 and 3 units, rather than three lines of 88305 with 1 unit each.

Taking this one step further, let’s say you have five units of 88305 to report and the MUE is three. Correct billing would be to report one line of 88305 with 3 units and one line of 88305-91 with 2 units. Modifier 91 Repeat clinical diagnostic laboratory test overrides the MUE, and reporting the multiple units on just two lines (instead of five) prevents a denial based on duplicate reporting.

The Centers for Medicare & Medicaid Services (CMS) posts the MUEs on their website.

Source: UnitedHealthcare Medicare Solutions

August 6th, 2014

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ICD-10 Tips and Resources: Featured Resources

Quick Reference for Asthma

The Asthma Quick Reference Guide is a tool that can be used to show the documentation points necessary to assist providers with the necessary documentation points for asthma in ICD-10-CM. It is in pdf form that can be copied and shared with anyone.

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