April 2017

2017 Fee Schedule Pricing Issue

The Centers for Medicare and Medicaid Services (CMS) announced there were errors in the fee schedule pricing for seven of the eight new evaluation codes for physical and occupational therapy (97161, 97162, 97163, 97165, 97166, 97167, and 97168).  This resulted in under payments from January through March 2017.  The pricing file will be corrected effective April 1, 2017 and apply retroactively back to January 1, 2017.  Past payment correction will only be done through claims adjustments and will not automatically be done by the Medicare Administrative Contractors (MACs).  Novitas Solutions will be installing the corrected file on May 8, 2017; until then claims will suspend with status SM9698 and then will process after the file has been corrected.  When submitting adjustment claims for January through March claims that have processed with Novitas Solutions, remember to delete the line and rekey it to ensure proper reprocessing.  Make sure to update the fee schedule in your billing software system as well to ensure proper accounts receivable calculations.

New Approved ABN Form

Effective June 21, 2017, the Office of Management and Budget has approved a new Advance Beneficiary Notice of Noncoverage (ABN) form and instructions.  This form is given to patients with traditional Medicare when it is believed that certain services will not be covered under Medicare part B, therefore making the patient responsible for the cost of the service.  The ABN form should specifically list the service, it’s cost, and the reason why the service might not be paid.  This allows the patient to make an informed decision about whether or not to continue with the current care plan, knowing that Medicare may not pay for the service.  This form is now available in an English and Spanish version at the following link www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html.

Billing Trends

Lately we have seen a significant increase in the amount of claims rejecting with Medicare due to open segments.  Open segments are situations were another insurance is primary over Medicare and therefore should be billed first for the services provided, such as workers compensation insurance, auto accidents, liability, and no fault.  It is important to have policies in place prior to admission to check eligibility and identify the insurance coverage as well as look for these other possible open segments that would cause Medicare to reject your claim.  Novitas Solutions states that adding remarks to the claims saying that your services are unrelated to the open segment will cause your claim to be reviewed by the processing unit.  They will check comments and diagnosis codes to make a determination if it is related or not.  If they are unable to determine, the claim will reject.  The most information that can be seen about an open segment is the other insurer’s name and a policy number.  Due to HIPPA, these insurers most likely will not share any information without the patient or patient’s family involved.  It is important to get these segments closed or find out if any current services performed would be related to this segment and bill that insurance first then Medicare as secondary.  Being proactive with your eligibility checks will help ensure a smooth billing process and quicker payments.


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