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January 2010 Client Newsletter


CMS and other insurers are VERY active with pro-payment and post-payment audits (CERT & RAC) and are carefully reviewing medical record documentation. One of the critical requirements that is checked on EVERY medical record is the presence of an acceptable provider signature. This type of denial is easy to avoid. In the December Highmark Medicare Report, page 3 (top) it states:

“Also, note that in keeping with standard auditing principles, items such as signatures, attestations, and other addendums which are added to the medical record after the date of the Additional Documentation Request (ADR) letter will generally not be considered as acceptable documentation. Furthermore, providers who exhibit a pattern of adding documentation after ADR requests could be subject to corrective action.

If you receive a request for medical records from the CERT contractor or Highmark Medicare Services, it is critical that the signed physician order for all diagnostic tests be included. Without the order, the services could be determined to be medically unnecessary and the claim will be denied.”

We have also been told by Highmark Medicare that “Electronically Signed” signatures are not acceptable – each document/note/order must have a handwritten signature.

Thus, before sending any documentation to Medicare or any other insurer, it is critical that all providers, physician and non-physician, are sure their signature is on EVERY document/note/order and that it be recognizable as their signature. CPB will be glad to review all documents for completeness prior to sending them to an insurer. See the separate article from the Highmark Medicare Medical Director in your MCO packet.


We occasionally are asked what constitutes a new patient. The definition of a new patient is found on the first page of the narrative instructions at the beginning of the E/M section of your CPT manual where it states: "...A new patient is one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past 3 years."

As you can see, the billing tax ID, change in office location, joining another practice, whether you need to set up a chart or not (maybe the first with the patient was in the hospital setting).....none of those things make any difference for determining new vs established. The only criterion is whether you've seen the patient in the past 3 years (36 months) or whether anyone else of your specialty in the same practice you're with at the time of the appointment has seen the patient within the past 3 years.

Though it isn’t necessarily a "federal guideline," the Medicare program does follow it. And, since it's part of the CPT definition of the service, it's applicable to all payers (including self pay) unless the payer tells you in writing they have an alternate definition for "new patient."


The Centers for Medicare & Medicaid Services (CMS) announced the Part B annual deductible for 2010 is $155.00 (it was $135 in 2008 & 2009). With the poor economy, it is more important than ever to make every effort to collect all co-pays, deductibles (if known), and co-insurances on the date of service. The key is getting the payment before they receive your services, or at worst, before they leave your office.


The Therapy Cap for 2009 is $1,860 through December 31, 2010. However, as of December 28th, the Medicare Cap Exceptions process for independently practicing physical, speech and occupational therapists has not been extended by Congress beyond December 31, 2009. Patients who near the Cap have the option of transferring their care to an outpatient hospital setting or signing an Advanced Beneficiary Notice.

Medicare PROVIDER Participation Status – DATE CHANGE

As you are probably aware the current Medicare Fee Schedule is set to decrease by 21% unless Congress acts to change it. One option that providers have is to change from participating to non-participating status. If you wish to consider becoming non-par due to the potential fee decrease and, for physician, the elimination of consults, it can be done until 3/17/10. Call me if you want to discuss financial ramifications. Non-par status offers about a 9-10% increase in what patients can be charged compared to the par fee schedule. There are some significant caveats to consider, including the need for patients to pay on the date of service (please call Rich to discuss), and patients will need to be notified ASAP.
2010 Client Newsletter Archive