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Letter from the editor: Accessing your newsletter content

The challenges healthcare professionals tackle each day don’t wait for solutions, and neither should you. That’s why Briefings on Coding Compliance Strategies is transitioning to a more frequent and robust publishing model this winter and expanding into a JustCoding membership.

Your updated member benefits gain you access to content and tools on JustCoding (JC)—with new resources added weekly to the website ( You’ll use the same login information you previously used to access Briefings on Coding Compliance Strategies at to access the articles and full-issue PDF at JC.

Plus, as a JC member, you gain instant access to more than 100 resources in our forms and tools library, including white papers, books, webcasts, and much more. If you are already a JC member, you will continue to receive the news and analysis you’ve come to rely on, plus expanded member benefits coming in December.

To help readers keep tabs on available content, we will announce new articles in JustCoding and Revenue Cycle Daily Advisor, HCPro’s daily e-newsletter for HIM directors and coders and coding managers. At the end of each month, we’ll roll the corresponding weekly articles into a digital issue of Briefings on Coding Compliance Strategies that mirrors the current format. As a member of JC, you can continue to download and print high-quality PDFs of the current issue, as well as several years of back issues of Briefings on Coding Compliance Strategies, directly from JC’s website. Printed editions of Briefings on Coding Compliance Strategies will no longer be mailed to subscribers.


We’re looking forward to delivering your coding and billing guidance and commentary in a timelier, efficient, and convenient manner. Feel free to contact editor Amanda Tyler at [email protected] with any questions. – Briefings on Coding Compliance Strategies

Exciting updates: More content, tools, and news at your fingertips!

The challenges healthcare professionals tackle each day don’t wait for solutions, and neither should you. That’s why Briefings on HIPAA is transitioning to a more frequent and robust publishing model this winter and expanding into a Revenue Cycle Advisor membership. – Briefings on HIPAA

How is your HIPAA auditing and compliance government entity doing?

OIG tells OCR to establish its permanent audit plan. OIG officials called OCR’s oversight of the HIPAA Privacy Rule "primarily reactive." It investigates possible noncompliance primarily in response to complaints. Establishing a permanent audit program would help OCR "proactively assess possible noncompliance from covered entities."

So when should entities expect to see the permanent audit program rolled out? Mac McMillan, FHIMSS, CISSM, cofounder and CEO of Cynergis Tek, Inc., Austin, Texas, and Phyllis A. Patrick, MBA, FACHE, CHC, CISM, founder of Phyllis A. Patrick and Associates, LLC., Southport, North Carolina, each say they expect the full program to hit the streets in early 2016. However, Patrick says, "I will believe it when I see it."

Covered entities, she adds, should always be ready for an audit. 

This article was originally published in Briefings on HIPAA. Subscribers can access the full article in the January 2016 issue. – HIM-HIPAA Insider

Questions about MOON and CMS notification regulations

Ask the Expert

Questions about MOON and CMS notification regulations

Learning objective

At the completion of this educational activity, the learner will be able to:

  • Identify strategies to comply with the Medicare Outpatient Observation Notice (MOON) notification and understand rules related to navigating the skilled benefit for Medicare


One of the topics raising the most questions in case management today is related to the MOON notification requirement. Hospitals were struggling this summer to comply with the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act, which was signed by President Barack Obama August 6, requiring hospitals to provide a verbal and written notice of outpatient status to any patient in observation who has been in the hospital for more than 24 hours. Just prior to the August 6 implementation date, hospitals received word that the notification requirement would be delayed pending approval of modifications made to the government’s notification form. (See related story on p. 1.)

But despite the delay, case managers still have questions about MOON, which were answered this month by Ronald Hirsch, MD, FACP, CHCQM, vice president of the Regulations and Education Group at Accretive Health in Chicago. Janet L. Blondo, MSW, LCSW-C, LICSW, CMAC, ACM, CCM, C-ASWCM, ACSW, manager of case management at Washington Adventist Hospital in Takoma Park, Maryland, and Peggy Rossi, BSN, MPA, CCM, a consulting associate for the Center for Case Management in Wellesley, Massachusetts, also tackled a Medicare notification question this month.


Q: What is the consequence if we miss giving a patient who meets the MOON criteria the notice? Has there been an update if the observation hours will need a modifier or the claim a value or condition code to show that the notice was given?


Hirsch: CMS has not stated the consequence of not issuing a MOON. CMS will be updating its survey tools in the future and may address it there. CMS stated in the IPPS final rule that, "all monitoring and enforcement of the MOON will be consistent with our oversight procedures for other hospital delivered notices."


Q: Now that CMS has released a new version of the MOON form, how should my organization proceed?


Hirsch: CMS released a new version of the MOON August 1, but it must go through the public comment period. After that time, it will be issued an Office of Management and Budget number and then there will be a 90-day implementation period. Until that time, hospitals should follow any state regulations for notices to outpatients and patients receiving observation services.


Q: I read your article on navigating the skilled benefit for Medicare and I have a few related questions. My understanding is that you can only use a Hospital-Issued Notice of Noncoverage (HINN) for inpatient, so you could use it if less than a three-day stay. We have been giving Advance Beneficiary Notices (ABN) for our traditional Medicare patients that are observation when families are not timely on getting a skilled nursing facility secured to those patients that require it. Is this correct?


Rossi: The HINNs have varied uses, and if a HINN is used it should be the HINN1, as this is a letter used to deny any admission?it is a preadmission denial and is issued when it is known the stay will not be covered. Another letter to use will be an ABN, as the ABN is a letter designed by CMS to deny outpatient services, when it is known they will not be covered.


Blondo: HINN1 is known as a preadmission/admission HINN and can be given prior to a hospital stay when it is expected that the entire stay will be denied for coverage. So if a patient was brought to the hospital ED for the purpose of SNF placement and the physician is writing an order to admit to inpatient, many hospitals have their ED case manager intervene by giving the patient and family the HINN1. The physician does not have to agree with the issuance of the denial notice. Seeing the denial notice often convinces the patient and family to choose another plan of care for the patient, and no admission takes place.

For patients placed in observation, ABNs are used for Medicare Part B outpatient services when it is believed Medicare will no longer pay for the services it normally would cover. Some common reasons one would issue an ABN include when services are not reasonable and necessary or when the care is custodial. So if the family hasn’t moved fast enough to take that available SNF bed and the patient’s care is considered custodial, it is correct to issue the ABN.

For more information, see Medicare Advance Beneficiary Notices, October 2015, Medicare Learning Network, Department of Health and Human Services, Centers for Medicare & Medicaid Services at:


Got a question on any case management topic that you’d like to ask our experts? Email it to Kelly Bilodeau at [email protected]. – Case Management Monthly

Q&A: Prepare for requirements when reporting biosimilars

Q: Last week, you said there is a code for reporting the biosimilar for filgrastim. How is CMS going to pay for the drugs and are there any “surprises” that we should look out for?
A: CMS has initiated the same type of payment that we are familiar with under the OPPS. For those who receive payment under the Medicare Physician Fee Schedule (MPFS) for drugs, it is a bit of a new concept. CMS will assign a single HCPCS code for the biosimilar, and all biosimilars for the same biological will be reported with the same HCPCS code. For example, cyclophosphamide is manufactured by more than 20 different companies. Regardless of the manufacturer, the drug is reported with HCPCS code J9070 (cyclophosphamide, 100 mg) and reimbursed under APC 1408 based on the average sales price information. This same concept will apply for biosimilars, which are eligible for pass-through payment, as well as subject to the same packaging and separately payable considerations as other drugs/biologicals.
As additional manufacturers begin providing filgrastim biosimilar, HCPCS code Q5101 (injection, filgrastim [G-CSF], biosimilar, 1 microgram) will be reported with the appropriate number of units for the dose ordered and administered, and will be reimbursed at the same rate under APC 1822 for 2016.
There is another reporting requirement for biosimilars. Based on discussion in the MPFS final rule, beginning January 1, 2016, CMS is going to issue manufacturer-specific modifiers that must be appended to the HCPCS code for the biosimilar based on which manufacturer supplied the product administered to the patient. Transmittal 1542 describes the process and notes that once the modifiers are communicated, it is a mandatory that the modifiers be reported on the claim. The first modifier is -ZA for Sandoz, which is the current manufacturer for filgrastim biosimilar.
As the number of biosimilars grows, and the number of manufacturers providing the biosimilars increases, this will be a huge operational consideration as the modifier will be specific to the product provided to an individual patient. It is a great idea to be proactive and begin working on how to operationalize this requirement.


Editor’s note: Denise Williams, RN, CPC-H, seniorvice president of revenue integrity services at Revant Solutions,in Fort Lauderdale, Florida, answered this question. – APCs Insider

Accepting payments from Medicare patients

We are a billing company and collect payments on behalf of our clients for the patient responsibility portion of the Medicare claim. The payment is processed through our bank as an aggregate. The question was asked if this is proper to accept these payments in our account on behalf of the client for Medicare patients? I cannot find anything that says that this cannot be done but I am looking for any feedback.

The money is allocated back to the clients at invoicing, every 30 days.

Medical Billing and Coding Forum



Editor’s note: This month’s "Q&A" was modified from the HCPro book The Medicare Billing Manual for Long-Term Care, written by Frosini Rubertino, RN, CDONA/LTC, C-NE, CPRA. 

For more information or to order this new long-term care billing resource, call customer service at 800-650-6787 or visit To submit a question for upcoming issues, email Product Manager Adrienne Trivers at [email protected]


Q: SNFs that are not accredited suppliers of durable medical equipment (DME), prosthetics, orthotics, and supplies (DMEPOS) lost the opportunity to bill their DME Medicare Administrative Contractor (MAC) for Part B supplies after September 30, 2009. What does this mean for SNFs that bill their fiscal intermediary (FI) or MAC for Part B?covered wound care supplies?


A: The DMEPOS accreditation requirement has to do with the supplier number, for which SNFs do not need to bill their FI/MAC. Therefore, SNFs billing their FI/MAC for certain Part B supplies, such as wound care, ostomy, and urological items, do not have to be accredited. Accreditation does not apply to the Medicare provider number.

Maintaining the ability to bill for wound care supplies is excellent news for SNFs, because many facilities use more wound care supplies than other Part B items, such as ostomy or urological supplies; this type of Part B billing may provide more revenue.


What can you bill?

Before billing for wound care supplies, SNFs must know what types of supplies they can actually bill to Medicare Part B.

Not all wound care supplies are covered by Part B. When it comes to wound care supplies, SNFs can only bill Part B for dressings used in debridement and surgical dressings, which are needed to treat wounds resulting from surgical procedures.

Debridement refers to the process of removing dead tissue or foreign material from and around a wound. Routine dressings, such as supplies used for cleaning purposes, are not billable under Part B.

Dressings are broken down into two categories: primary and secondary. Primary dressings are applied directly to the wound, and secondary dressings, such as tape and gauze, protect the primary dressings. Medicare will cover both the primary and secondary dressings if the wound being treated is caused by a surgical procedure, has been or is being debrided, and is under a physician’s order.


Gather the information

Although a good working relationship between the clinical and billing staff is always important, collaboration is essential to the wound care billing process. The clinical team must provide the biller with specific information before wound care supplies can be properly billed. For example, clinical documentation must include information about swelling, pain, size, or dimensions of the wound, as well as when the dressings were changed.

The documentation must also include detailed information about any changes or improvement in the wound. If there is no indication of healing, there should be some documentation of dialogue with the physician about changing treatment to facilitate improvement.

SNF billers rely on the clinical staff to provide information about the type and quantity of supplies used by each resident. Unless wound care supplies are ordered specifically for a resident, tracking and determining the cost per patient for certain supplies, such as a bag of gauze or roll of tape, can become quite cumbersome.

However, the clinical staff can make this task easier by documenting the supplies and quantities used and recording this information on the resident’s treatment sheet.


Coverage criteria

SNFs must understand the policies and local coverage determinations (LCD) of their FI/MAC before billing for wound care supplies. Every FI/MAC has its own set of LCDs, which can be interpretations or further explanations of the national coverage determinations (NCD) established by CMS. FIs and MACs also develop their own unique LCDs that are separate from the NCDs.

SNFs must carefully adhere to the LCDs of their FI/MAC, which can be found on the contractor’s website, because the LCDs outline specific criteria that must be met for services to be covered. For example, LCDs can indicate frequency requirements for dressing changes or the type of documentation needed to support the medical necessity of wound care supplies. LCDs will also indicate appropriate modifiers to include on the UB-04.

If the FI/MAC does not have an LCD, the NCDs on the CMS website apply.


A great place to start

When it comes to billing Part B supplies, wound care is a great place to start. Wound care supplies are excellent revenue sources, and billing your FI or MAC for these Part B items tends to be easier than billing for other supplies. For most facilities, everything for wound care is done in-house; a treatment nurse performs the wound care, you know how the wound originated, and you know what is being provided.

To be successful with wound care billing, it is critical to establish procedures for tracking the supplies used by each resident. Although establishing these tracking measures, as well as the billing procedures, may be time-consuming, these systems can often be applied to other Part B?billable supplies, making Part B billing a more manageable process.


Common wound care supplies

Facilities submitting Part B claims for wound care supplies will bill for a variety of items. The following is a list of some of the more common types of items used for wound care:

  • Wound pouches
  • Alginate dressings
  • Composite dressings
  • Contact-layer dressings
  • Foam dressings
  • Gauze
  • Hydrocolloid dressings
  • Hydrogel dressings
  • Special absorptive dressings
  • Transparent film


Surgical Dressings

Surgical dressings are limited to primary dressings, which are either therapeutic or protective coverings applied directly to wounds or lesions that are on the skin or are caused by an opening to the skin, and to secondary dressings, which are therapeutic or protective (i.e., are needed to secure the primary dressing).

The wound can be either from a surgical procedure or from a debridement of a wound by the following procedures:

  • Surgical, with the use of a sharp instrument or laser
  • Mechanical, such as irrigation of the wound or the use of wet-to-dry dressings
  • Chemical, such as topical application of enzymes
  • Autolytic, such as application of occlusive dressings to an open wound


The dressings used for mechanical debridement to cover chemical debriding agents or wounds to allow for autolytic debridement are covered, but the agents themselves are not. Autolysis is a breakdown of all or part of a cell or tissue by self-produced enzymes.

When billing the DME MAC for surgical dressing supplies, review the allowable product list maintained by the Pricing, Data Analysis, and Coding (PDAC) Contractor by visiting and selecting DMECS Coding listed under Top PDAC Links.

Before beginning to bill Medicare for surgical dressings, obtain the LCDs from your FI/MAC. If it does not have an LCD for surgical dressings, obtain the LCD in effect for your DME MAC. The DME MAC LCD is located in the supplier manual’s medical policy section, which you should review thoroughly. It will outline the limitations of coverage and medical necessity requirements that are essential for accurate billing for surgical dressings. It also will note any HCPCS modifiers that may be required for specific HCPCS codes. Pay special attention to billing limits that are discussed by HCPCS classification.

Just because a HCPCS code is listed in the LCD does not mean it is always an allowable Medicare item. Review the entire policy and read the fine print to be sure you understand it thoroughly. Often, specific conditions must be met for a particular supply to be covered under the surgical dressing benefit category, or a set of modifiers may be required. Be sure to read all materials provided with the policy to ensure that all billing requirements are met.

Surgical dressings are subject to the annual Part B deductible and the 20% coinsurance payment. The payments are made based on the DMEPOS Fee Schedule. To bill for the surgical dressings, you must track the following:

  • Name of the resident
  • Date of services
  • HCPCS codes to identify the supplies used
  • Number of units
  • ICD codes for supplies provided

Review each HCPCS code to determine how to report units. Most surgical dressing HCPCS codes use square-inch measurements (e.g., A6196 alginate or other fiber-gelling dressing, wound cover, pad size of 16 inches or less, each dressing). – Billing Alert for Long-Term Care

2017 OPPS proposed rule looks to implement provider-based changes

2017 OPPS proposed rule looks to implement provider-based changes

CMS is looking to implement the Section 603 provisions of the Bipartisan Budget Act of 2015 regarding off-campus, provider-based departments (PBD) by January 1, 2017, according to the 2017 OPPS proposed rule ( The agency is proposing to pay the nonfacility or office Medicare Physician Fee Schedule (MPFS) amount to the performing/supervising physician and preclude hospitals from billing on a UB-04 form or receiving OPPS payment for services performed at these locations for 2017, but plans to explore other options for 2018 and beyond.

Physicians would be paid at the higher nonfacility rate of the MPFS, but only hospitals that have employed or contracted physicians that reassign their billing to the hospital would get paid under the MPFS for these services.

Hospitals would be able to bill claims on CMS-1500 forms for physicians who have already reassigned their billing to the hospital, as in the case of employed physicians. Otherwise, hospitals would have the option of enrolling the location as the type of provider or supplier it wishes to bill to meet the requirements of that payment system (e.g., ambulatory surgery center or group practice).

"This proposal will be very challenging for hospitals that have community physicians practice at their off-campus outpatient departments that will no longer be paid under OPPS," says Valerie Rinkle, MPA, lead regulatory specialist and instructor for HCPro, a division of BLR, in Middleton, Massachusetts.

"These physicians would bill with the office place of service code and the hospital would have to figure out how to get compensated," she says. "This will likely require hospitals to rewrite their agreements with these physicians."

CMS’ proposal for operationalizing Section 603 comes as somewhat of a surprise since the burden is being placed squarely on providers, with CMS’ own systems not ready to allow existing billing practices, says Jugna Shah, MPH, president and founder of Nimitt Consulting, Inc.

"Some providers hoped CMS would delay implementation and others speculated that modifier ?PO might get repurposed for CY 2017," says Shah. "Perhaps commenters will be able to offer CMS solutions that will minimize provider operational burden."

CMS writes in the proposed rule:

We intend the policy we are proposing in this proposed rule to be a temporary, 1-year solution until we can adapt our systems to accommodate payment to off-campus PBDs for the non-excepted items and services they furnish under the applicable payment system, other than OPPS.


CMS would allow certain excepted items and services to still be billed under the OPPS:

  • All items and services furnished in a dedicated emergency department
  • Items and services furnished in a hospital department within 250 yards of a remote location of the hospital and within 250 yards of the main hospital (i.e., on-campus)
  • Items and services that were furnished and billed by an off-campus PBD prior to November 2, 2015

Hospitals could also continue to bill for services at these facilities that are not paid under the OPPS, such as laboratory services.

Off-campus PBDs built and billing before November 2, 2015, would retain grandfathered status or what CMS calls "excepted" status and continue billing under the OPPS, but the proposed rule includes some caveats. While the agency proposes that a change in ownership would not change an off-campus PBD’s excepted status as long as the new owner assumes the same provider agreement, a change in location would. However, CMS is requesting comments on this provision and whether certain exceptions should apply for situations beyond a hospital’s control such as a natural disaster.

Off-campus PBDs that expand services beyond those offered and billed before November 2, 2015, will not be allowed to bill them under the OPPS. CMS has proposed clinical families based on APCs that would determine whether those expanded services would continue to be excepted (see Table 21 on page 342 of the proposed rule).

CMS also proposed a 90-day Medicare EHR incentive program reporting period in 2016 for all eligible professionals, eligible hospitals, and critical access hospitals (CAH). If passed, the reporting period would be 90 continuous days between January 1, 2016, and December 31, 2016. CMS proposed the elimination of clinical decision support and computerized order entry objectives and measures for eligible hospitals and CAHs attesting under the program. The thresholds for the modified stage 2 for 2017 and stage 3 for 2017 and 2018 would be reduced. These proposed changes do not apply to the Medicaid EHR incentive program.

CMS proposed that EHR incentive program participants that have not yet demonstrated meaningful use attest to the modified stage 2 by October 1, 2017. This is in part due to the fact that after publishing the 2015 EHR Incentive Programs Final Rule, CMS realized it was not possible for new incentive program participants to attest to stage 3. However, any eligible hospital, eligible professional, or CAH that has attested to meaningful use in the past will report to different systems.

The proposed rule states that some eligible professionals who have not demonstrated meaningful use but intend to attest in 2017 and transition to MIPS should be granted a hardship exception.

CMS also proposed modifying the measure calculations for the EHR incentive program. Under the proposal, actions in the numerator must occur during the reporting period when the period is a full calendar year. If the reporting period is not a full calendar year, the numerator must be reported in the same calendar year as the reporting year.

CMS also proposed removing six procedures from its inpatient-only list, including four spine procedures as well as two laryngoplasty procedures. CMS is requesting comments on whether to remove total knee arthroplasty from the inpatient-only list in the future.

"The deletion of procedures from the inpatient-only list is long overdue," says Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, chief operating officer and founder, First Class Solutions, Inc., in Maryland Heights, Missouri. "It’s unfortunate that the knee arthroplasty wasn’t included. I question whether there is value to the inpatient-only list any longer."

Some conditional packaging status indicators are currently based on the date of service, while others package based on the claim’s from and through dates, meaning packaging crosses all dates encompassed in those fields (FL6) of the claim. For CY 2017, CMS proposes to change its packaging logic for all conditional packaging status indicators so that it occurs at the claim level.

The proposal would change the logic for status indicators Q1 and Q2, which currently package items or services provided on the same date of service as those assigned status indicator S, T, and V. CMS also proposes deleting modifier ?L1 (separately reportable laboratory test), which had been operationally burdensome and confusing to report, led to a billion dollar CMS miscalculation, and was subsequently replaced in functionality with status indicator Q4. If CMS finalizes its proposal, all laboratory tests that appear on a claim with other hospital services would be packaged, even if ordered by a different provider for a different diagnosis than the other services.

For more information, see CMS’ fact sheet, available at: – HIM Briefings