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November 2009 Client Newsletter


CPB will be closed Thanksgiving Day and the Friday after Thanksgiving to provide our staff a long weekend. We hope you enjoy the holiday also!

We will also close at noon on Wednesday, December 2nd for our annual Employee Appreciation Day.

Medicare AUDITS

CPB has seen the first of pre-payment audits that are being conducted by Highmark Medicare. The provider billed a 99254 - but when the Consult report was reviewed Highmark downcoded it to 99253. Upcoding of E&M codes is a major focus of all CERT & RAC audits so it is important to be accurate. As of October 29th, we have also now seen several post-payment audit requests.

The new daily max for PIP claims was increased from $90 to $99 effective for treatment on or after 8/10/09.


Effective October 1, 2009 CMS is expanding the claim editing requirements in claims for ordering/ referring physicians for DMEPOS products and services. The claim editing is being added to verify that the ordering/referring provider on a claim is eligible to order/refer and is enrolled in Medicare by comparing enrollment in Medicare's PECOS software. This affects both physician and nonphysician practitioners. Until December 31 this will only be a warning but effective January 4, 2010 if the ordering/referring provider is not on the national PECOS file, claims will not be paid.

A partial list of providers who can order/refer are:
Doctor of Medicine or Osteopathy;
Podiatric Medicine;
Chiropractic Medicine;
Physician Assistant;
Certified Clinical Nurse Specialist;
Nurse Practitioner;
Clinical Psychologist; and
Clinical Social Worker.

We strongly advise that you verify you are current on the PECOS database as soon as possible since we fully expect long delays getting approved after January 1. To verify with PECOS that you are setup, you can call 866-484-8049. If you filed a new enrollment application and were approved within the last two years or so, you should be fine. If not, and you are the ordering or referring physician for any DMEPOS provider (including your own claims), after January 4 that provider will not be paid.

To login to PECOS, use your NPI user name and password. Go to: on the CMS website.

Providers can read the educational material about Internet-based PECOS that is available at
Once at that site, scroll to the “Downloads” section of that page and click on the materials that apply to you and your practice.

Starting January 1, 2010 Medicare is considering no longer recognizing CPT consulting codes. If that occurs, you will need to bill the appropriate E/M service code, either outpatient or inpatient, new or established. We will let you know if/when that is confirmed.


The Health Information Technology Committee has made its initial recommendations to define “meaningful use.” If you would like to view their matrix, let Rich know – the URL is VERY long and it will be easier for you if it is emailed. Then you can click the link rather than manually enter it or follow a rather convoluted trail to get there.


The FTC announced on July 29th that the Red Flag Rules will be delayed again with a new date of November 1, 2009. CPB expects this to be the final delay, or not! Once the FTC releases their guidance, CPB will create a sample policy & procedure available to all clients which can be modified to suit each provider.

HITECH also requires changes to HIPAA Privacy & Security. We expect to create a sample policy & procedure which will be made available for clients. If you are interested in either or both, please give Rich a call.
2009 Client Newsletter Archive