It’s best to be prepared in the event that you’re the subject of an investigation by a private payer’s special investigations unit (SIU), which are more serious and have stronger repercussions than a routine payer billing audit (PBN 1/30/12).

In addition to the five scenarios that are holding up provider payments (see related story), the Medical Group Management Association (MGMA) released its letter Feb. 1 to HHS outlining a dozen 5010 transition issues that are clogging claims processing. TIP: You can see MGMA’s full letter to HHS at: www.mgma.com/WorkArea/DownloadAsset.aspx?id=1369699. 

This chart presents four wound care debridement codes and their corresponding denial rates for each year from 2000 until 2010 based on CMS claims data. NOTE: CMS claims data for 97597 was not available before 2004. The data from 2004 was negligible because the code was not in effect until 2005 and all claims that billed 97597 that year were automatically denied.

Can a physician who performs electrocardiograms (EKG) in his or her practice bill the service as part of medical decision-making? Example: One point for ordering the test plus two points for independent visualization to equal three points. Is this considered “double-dipping”?

Your Medicare payments will be docked 1% if your e-Prescribing (e-Rx) hardship exemption request for the e-Rx Incentive Program is still pending or if you listed your group national provider identifier (NPI) instead of your individual NPI on your exemption, Part B News has learned.

Your Physician Quality Reporting System (PQRS) bonus payment for services rendered in 2011 is at risk if you don’t act by Feb. 24, Part B News has learned. Seven G-codes related only to the PQRS measures were inadvertently deleted during CMS’ transition to HIPAA version 5010 last year, resulting in rejected claims, CMS says.

You can turn annual wellness visits (AWVs) into part of your revenue solution, not part of the problem, by billing Medicare for this non-deductible service repeatedly, offsetting the financial woes typically seen in the first quarter. A two-physician primary care practice in Georgia got $25,000 alone from AWVs in last year's Q1.

While it’s no fun undergoing a routine billing audit from a private payer, it’s usually just part of doing business. But your relationship with a payer can really take a nosedive if you end up investigated by a payer’s “special investigations unit” (SIU). Unlike a general payer audit, SIUs specialize in combating fraud, waste and abuse, typically launching an investigation once a larger billing problem has been identified by the payer.

This chart presents 10 heavily-billed codes along with the potential Medicare payment increase these codes would have seen nationally were it not for denials. The data labels represent 2010 potential increases, but are graphed alongside the 2009 figures as a comparison. These percentages were derived by dividing the total denial amount for each code by the total Medicare payment for that code. The resulting percentage represents how much the overall Medicare payment for the codes would have increased if zero denials were issued.

Your Physician Quality Reporting System (PQRS) bonus payment for services rendered in 2011 is at risk if you don’t act by Feb. 24. A total of seven G-codes were inadvertently deleted during CMS’ transition to HIPAA version 5010 last year, affecting 30 PQRS measures. Following is a table listing all meaures impacted by the deleted codes.