$4.6 Million was paid by CMS for claims that did not comply with Medicare requirements. The claims were paid in 2017 and reported by the Office of Inspector General (OIG) stating, "A 2017 Office of the Inspector General (OIG) report noted that, in some cases, pharmacies incorrectly billed Medicare Part B for claims using the KX modifier for immunosuppressive drugs. It is estimated that Medicare paid $4.6 million for these claims that did not comply with Medicare requirements".
The KX modifier is used to report correct documentation is on file, this modifier should be used in the context of the claim, indicating that the provider or supplier has ensured coverage criteria for the product or service has been met and documentation exists to support the medical necessity.
KX - SPECIFIC REQUIRED DOCUMENTATION ON FILE
Be sure you are using this modifier correctly, clarify the usage of the following documents.
In 2022 there were 159 new codes; the 2023 ICD-10-CM code update includes 1,176 new, 28 revised, and 287 deleted codes, a substantial change from last year. The 2023 ICD-10-CM codes are to be used for discharges from October 1, 2022 through September 30, 2023, and for patient encounters from ...
CMS pays emergency department visits through a payment method using Ambulatory Payment Classifications (APCs). Most payers also use the APC reimbursement system; however, there may be some differences in payer policies (always review your specific payer policy). APCs are the primary type of payment made under the OPPS, comprising groupings ...
It has been said that the healthcare industry is notoriously slow in terms of technology adoption. One need only look at how convoluted medical coding and billing are to know that it needs a technology injection. Specifically, medical coding and billing software desperately needs artificial intelligence (AI).
Attention providers, suppliers, billers, and vendors who bill Durable Medical Equipment (DME) to Medicare! Currently, a supplier receives a signed Certificate of Medical Necessity (CMN) from the treating physician or creates and signs a DME Information Form (DIFs); these are required to be sent with the claim.
However, this is about ...
Your practice has utilized the same medical billing software for years. The medical billing staff says it is time for a change. You don't necessarily disagree, but you also don't know where to begin your search for new software. There are so many vendors offering so many products that making sense of it all can be challenging.
Each year CMS publishes an Advance Notice of the upcoming years Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies and asks for comments related to it. Each of the comments are carefully reviewed and responded to and often are impactful to changes seen between the Advance Notice and final publication referred to as the Rate Announcement. With health equity as a primary focus for 2023, CMS announced some policy changes that may impact your organization.
Medicare Advantage Organizations (MAOs) have gone back and forth on whether or not to use data collected from telehealth, virtual Care, and telephone (audio-only) encounters with Medicare beneficiaries for risk adjustment reporting, but the following published documents from CMS cleared that up once and for all by providing an answer to a question specifically related to this question.