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Regulations
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Medicare Coverage and Reimbursement Rules for the H1N1 Vaccine
Published on line 09/03/2009
Medicare coverage and reimbursement rules for the H1N1 vaccine were recently published in a Medlearn Matters article. All providers administering this vaccine should review this publication and be sure that their billing staffs are aware of this information.
Note that Medicare will pay for seasonal flu vaccinations even if the vaccinations are rendered earlier in the year than normal. We understand that such preparations are critical for the upcoming flu season, especially in planning for the influenza A (H1N1) vaccine.
Please be advised that if either vaccine is provided free of charge to the health care provider, then Medicare will only pay for the vaccine’s administration (not for the vaccine itself).
To access the Medicare information, please click on H1N1 Vaccine
CMS Wrong Surgical Events
Published on line 06/22/2009
Effective January 15, 2009, CMS will not cover a particular surgical or other invasive procedure to treat a particular medical condition when the practitioner erroneously performs: 1) a different procedure altogether; 2) the correct procedure but on the wrong body part; or 3) the correct procedure but on the wrong patient. Medicare will also not cover hospitalizations and other services related to these non-covered procedures as defined in the Medicare.
Below are two recent Medicare Transmittals, which details appropriate modifiers to use, national indicators, and such. Please click on the title to access the information -
Part B Non-Covered Codes
Published online 04/22/2009
Trailblazer Health has published a list of national non-covered CPT and HCPCS codes. This list contains codes for such areas as devices, laboratory procedures, drugs/biologicals, surgical/medicine procedures, and evaluation/management (E/M) services. To access the list, please click on Non-Covered Codes. The list may also be found on the Trailblazer Health website under the publications page, in the job aid section.
Consultation Services Update
Re-Published online 02-14-2008
Centers for Medicare and Medicaid Services (CMS) and the Office of Inspector General (OIG) recently clarified the requirements for consultation services. The revised policy addresses when and by whom the initial Consultation may be reported. By definition, a Consultation services is distinguished from other evaluation and management (E/M) visits because it is performed by a physician or a qualified non-physician practitioner (NPP) whose opinion or advice regarding a specific condition is requested by another physician or other appropriate source. Please remember the receiving provider (consultant) does not decide if the service is a consult. The requesting provider determines the service, based on whether a consult or transfer of care for a specific condition is needed.
A transfer of care occurs when a qualified provider requests that another qualified provider take over the responsibility for managing the patient's complete care of the condition and does not expect to continue treating or caring for the patient for that specific condition. IN a transfer of care the receiving provider would report the service with the new or established patient visit codes according to the place of service and the level of service performed and shall not report a consultation service.
Documentation requirements state a written request for a consultation from an appropriate source and the need for a Consultation (i.e., the reason for the consultation) must be documented in the patient's medical record. The initial request may be a verbal interaction between the requesting provider and the consulting provider; however, the verbal conversation must be documented in the patient's medical record, indication a request for a consult was made by the requesting provider. The reason for the consultation must be documented by the consultant in the patient's medical record and included in the requesting provider's plan of care.
A written report regarding the Consultation must be furnished to the requesting provider. In the inpatient/outpatient setting in which a medical record is shared, the request and report may be documented in the progress notes. The request for the consultation may also be documented in the physician's orders when a medical record is shared. In the office setting, the documentation requirement must be met by a specific written request for the consultation and a written report documenting the communication back to the requesting provider.
Several consultation services were deleted by the American Medical Association (AMA) in 2006. Follow-up inpatient consultation codes 99261 - 99263 no longer exist. Therefore, follow-up consultations are now to be reported utilizing the subsequent daily care codes 99231 - 99233. Confirmatory consults were also deleted in 2006. A patient is not allowed to request a confirmatory consult or 'second opinion'. If a patient seeks out a second opinion, report those services using either new or established E/M visit codes.
Also clarified in the policy revision is the use of NPPs for split/shared visits with the physician. The NPP or physician may not perform or report a consult utilizing a split/shared visit. If the NPP chooses to perform a consultation, the service must be billed under the NPI of the NPP.
For the complete report from CMS, please click on Transmittal 788. for the complete report from the OIG, please click on Consultations in Medicare.
Section 15016, Supervising Physicians in Teaching Settings
CMS revised
section 15016 of the Medicare Carriers Manual to clarify the documentation
requirements for evaluation and management (E/M) services billed
by teaching physicians. The revised language makes it clear that
for E/M services, teaching physicians need not repeat documentation
already provided by a resident. In addition, the revisions clarify
policies for services involving students and other issues and update
regulatory references. Go to the program transmittal now -
Updated
Section 15016 - January 13, 2006
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