Blog Posts About Regulatory Updates

The case was handled through the Health Care Fraud Strike Force Program, which currently operates in nine Strike Forces across the country.

Prior authorization (PA) is costly, inefficient and responsible for patient care delays. The...

A new ICD-10 Clinical Modification (ICD-10-CM) code set took effect October 1, 2023.  In this new code set, there are many code additions, deletions, and modifications.

CMS has issued guidance requiring the use of Modifier JW on all claims for biologicals from single-dose containers that are separately payable under Medicare Part B when there are unused / discarded amounts.

On July 13, 2023, CMS issued proposed rules for the 2024 Physician Fee Schedule (PFS) and the Hospital Outpatient Prospective Payment System (OPPS).

Attorney Knicole Emanuel has posted a chilling blog on her site about hidden RAC (Recovery Audit Contractor) audits.

We cannot submit CPT®[1] coding for both ulcer debridement and total contact cast application when both are performed for the same ulcer at the same encounter.

Three Medicare Administrative Contractors (MACs) issued their final Local Coverage Determinations (LCDs) for Cellular and/or tissue-based products (CTPs).

You should read the documents yourself, but here are some highlights of the 2024 OPPS proposed rule (in no particular order).

This policy is being contested by multiple stakeholders, including the American Podiatric Medical Association.

In Knicole Emanuel’s latest blog, she discusses the new Medicare rules stating that no extrapolation may be run if the error rate is under 50%.

In the HOPD, for injuries and external causes, the “A” value should be used for the 7th character to report for active treatment.

The Big Picture of Physician Payment Within CMS The big picture is still playing out for physician...

Nearly every wound care and hyperbaric medicine practitioner is undergoing some sort of Medicare audit.

These CPT codes can be used if the patient is not in a global period for the provider who removes the sutures / staples.

Unfortunately, some Medicare auditors are not following the law as it pertains to the presence or absence of a beneficiary’s potential for improvement.

In its effort to debunk regulatory myths, the American Medical Association (AMA) has produced this useful fact sheet, “Who can document components of E/M services?”

The AMA reminds physicians that that there is no requirement to document the total time spent if the physician is not using time to calculate the level of service.

The American Medical Association (AMA) has been debunking several myths in a project called “Debunking Regulatory Myths.”

The CY 2024 Final Home Health Prospective Payment System Final Rule contains significant changes that expand coverage for lymphedema treatment.

A new post by attorney Knicole Emanual is vitally important for anyone under a Medicare audit.

Check out this article by Kathleen Schaum in Today’s Wound Clinic: Are You Prepared to Implement the 2023 CTP Final Rules?

On January 30, 2023, the Biden-Harris Administration announced its intent to end the national emergency and public health emergency (PHE) declarations related to the COVID-19 pandemic on May 11, 2023.

The process by which office and other outpatient evaluation and management (E&M) levels (CPT® 99202 – 99215) are selected was changed by the AMA CPT® Editorial Panel effective January 1, 2021.

Are you feeling frustrated and helpless in the face of overwhelming regulatory burdens, capricious...

Effective January 1, 2023[1], under the guidance of the AMA CPT Editorial Panel, many evaluation...

The way these audits work, it’s assumed you are guilty and you have to prove you are not – in a one way conversation.

Not only do you need to document the goals of therapy, but you need to document whether your treatments are achieving them.

Healing does not have to be the goal, but if not, we had better state goals like, “getting the wound to a state in which the patient and family can care for it with only periodic physician assessment,” or “preventing progression and hospitalization.”

I am going to discuss the wound care policy that’s been in effect since 07/23/2020 for the Novitas jurisdiction.

The full attention of every aspect of CMS is now focused on the use of CTPs. Why do you think that is?

Sweeping changes are proposed for cellular and/or tissue-based products (CTPs) when applied in the physician’s office.

This portal contains a single, searchable, indexed database that contains links to all DEA guidance documents.

If you perform either or both of the procedures represented by CPT 28820 and 28825, be sure to code appropriately for the services performed during the postoperative global period.

As wound care begins to shift into the private doctor’s office – doctors are not going to be able to just may paybacks without a fight.

“Maybe it’s time to switch our telescopic lens from auditing providers to auditing MCOs and MAs. Let’s get these RAC, ZPIC, and TPE auditors focused on the stewards of our tax dollars, the prepaid entities.”

Dr. David Charash has just put out an article in Today’s Wound Clinic describing his experience with a TPE (Targeted Prove and Educate) audit. Check it out!

HBOT treatments are most commonly provided in the hospital-based outpatient department (HOPD) but are also sometimes provided in the physician’s office.

Did you notice that Acute Arterial Insufficiency is NOT on the list? The rest of us hadn’t paid attention to that either…

In this game, you may find out the rules only when someone gets a penalty.

The MACs have been auditing wound debridements. I thought it might be useful to understand the history of debridement audits.