Did You Know:
Charging for Copying of Medical Records
Here is a great URL that will give you the information per State:
http://www.lamblawoffice.com/medical-records-copying-charges.html
Like Alabama
Section 12-21-6.1 Alabama Code Reproduction
The reasonable costs of reproducing copies of written or typed documents, or reports shall not be more than:
- One dollar ($1) for each page of the first 25 pages
- Not more than 50 cents ($.50) for each page in excess of 25 pages
- A search fee of five dollars ($5)
- If the medical records are mailed to the person making the request, reasonable costs shall include the actual costs of mailing the medical records
- A person may charge in addition to the above fees, the actual cost of reproducing X-rays and other special medical records
WAC 246-08-400
- No more than ninety-six cents per page for the first thirty pages
- No more than seventy-three cents per page for all other pages
- The provider can charge a twenty-two dollar clerical fee for searching and handling records
- If the provider personally edits confidential information from the record, as required by statute, the provider can charge the usual fee for a basic office visit
- UPDATE: July 2009 through June 2011
South Dakota Administrative Rules
Reimbursement for copies. The maximum reimbursement for copies of provider records is ten dollars for the first ten pages, and thirty-three cents for each additional page.
Military and Debt collections:
Before you take collection actions regarding members of the Armed Services you will want to check out this article published in the Debt3 Commercial Law League of America http://www.debt3online.com/index.html?page=article&article_id=13. This is a great written article and helps offices understand what they can and cannot do in their efforts to collect debts.
Don't jump to neoplasm codes, when the provider does not state 'neoplasm'
ICD-9 Coding Clinic Vol 23 No 1, 1st Qtr 2006
"When coding a diagnosis documented as a MASS of a particular site and that site is not listed under the main term “MASS,” is it appropriate to look under the term “LESION,” and if not found under “LESION” should we refer to the site in the Table of Neoplasms?
Answer:
It is incorrect to select a code from the neoplasm table when only the terms “MASS” or “LESION” are used. The coder should follow the cross-references under the main term representing the documented diagnosis. If a final diagnosis is documented as “lump” and there is no index entry for the affected organ or site under “lump” in the index, look up the main term “MASS,” as directed by the “see also” note under the main term “lump.” If there is no index entry for the specific site under “MASS,” look up the main term “disease.” The index directs you to see Disease of specified organ or site for “MASS, specified organ NEC.”
If a final diagnosis is documented as “LESION” and there is no index entry for the specified organ or site under the main term “LESION,” look up the main term “Disease.” The index directs you to see Disease by site for “LESION, organ or site NEC.”
UHC agrees to close Ingenix "reasonable and customary" databases
Private payers' methods of determining "reasonable and customary" payment rates for out-of-network services are destined to change, thanks to a fraud settlement struck by the New York Attorney General's office and UnitedHealthCare.
Specifically, UHC has agreed to close two Ingenix databases widely used by private insurance companies to set their "reasonable and customary" pay rates for out-of-network care. The company will then pay $50 million to open a new, wholly independent non-profit database.
Insurers often promise to cover as much as 80 percent of "reasonable and customary" rates for claims from providers outside their network, according to the attorney general's office. But the investigation found the rate of underpayment by insurers ranged from 10 to 28% for various medical services across the state.
The settlement caps a year-long investigation into Ingenix's operation of the databases, which Attorney General Andrew Cuomo says were rife with conflict of interest. Cuomo's office looked into allegations that the
Ingenix database intentionally skewed "usual and customary" rates downward through faulty data collection, poor pooling procedures, and the lack of audits
According to Cuomo's office, the attorney general "found that having a health insurer determine the 'usual and customary' rate - a large portion of which the insurer then reimburses - creates an incentive for the insurer to manipulate the rate downward."
UnitedHealth officials noted that Ingenix provides data for insurers but does not calculate reimbursement rates. They also said that information is just one tool insurers can use to calculate out-of-network reimbursement. Others include Medicare-based reimbursement rates.
UnitedHealth regrets that conflicts of interest "were inherent" in the databases, said Mitch Zamoff, general counsel for its subsidiary UnitedHealthcare. He said the agreement will "finally and decisively" resolve questions about independence.
The new database will include a Web site that allows consumers to learn in advance how much they may be reimbursed for common out-of-network services in their area.
Cuomo said he hopes to have the new database running in six months, but he concedes that may be an optimistic time frame. Until then, insurers will continue to use Ingenix.
For more information, visit:
<http://www.oag.state.ny.us/bureaus/health_care/HIT2/reimbursement_rates.htm
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http://www.oag.state.ny.us/bureaus/health_care/HIT2/reimbursement_rates.html
OIG TRACKS FALSE CLAIMS BY STATES:
OIG today adds a new section to the website on State False Claims Act Reviews.
As enacted by section 6031 of the Deficit Reduction Act of 2005, section 1909 of the Social Security Act (Act) provides a financial incentive for States to enact false claims acts that establish liability to the State for the submission of false or fraudulent claims to the State's Medicaid program. If a State false claims act is determined to meet certain enumerated requirements, the State is entitled to an increase of 10 percentage points in its share of any amounts recovered under a State action brought under such a law.
On August 21, 2006, OIG published a notice in the Federal Register (71 FR 48552 PDF) that sets forth OIG's guidelines for reviewing State false claims acts. The guidelines invited States to request OIG's review of State laws to determine if the laws meet the requirements of section 1909(b) of the Act.
So far, OIG has reviewed State laws from California, Florida, Illinois, Indiana, Louisiana, Massachusetts, Michigan, Nevada, Tennessee, and Texas.
For more background information, and links to specific State reviews, go here:
http://oig.hhs.gov/fraud/falseclaimsact.html
MRI AND STARK
If you own your MRI unit and self refer patients remember you must give then a choice of facilities and you must let them know that you own or are part owner in the MRI facility.
Maryland Ortho Group is being brought to task on this issue:
AAOS files amicus brief on MRI issue in
The American Association of Orthopaedic Surgeons (AAOS) has filed an amicus brief in a case involving the Maryland Self Referral Law. The case, Potomac Valley Orthopaedic Associates et al. v. Maryland State Board of Physicians, is an appeal of a declaratory ruling of the Maryland State Board of Physicians (Board). In 2006, 13 years after passage of the Self Referral Law, the Board ruled that physicians could not refer patients for tests to be conducted on magnetic resonance imaging (MRI) equipment that the physician owned or leased. Insurance carriers have since indicated that they will seek refunds from physicians who were paid for such tests conducted in violation of the Self Referral Law. The AAOS argues that the ruling is unnecessary and contrary to a federal policy determination and medical community views. The Board's response is expected in 30 days. A PDF file of the ruling can be viewed at:
http://www.mbp.state.md.us/forms/2006-1.pdf
For Immediate release Contact: CMS Office of Media Affairs
January 15, 2009 (202) 690-6145
CMS ISSUES THREE NATIONAL COVERAGE DETERMINATIONS TO PROTECT PATIENTS FROM PREVENTABLE SURGICAL ERRORS
The Centers for Medicare & Medicaid Services (CMS) announced today three national coverage determinations (NCDs) to establish uniform national policies that will prevent Medicare from paying for certain serious, preventable errors in medical care.
The following errors, called “never events,” covered in these NCDs are identified in the National Quality Forum’s (NQF) list of Serious Reportable Events:
Wrong surgical or other invasive procedures performed on a patient;
Surgical or other invasive procedures performed on the wrong body part; and
Surgical or other invasive procedures performed on the wrong patient.
In addition, consistent with current policy for non-covered services, Medicare does not cover any services related to these non-covered services.
“The national coverage policies for certain types of surgical errors are important steps for Medicare in working to reduce or eliminate their occurrence and their associated payments.” said CMS Acting Administrator Kerry Weems. “These policies have the potential to reduce causes of serious illness or deaths to beneficiaries and reduce unnecessary costs to Medicare.”
In 2002, prompted in part by the release of the 1999 Institute of Medicine report titled, “To Err is Human: Building a Safer Health System,” the NQF created a list of 27 never events, which was expanded to 28 events in 2006.
As part of the ongoing implementation of Section 5001(c) of the Deficit Reduction Act (DRA) of 2005, CMS has addressed some of the NQF never events through the Hospital-Acquired Conditions (HACs) provisions in the Inpatient Prospective Payment System (IPPS) final rule for fiscal years (FY) 2008 and 2009.
For discharges occurring on or after Oct. 1, 2008, Medicare will no longer pay a hospital at a higher rate for an inpatient hospital stay if the sole reason for the enhanced payment is one of the selected HACs, and the condition was acquired during the hospital stay. CMS is exploring the feasibility of adapting this policy to its other payment systems.
In the IPPS FY 2008 final rule, CMS selected eight categories of conditions for the HAC list, a number of which were among the 28 never events listed by the NQF and include retained foreign object after surgery, air embolism, blood incompatibility, stage III & IV pressure ulcers, and injuries related to falls and traumatic events such as electric shock and burns.
In the IPPS FY 2009 final rule, CMS added manifestations of poor glycemic control, including hypoglycemic coma, to the list. Hypoglycemic coma is closely related to NQF’s listing of death or serious disability associated with hypoglycemia.
CMS determined that not all conditions included on the NQF list of Never Events should be addressed by the HAC payment provision and therefore determined that the NCD process was appropriate to address coverage for the three types of surgical errors cited above. Unlike the HAC provisions, which affect only payments to hospitals for inpatient stays, these NCDs may affect payment to hospitals, physicians, and any other health care providers and suppliers involved in the erroneous surgeries.
These NCDs are effective immediately, however; implementation instructions for processing such claims will occur at a later date. To view the NCDs, visit:
Wrong body part: www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=222
Wrong patient: www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=221
Wrong surgery performed on a patient: www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=223
CMS offers PQRI PowerPoint.
CMS has made available a PowerPoint presentation explaining the Physician Quality Reporting Initiative (PQRI), which authorizes a financial incentive for physicians to participate in a voluntary quality reporting program. AAOS worked closely with the AMA Physician’s Consortium for Performance Improvement and the National Quality Forum to develop some of the measures that are included in the program. Eligible professionals who choose to participate and successfully report on a designated set of quality measures for services provided between July 1, 2007 and Dec. 31, 2007 and paid under the Medicare Physician Fee Schedule may earn a bonus of 1.5 percent of their charges during that period, subject to a cap. The PowerPoint presentation and a complete description of the program can be accessed at:
Survey: Physicians find P4P attractive, but doubts remain strong.
According to Government Health IT, a study published in the April/May issue of the journal Health Affairs finds that more than 75 percent of primary care physicians are in favor of pay-for-performance (P4P) programs if quality measures are accurately implemented, yet a majority of doctors have little confidence that they would be. In a survey of 1,168 general internists, only 32 percent supported the public reporting of individual quality scores, and 45 percent supported public reporting of group scores. Many of those surveyed commented that they feared unintended consequences of P4P, stating that a poorly designed program could result in certain undesirable patients being refused care. For more information:
http://govhealthit.com/article97829-03-06-07-Web
The
http://www.kaisernetwork.org/daily_reports/print_report.cfm?DR_ID=43477&dr_cat=3 and
http://waysandmeans.house.gov/hearings.asp?formmode=detail&hearing=534&comm=1
Must support number of Xray views
If the number of views is not mentioned in the report, the coder should not assume the procedure performed. Instead, the coder should work closely with the interpreting physician to clarify and obtain the appropriate information. This will help ensure that all pertinent information has been captured, allowing for submission of the correct procedural CPT code, which reflects the level of work performed. It is the radiologist who should decide ultimately the number of views performed to answer the clinical question at hand.
Please note that policy from the Centers for Medicare and Medicaid Services supports this statement. Medicare Carriers Manual, Section 15021 (E)(1), explains, “Unless specified in the order, the interpreting physician may determine, without notifying the treating physician/practitioner, the parameters of the diagnostic test (eg, number of radiographic views obtained, thickness of tomographic sections acquired, use or non-use of contrast media) [emphasis added].”