OPBS News

CMS TRAINING WORKSHOP

2011-09-02T09:07:00.004-05:00

We would like to encourage you to attend the upcoming "Navigating Medicare in 2011" workshop taking place October 11, 2011, in San Antonio, TX. The Provider Outreach and Education Team at CGS, your Jurisdiction C DME MAC Contractor, is spearheading this educational event. They will provide in-depth information on compliance, documentation and LCDs specific to orthotics and prosthetics. Documentation examples and scenario-based learning will be a part of various breakout learning sessions. Attendees will have the opportunity to get questions answered throughout the day and network with other providers.

If you are a Medicare provider of orthotics and prosthetics equipment, this one-day workshop will benefit your business. The registration fee covers your registration materials, continental breakfast, lunch and beverages for the day.

Registration information can be found by clicking on the following link:
https://www.cgsmedicare.com/jc/education/workshops.html

If you have any qestion please contact
Cathie Pruitt
901-753-8441

CMS Announces National Version 5010 Testing Day

2011-06-02T09:48:00.003-05:00

The Version 5010 compliance date – Sunday, January 1, 2012 – is fast approaching. All HIPAA-covered entities should be taking steps now to get ready, including conducting external testing to ensure timely compliance.

Medicare encouraged all trading partners to get ready for testing to gain a better understanding of MAC testing protocols and the transition to Version 5010. You are encouraged to begin working with your MAC now to ensure timely compliance. Note that successful testing is required before a trading partner may be placed into production.

CMS announced a National 5010 Testing Day to be held Wednesday, June 15, 2011.

F.Y.I Medicare Fee

2011-04-18T14:14:00.003-05:00

Effective March 25, 2011

Medicare will charge a fee of 500.00 for all new location and re-enrollment applications. Please correct any changes to your location. If your number is deactivated you will have to pay the new 500.00 to re-activate your number.

FYI-BE AWARE!

2011-03-10T15:07:00.004-06:00

The OPBS teams wants you to BE AWARE! Make sure to cross reference your EOB'S with your contracted rates. We have found that some insurance company's are not paying you at the correct reimbursement.

Timely Filing Requirements for Medicare Fee-For-Service Claims

2011-01-25T10:23:00.004-06:00

On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act.Which amended the time period for filing Medicare fee-for-service claims as one of many provisions aimed at curbing fraud, waste, and abuse in the Medicare program.The timely filing requirements is to reduce the maximum time period for submission of all Medicare claims to one calendar year after the date of service.

Under the new law, claims for services furnished on or after January 1, 2010, must be filed within one calendar year after the date of service. The following rules apply to claims with dates of service prior to January 1, 2010. Claims with dates of service October 1, 2009, through December 31, 2009, must be submitted by December 31, 2010. At this time, no exceptions have been established.

Medicare policy for therapeutic shoes and inserts

2010-12-06T11:48:00.007-06:00

Effective 1/1/2011
An M.D. or D.O. must be managing the patient's diabetes under a comprehensive plan of care and must certify that the patient needs therapeutic shoes and the certifying physician must document that the patient has one or more of the following qualifying conditions:
- Foot deformity
- Current or previous foot ulceration
- Current or previous pre-ulcerative calluses
- Previous partial amputation of one or both feet or complete amputation of one foot
- Peripheral neuropathy with evidence of callus formation
- Poor circulation

The following documentation is required in order for Medicare to pay for therapeutic shoes and inserts and must be provided by the physician to the supplier, if requested:

1. A detailed written order. This can be prepared by the supplier but must be signed and dated by you to indicate agreement.

2. A copy of an office visit note from your medical records that shows that you are managing the patients diabetes. This note should be within 6 months prior to delivery of the shoes and inserts.

3. Either(a)a copy of an office visit note from your medical record that describes one of the qualifying conditions or (b) an office visit note from another physicians (podiatrist) or form a PA, NP, or CNS that describes one of the qualifying conditions. If option (b) is used, you must sign, date, and make a note on that document indicating your agreement and send that to the supplier. The note documenting the qualifying condition(s) must be more detailed that the general descriptions that are listed above.

4. A certification form stating that the coverage criteria described above have been met. This form will be provided by the supplier but must be completed, signed, and dated by you after the visits described in #2 and 3. If option 3(b) is used, that visit note must be signed prior to or at the same time as the completion of the certification form.

CMS ANNOUNCED

2010-09-30T09:21:00.004-05:00

CMS announced if you have had any enrollement with Medicare within the last 5 years, you are already enrolled in Pecos. Phase two will began January 3, 2011. If you are not enrolled with Pecos your claims will be rejected.

CMS has annoounced ICD-10 will began December 31, 2010 and it will end October 1, 2013. For more information you can go to www.cms.gov/icd10.com

SEARCH PECOS DATABASE THE EASY WAY!

2010-07-01T08:38:00.002-05:00

PECOS WEBSITE

Click below:

www.oandp.com

TOP LEFT HAND CORNER SHOULD SAY SEARCH PECOS

PECOS Implementation Date Moved Up to July 6, 2010

2010-06-08T08:42:00.002-05:00

The Centers for Medicare and Medicaid Services (CMS) has published a change to the date by which referring physicians must have active accounts in the Provider Enrollment Chain and Ownership System (PECOS), from January 3, 2011 back to July 6, 2010. According to Jim Bossenmeyer from CMS, the earlier implementation date is a requirement of provisions contained in the Patient Protection and Affordable Care Act (PPACA) passed earlier this year.

In order for a physician's or other qualified healthcare practitioner's referral or order to be considered valid for Medicare claim submission purposes, it must come from a provider with a current PECOS enrollment record.

Originally scheduled for implementation on January 4, 2010, the PECOS requirement has been delayed several times in order for CMS to develop proper system edits to properly enforce it. While Mr. Bossenmeyer stated in a May 26, 2010 CMS Open Door Forum that PECOS system edits may not be fully functional by July 6, CMS reserves the right to reprocess claims that should not have been paid due to an invalid referral once the edits are fully functional. This means that you may still get paid for claims with an invalid referral, however your DME MAC may come back later and request a refund.

The four DME MACs are continuing to generate warning notices when services are referred by physicians who do not have a current PECOS record. If you receive one of these notices, you need to first check that the provider information submitted on your claim included the provider's correct individual NPI number and name. The name must be in all capital letters and match what the physician entered in the NPI registry system. The referral physician's name on the claim information should not contain credentials (e.g. MD), titles, or punctuation, except for the hyphen in hyphenated names, and must not be a nickname (e.g. use Robert, not Bob).

Spinal Orthoses: TLSO and LSO - Policy Article - Effective July 2010

2010-04-21T14:50:00.003-05:00

The Coding Guidelines section of the Policy Article states:

Effective for claims with dates of service on or after July 1, 2010, the only products that may be billed using codes L0450, L0454-L0472, L0488-L0492, L0625-L0628, L0630, L0631, L0633, L0635, L0637, and L0639 for prefabricated orthoses are those that are specified in the Product Classification List on the Pricing, Data Analysis, and Coding (PDAC) contractor web site at https://www.dmepdac.com/dmecsapp/do/search.

There are two categories custom fabricated spinal orthoses (codes L0452, L0480-L0486, L0629, L0632, L0634, L0636, L0638, and L0640):

Orthoses that are custom fabricated by a manufacturer/ central fabrication facility and then sent to someone other than the patient. Effective for claims with dates of service on or after July 1, 2010, these items may be billed using one of these codes only if they are listed in the Product Classification List on the PDAC web site.
Orthoses that are custom fabricated from raw materials and are dispensed directly to the patient by the entity that fabricated the orthosis. These items do not have to be listed on the PDAC web site in order to be billed using a custom fabricated spinal orthosis code. However, the supplier must provide a list of the materials that were used and a description of the custom fabrication process on request.
Effective for claims with dates of service on or after July 1, 2010, prefabricated spinal orthoses and spinal orthoses that are custom fabricated by a manufacturer / central fabrication facility which has not received coding verification review from the PDAC must be billed with code A9270.

The Coding Guidelines section of the Policy Article states:

Effective for claims with dates of service on or after July 1, 2010, the only products that may be billed using codes L0450, L0454-L0472, L0488-L0492, L0625-L0628, L0630, L0631, L0633, L0635, L0637, and L0639 for prefabricated orthoses are those that are specified in the Product Classification List on the Pricing, Data Analysis, and Coding (PDAC) contractor web site.

There are two categories custom fabricated spinal orthoses (codes L0452, L0480-L0486, L0629, L0632, L0634, L0636, L0638, and L0640):

Orthoses that are custom fabricated by a manufacturer/ central fabrication facility and then sent to someone other than the patient. Effective for claims with dates of service on or after July 1, 2010, these items may be billed using one of these codes only if they are listed in the Product Classification List on the PDAC web site.
Orthoses that are custom fabricated from raw materials and are dispensed directly to the patient by the entity that fabricated the orthosis. These items do not have to be listed on the PDAC web site in order to be billed using a custom fabricated spinal orthosis code. However, the supplier must provide a list of the materials that were used and a description of the custom fabrication process on request.
Effective for claims with dates of service on or after July 1, 2010, prefabricated spinal orthoses and spinal orthoses that are custom fabricated by a manufacturer / central fabrication facility which has not received coding verification review from the PDAC must be billed with code A9270.

PLEASE VISIT CIGNA GOVERNMENT SERVICES FOR MORE DETAILS @ cignagovernmentservices.com

PECOS REJECTIONS DELAYED

2010-02-19T09:14:00.006-06:00

CMS has just announced a new implementation date for PECOS rejections of January 3, 2011. CMS announced this delay yesterday. Prior to this announcement CMS maintained that implementation of rejections would begin to occur on April 4, 2010 for any services ordered by physicians who are not in PECOS. Suppliers will continue to get warnings on their remittance notices when your referring physician is not in PECOS, but claim rejections will not happen until next year. At some point during 2010, CMS will send letters directly to any physician not in PECOS, telling them that they must reenroll or they will not be able to make referrals. CMS staff also has indicated that the PECOS system will become available for DMEPOS supplier enrollment some time in 2010. We will notify you of any new information as it is announced.

Medicare 2010 Claim Alert

2010-01-06T09:47:00.001-06:00

CMS has issued a notice stating that claims submitted between January 1, 2010, and January 15, 2010, for 2010 dates of service will be held pending final review of the Medicare Physician Fee Schedule (MPFS). CMS will release claims for payment on January 19, 2010.

Claims for dates of service on or before December 31, 2009, will be processed and paid under normal procedures.

PECOS REQUIREMENT

2009-12-15T09:08:00.002-06:00

CMS' January 4, 2010 deadline requiring physicians to be registered with PECOS in order to write a valid prescription. No registration would result in no reimbursement to the O and P facility providing services under the unregistered physician's prescription. CMS agreed to delay implementaion until April 1, 2010 and promised that the PECOS physician regisrty will be on line before the program goes into effect.
The effective date was postponed to provide time to educate physicians and facilities the requirements.

CMS/PECOS REQUIREMENTS FOR ALL DME MACs

2009-11-04T11:30:00.016-06:00

This article was revised on September 14, 2009, to add clarifying language to emphasize that billed services requiring an ordering/referring provider on the claim must contain the ordering/referring provider under both phases of this change or the claim will not be paid.

This article is based on change request which requires Medicare implementation of system edits to assure that DMEPOS suppliers bill for items or services only when those items or services are ordered or referred by physician and non-physician practitioners who are eligible to order/refer such services.Physician and non-physician practitioners must be enrolled in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and of the type/specialty eligible to order/refer services for Medicare beneficiaries. Be sure billing staff are aware of these changes that will impact DMEPOS claims received and processed on or after October 5, 2009.

The two phases are list below:

During Phase 1 (October 5, 2009-January 3, 2010):
If the ordering/referring provider is on the claim, Medicare will verify that the ordering/referring provider is in PECOS and is eligible to order/refer in Medicare. If the ordering/referring provider is not in PECOS or is in PECOS but is not of the type/specialty to order or refer, the claim will continue to process.

1. If the DMEPOS supplier claim is an ANSI X12N 837P standard
electronic claim, the DMEPOS supplier will receive a warning
message on the Common Electronic Data Interchange (CEDI)
GenResponse Report.
2. If the DMEPOS supplier claim is a paper CMS-1500 claim, the
DMEPOS supplier will not receive a warning and will not know that
the claim did not pass these edits.

During Phase 2, (January 4, 2010 and thereafter):
If the ordering/referring provider is not on the claim, the claim will not be paid. If the ordering/referring provider is on the claim, Medicare will verify that the ordering/referring provider is in PECOS and eligible to order and refer. If the ordering/referring provider is not in PECOS or is in PECOS but is not of the specialty to order or refer, the claim will not be paid. It will be rejected.

Below is a link found that might help in checking if a physician is enrolled in PECOS… it looks like this is a list of providers who accept assignment. Please play around with it and see what you find.
We suggest that you select a few with the green symbol beside them and personally call and ask if they are PECOS enrolled. Please let us know your feedback and the results from your phone calls. CLICK HERE TO FIND OUT IF YOUR PHYSICIANS IS ENROLLED IN PECOS

Upcoming Changes to the Orthopedic Shoe Policy

2009-10-07T11:04:00.001-05:00

Beginning October 1 each claim line for orthopedic shoes must include the KX or the GY modifier. If the items you are providing meet the coverage criteria set forth in the policy, each claim line would include a KX modifier. If an item does not meet the coverage criteria or is a non-covered item (i.e. shoes not attached to a brace) the claim line must include the GY modifier and this claim line will be denied. Therefore, each shoe, insert or modification must include either the KX or the GY modifier. If a claim line doesn't include a modifier, then that line will be rejected and you will have to resubmit that claim line with the appropriate modifier.

Medicare/Consignment Closets

2009-09-04T14:29:00.003-05:00

The Centers for Medicare & Medicaid Services (CMS) has announced changes to the compliance standard for consignment closets and stock and bill arrangements. In such arrangements, “an enrolled supplier of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) maintains inventory at a practice location which is not owned by the enrolled DMEPOS supplier, but rather, owned by a physician, non-physician practitioner or other health care professional for the purpose of distribution,” according to CMS. The changes are effective March, 2010.

Although most consignment closet or stock and bill arrangements do not satisfy the DMEPOS supplier standards, CMS has identified a limited arrangement that may be permissible. This scenario involves a DMEPOS supplier selling DMEPOS items to the practice of the physician or other non-physician practitioner, and the billing and furnishing of a DMEPOS item(s) would be done by the physician or non-physician practitioner, each arrangement will be evaluated on a case by case basis. The CMS wants to ensure that beneficiaries are aware that the enrolled supplier who has billed Medicare on their behalf has furnished their DMEPOS item(s).

New Prothetics Bill signed in Iowa

2009-07-30T13:05:00.005-05:00

Governor Chet Culver of Iowa signed a bill that prosthetic devices must be covered by insurance, if they are medically necessary. The health insurance mandate affects only state-regulated health insurance policies - which means plans held typically by smaller businesses and individuals. Larger companies' insurance plans are typically regulated by the federal government.

Protect your Practice from Recovery Audit Contractor's (RAC).

CMS will continue with the implementation of the RAC( Recovery Audit Contractors) program. By 2010, CMS plans to have 4 RAC's in place. Each RAC will be responsible for identifying overpayment and underpayments in approximately 1/4 of the country. The RAC demonstration program has proven to be successful in returning dollars to the Medicare trust funds and identifying monies that need to be returned to providers. It has provided CMS with a new mechanism for detecting improper payments made in the past, and has also given CMS a valuable new tool for preventing future payments. You may visit CMS website at http://www.cmshhs.gov/ for more information.

Confused About Billing?

2009-06-18T10:12:00.010-05:00

Billing & Coding Workshop Designed Specifically for O & P Facilities

This Workshop is Presented by CARIS Innovation, Inc.
&
O & P Billing Solutions, Inc.

Date of Workshop: November 18, 2009
Session 1: 8:30 am - 12:00 pm
Session 2: 1:00 pm - 4:30 pm

Continuing Education Credits: 3.5

Location:
Holiday Inn Express and Suites
309 St. Hwy 114 West
Grapevine, TX 76051

Click link below to download your register form for this Workshop!

Workshop Registration Form

Accreditation Mandatory

2009-05-05T15:51:00.003-05:00

Effective May 4, 2009

Medicare liability insurance requirments, which currently are $300, 000. This clarification would change that to 300,000 per incident and would require that such liability insurance be obtained prior to submitting an enrollment application. Since Medicare requires that it be able to verify the insurance not only with the insurance agent but also with the underwriter, it means that there may be a significant delay between the time the insurance application is approved and the time that the supplier may submit a Medicare enrollment application. There is often a lag of several months between insurance and notification of the underwriter.

Effective Oct 2, 2009

The mandatory accreditation date for individual facilities will vary, depending on whether or not your facility already has an NPI number and is enrolled to provide Medicare services. For DME facilities that already have an NPI and Medicare TPAN number, accreditation is not required until October 2, 2009. New DME facilities, including new branch offices of existing facilities, must become accredited before they can submit their application for a PTAN number to the National Suplier Clearinghouse.

Changes in DME MAC Medical Policy

2009-04-08T09:37:00.021-05:00

The DME MAC's have announced and released the following changes .

AFO/KAFO, KO, TLSO/LSO Policy
Medicare made the decision that the elastic braces and code L2770 are no longer a covered benefit. Medicare has added the following new diagnosis codes ICD-9 844.2 and 996.40 - 996.49, these codes will be acceptable for the following braces L1830, L1832, L1834, and L1843-L1846. KX modifier will need to be added to the base code and any additional codes used. The new CG Modifier should only be used when providing a flexible LSO/TLSO made of non-elastic material or it should have a solid posterior panel.