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Find news and solutions for healthcare payers and providers. Recognize and avoid potential fraud, waste, and abuse scenarios. Real-time clinical claim editing are analyzed to maximize provider reimbursements.

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Medicare Advantage Plans Under the FWA Microscope

  • Margaret Klasa DC, APN BC
  • Jun 29, 2017
  • Comments

HEALTHCARE  is again the most popular topic for the past few weeks.  Even friends that don’t know much about the industry have asked: what’s going on with Medicare?  Apparently, recent allegations of high dollar medical fraud have raised concerns about Medicare Advantage Plans and Payment Integrity.  One law firm pointed out that this is just the start.  “DOJ’s big settlement — $16.7 million for risk adjustment “upcoding” ...

FWA, Waste and Abuse, Fraud, healthcare, payment integrity,

Payers Use UCR Data to Drive Behavioral Health Outcomes

  • Margaret Klasa DC, APN BC
  • May 10, 2017
  • Comments
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Context's UCR data can help with Behavioral Health population health management. Behavioral Health issues compound the chronic condition scenario. The United States spends more on mental health and addiction than on any other medical condition including heart disease, trauma, and cancer.

population health, UCR, population management, behavioral health,

Payment Integrity and ACO Success

  • Margaret Klasa DC, APN BC
  • Apr 27, 2017
  • Comments
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An ACO must show that the care given to the patient has achieved its quality measures.

Reference Based Pricing, ACO,

CodeLink Pro ® 2017 Now Boasts Medical Necessity with Bill Editing

  • Margaret Klasa DC, APN BC
  • Apr 13, 2017
  • Comments
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Context4 Healthcare is proud to announce that its flagship CodeLink Pro® medical coding compliance solution CodeLink Pro® 2017 has been enhanced

Why Your EHR System Might Get You Audited: ICD-10 Dropdown Menu Fails

  • Margaret Klasa DC, APN BC
  • Mar 15, 2017
  • Comments
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Most EHR systems have drop-down menus in which ICD-10 code choices or search returns are in numerical order where say the fifth digit of 0 – indicating unspecified – is the first return or choice, while the more specific choices are farther down the list. Physicians are often picking the first code that appears in the drop-down menu therefore claims may be at risk due to continuous submission of unspecified diagnoses.

EHR coding, EHR coding issues, EHR coding risk, medical coding, ICD 10, ICD-10,

RAC Ramp Up for 2017

  • Margaret Klasa DC, APN BC
  • Feb 27, 2017
  • Comments

The five regional Recovery Audit Contractors (RACs) are ramping up their automated and complex reviews starting this month. The Centers for Medicare & Medicaid (CMS) Medicare Fee for Service (FFS) audit program awarded contracts in October 31, 2016 ....

healthcare, rac audit, healthcare compliance, program integrity, CMS audit, medicare, medicaid, FFS, FFS audit,

New HCPCS Modifiers for 2017 Impact Reimbursement Rates

  • Margaret Klasa DC, APN BC
  • Dec 05, 2016
  • Comments
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The Centers for Medicare & Medicaid Services (CMS) has established 2 new HCPCS modifiers that will affect reimbursement rates for the year 2017. The first new HCPCS modifier is FX, which is X-ray taken using film. The Consolidated Appropriations Act of 2016 (Section 502(a)(1)) Medicare Payment Incentive for the Transition from Traditional X-Ray Imaging to Digital Radiography and Other Medicare Imaging Payment Provision amends the Social Security Act by reducing the payment amounts under th ...

ICD-10 Grace Period: The End is Near

  • Margaret Klasa DC, APN BC
  • Aug 05, 2016
  • Comments

On October 1, 2016, the joint initiative between the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA), also known as the “grace period” will come to an end. The one year “grace period” allowed unspecified ICD-10-CM codes to be submitted on Medicare Part-B physician claims. The grace period was created to help ease the transition from ICD-9 to ICD-10 coding systems for physicians. While Medicare required the correct level of ICD- ...

MACs Revise LCDs Due to ICD-10 Errors Reported After Transition Date

  • Margaret Klasa DC, APN BC
  • Nov 19, 2015
  • Comments

The October 1, 2015, ICD-10 mandated code change caused some issues for 8 of the 12 Medicare Jurisdictions that impact at least 32 states. Some of the Medicare Administrative Contractors (MACs) relied on the General Equivalence Mappings (GEMs) to map ICD-9 to ICD-10 codes, which was insufficient for the Local Coverage Determinations (LCDs). Most of the GEM mappings provide unspecified codes and where ICD-9 LCDs relied on exact codes the GEM mappings are unspecified. The announcement by the Cent ...

Outsourced Coding Vendors Face ICD-10 Challenges Related to Transition

  • Margaret Klasa DC, APN BC
  • Oct 29, 2015
  • Comments

The October 1, 2015 implementation date for ICD-10 has finally come and gone. While many industry experts had predicted complete chaos, shut-downs and major loss of productivity, as we enter the last week of October, only some of those predictions have come to fruition. It has been extremely quiet on both the provider and payer ends in the month of October. Some have even suggested that all these predictions of doom have come to resemble the Y2K nightmare that never materialized. Or it could be ...

Worker’s Compensation, PC Providers & Insurers to Use ICD-9 & ICD-10

  • Margaret Klasa DC, APN BC
  • Sep 28, 2015
  • Comments

October 1, 2015, and beyond will certainly bring on the challenges for both providers and payers – from revenue cycle complications to compliance and technical issues that will be a hurdle to overcome on both ends of the payer and provider sides. Some segments of the insurance industry are not required to follow suit and transition to the new ICD-10 coding set, however that does not mean they will be untouched by this transition and will spend an increased amount of time sorting and ident ...

WEDI Survey Reveals That Half of Physicians Are Not Ready for ICD-10

  • Margaret Klasa DC, APN BC
  • Aug 14, 2015
  • Comments

The results from The Workgroup for Electronic Data Interchange ( WEDI ) 2015 ICD-10 Industry Readiness Survey are in. WEDI surveyed payers, providers, and vendors and has identified that only about 20 percent of physician practices surveyed have started or completed external testing and less than 50 percent responded that they were ready or would be ready for Oct. 1, 2015. “The survey results are based on responses from 621 respondents, consisting of 453 providers, 72 vendors and 96 heal ...

ICD-10 Testing & Training Procrastination: 98 Days Until the Deadline

  • Margaret Klasa DC, APN BC
  • Jun 25, 2015
  • Comments

Do you ever have that nightmare where you are back at school, sweating at your locker trying to find your school books to study for the test that is coming up in minutes and then the bell rings and you wake up? Providers, are you having that nightmare now about the ICD-10 code transition? Are you secretly deep down inside crossing your fingers that there will be a delay or some type of miracle at the last minute so that you don’t have to worry about it? Well, unfortunately, even with a c ...

Context 4 Healthcare, Inc. Can Solve Your GEM of an ICD-10 Problem

  • Margaret Klasa DC, APN BC
  • Feb 20, 2015
  • Comments

Most healthcare professionals - from vendors to coders to physicians - are concerned about one aspect of the upcoming, mandated transition to the ICD-10 code set slated for October 1, 2015. A growing consensus across the healthcare industry is that the commonly used General Equivalence Mappings (GEMs ) files, published by the Centers for Medicare & Medicaid Services (CMS), are not enough to ensure accurate and appropriate results between ICD-9 and ICD-10 codes. Both in forward and reverse m ...

U.S. House Committee to Hold ICD-10 Implementation Hearing Today

  • Margaret Klasa DC, APN BC
  • Feb 11, 2015
  • Comments

The U.S. House Energy and Commerce Committee ’s subcommittee on healthcare is holding a hearing on ICD-10 implementations today, Wednesday, February 11, 2015. The Subcommittee on Health, chaired by Rep. Joe Pitts (R-PA), titled this meeting, “Examining ICD-10 Implementation” and subcommittee members will hear from a number of ICD-10 stakeholders. This subcommittee has been working with the Centers for Medicare and Medicaid Services ( CMS ) for several months to ensure this de ...

U.S. House Committee to Hold ICD-10 Implementation Hearing on Feb 11th

  • Margaret Klasa DC, APN BC
  • Feb 06, 2015
  • Comments

The U.S. House Energy and Commerce Committee ’s subcommittee on healthcare will hold a hearing on ICD-10 implementations on Wednesday, February 11, 2015. The Subcommittee on Health, chaired by Rep. Joe Pitts (R-PA), titled this meeting, “Examining ICD-10 Implementation” and subcommittee members will hear from a number of ICD-10 stakeholders. This subcommittee has been working with the Centers for Medicare and Medicaid Services ( CMS ) for several months to ensure this deadlin ...

CMS Announcement - Holding of 2015 Date-of-Service Claims - MPFS

  • Margaret Klasa DC, APN BC
  • Dec 30, 2014
  • Comments

While the Compliance Edge blog is typically reserved for original content authored by Margaret Klasa, DC, APN, Bc, at times, we will re-post industry news or announcements that are relevant to our customer base. Holding of 2015 Date-of-Service Claims for Services Paid Under the 2015 Medicare Physician Fee Source: MLN Connects™ Provider e-News Monday, December 29, 2014 On November 13, 2014, the CY 2015 Medicare Physician Fee Schedule (MPFS) final rule was published in the Federal Regi ...

New Anti-Fraud Safeguards Under ACA Impact Medicare Billing Privileges

  • Margaret Klasa DC, APN BC
  • Dec 16, 2014
  • Comments

  As a result of new anti-fraud measures under the Affordable Care Act (ACA), the Centers for Medicare & Medicaid Services (CMS) finalized a policy on December 3, 2014 which would revoke or deny Medicare billing privileges from providers that routinely bill for services that do not meet Medicare requirements. This 140 page rule will stop providers from coming back into the system and is designed to protect patients.  Both CMS and provider groups agree that fraud must ...

RAC Procurement Updates - New Contracts Under Pre-Award Protest

  • Margaret Klasa DC, APN BC
  • Dec 08, 2014
  • Comments

It is almost the end of the year and no new Recovery Audit Contractors (RAC) contracts have been awarded. The Centers for Medicare & Medicaid Services (CMS) has recently posted a RAC procurement update stating that as of November 4, 2014, the new contracts for Recovery Auditor Regions 1, 2, and 4 remain under a pre-award protest, which is expected to continue into late summer of 2015. The procurement process continues for Region 3 (Part A / Part B claim reviews), which includes Florida, Ten ...

Big Change This Fall! MUE Allows 2 E/M Codes Billed for the Same Day

  • Margaret Klasa DC, APN BC
  • Nov 03, 2014
  • Comments

  In the past, Medicare has allowed only one Evaluation and Management (E/M) visit per day. Now, as of October 1, 2014, the Medically Unlikely Edits (MUE) allows you to report two medically necessary E/M visits per patient, per day. (Although until you receive notification from your Medicare carrier, it would be reasonable to follow existing coding guidelines.) There are episodes when a patient sees a provider in the morning and for a different problem unrelated to the first presents late ...

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