Medicare’s new method of calculating payment rates for laboratory tests, intended to reduce Medicare spending by $360 million in the first year, could cost the agency billions in overpayments, according to a recent report from the U.S. Government Accountability Office.
CMS established new payment rates for Medicare Part B laboratory services, effective in 2018. CMS was required under the Protecting Access to Medicare Act of 2014 (PAMA) to base the new rates on private payer data rather than on historical laboratory fees, which were typically higher than the rates paid by private payers. CMS is gradually phasing in reductions to Medicare payment rates, limited annually at 10% from 2018 to 2020, as outlined in PAMA.
Q: How should multiple units of the same HCPCS code given on the same day be listed on the UB-04 (e.g., four units of 97530 in occupational therapy)?
A: Units of the same HCPCS code provided by the same discipline on the same day should be listed on the same line item. In the above example, it would be one line with four units of 97530, and the individual unit charge would be multiplied by four.
On October 12, 2018, the Centers for Medicare & Medicaid Services (CMS) released the 2019 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs. Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and certain other medical and health services not covered by Medicare Part A.
As clinical teams work diligently to educate their residents about the flu, and offer and/or administer the influenza virus (or flu) vaccination to residents, the billing team should ensure that costs for the vaccination are captured and revenue is not left on the table for the billable service.
Medicare Part B pays 100% of flu vaccine costs, including costs associated with its administration. Part D benefits do not cover these costs. Payment is made on a cost basis for the vaccine and is based on the physician fee schedule for the administration. Deductibles and coinsurance do not apply to influenza, pneumococcal, or hepatitis B vaccines.
CMS has confirmed that they are processing claims and eligibility requests with the Medicare Beneficiary Identifier (MBI), showing that providers are successfully using the new number. This week the agency began mailing new Medicare cards to people who live in Wave 6 states, which include Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Texas, Utah, Washington, and Wyoming.
There are multiple data requirements for the UB-04. Each line contains a form locator (FL), and a narrative description is used to label the FL. A “Line” field is used so that you will know which line to use to record the information. For example, a provider should enter its provider name on line 1 in FL 1. It should enter its street address on line 2 in FL 1. The “Type” field identifies whether the data elements are alphabetic characters or numeric characters.
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Once an initial claim determination is made, beneficiaries, providers, and suppliers have the right to appeal Medicare coverage and payment decisions. There are five (5) levels in the Medicare A and B appeals process. Standard appeals give the resident the opportunity to have the SNF's decision that care will not be covered by Medicare reviewed after the care is rendered. Beneficiaries who elect this second appeal option should be cognizant of the possibility of financial liability if the appeal is not successful.
Most audits are conducted in very similar manners. They also determine their focus using very similar techniques. Recovery Audit Contractors (RAC) are announcing their focus for complex reviews on their websites. The main difference between them is what they are specifically looking for. These examples are taken from various real-life scenarios and potential scenarios.