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October 2014 Client Newsletter



October 1, 2014


CPB Back Line


CPB is changing our Back Line phone # to 609-463-8408 to remove some of the calls from 609-463-8075 hunt group.  If “8408” is busy, please call “8075.”


CMS Issues New Program Integrity Provisions on Denial of "Related" Claims


CR 540 establishes new program integrity manual provisions, which allow a MAC and/or ZPIC to have the discretion to deny other "related" claims submitted before or after a claim in question. If documentation associated with one claim can be used to validate another claim, those claims may be considered "related."

CMS outlines the following newly approved "related" claim denial policy in the CR:

 "When the Part A Inpatient surgical claim is denied as not reasonable and necessary, the MAC may recoup the surgeon's Part B services. For services where the patient's history and physical (H&P), physician progress notes or other hospital record documentation does not support the medical necessity for performing the procedure, post-payment recoupment may occur for the performing physician's Part B service."



We recently looked at several major insurers and their policy to register for ERA & EFT. Each payor allows for separation of the two.

  • < > allows for enrollment in EFT without ERA and offers the opportunity for providers to receive emails when deposits are made. < > promotes ERA and EFT separately. ERA enrollment is not compulsory but the default is to turn off paper when providers enroll in EFT.

    United Healthcare has made remittance and EOBs available online and they are working to emphasize this with providers.  We already get ERA’s. 


    Horizon Managed Care & PPO Fee Schedules


    Ob September 10th, Horizon announced that effective December 15, 2014 the will begin paying their managed care & PPO claims based on the 2014 Medicare fee schedule.  Currently they pay based on the 2011 Medicare fee schedule.  We have not seen the new rates yet, but overall we expect that to be a positive for most specialties. 


    Billing for Bilateral Impacted Cerumen


    The CPT description for removing cerumen bilaterally changed on 1/1/14.  Each ear is now billed as a separate unit.  Medicare is requiring office notes for all 69210 billed with 2 units.

    As such, it is critical that the notes are very clear:

  • Impacted Cerumen found in one/both ears (specify left and/or right ear)
  • Whether flushing did/did not work
  • Why using an instrument was needed (i.e., flushing did not remove all of the cerumen).
  • Clearly documenting that instrumentation was used to clean each ear where cerumen remained.
  • Documentation indicating the instrumentation was successful – or not.

CMS Update of Ambulance Signature Requirements


On July 11, 2014 CMS issued Transmittal 2984 (Change Request 8760) which eliminated the requirement to get the address of a representative signing on behalf of a patient.  The requirement appeared in the Medicare Claims Processing Manual, Chapter 26, Section 10.3, The Transmittal states that the new policy was effective for services on or after July 1, 2014


CMS will still require the other information about the representative and a documented reason why the patient could not sign.   




2014 Client Newsletter Archive