Medical Billers and Coders

  Determining Medicare Drug Coverage While  billing for Skilled Nursing Facilities (SNF)  or for  hospital billing , billers always make the mistake of considering the wrong Medicare drug coverage. For example, Medicare Part A and Part B generally do not cover outpatient prescription drugs, most of which are covered under Part D. In this article, we shared an excerpt from a CMS document, which will act as a basic tool to assist you in understanding Medicare drug coverage determinations under Part A, Part B and Part D of Medicare, and to clarify coverage for specific Part D products/drugs/categories.  We also shared billing scenarios, which will help you to determine which part of Medicare covers a drug in a particular situation, assuming all other requirements are met, e.g., a drug must still be medically necessary to be covered. This information is applicable to people in the Original Medicare Plan. People who have a Medicare Advantage HMO or PPO Plan with prescription drug covera

  Medical billing for Skilled Nursing Facilities has undergone metamorphic changes ever since the Balanced Budget Act of 1997 came into effect in 1998. One of the significant requirements under the new legislation is that Skilled Nursing Facilities are not permitted to unbundle services administered by contracted healthcare providers. As a result, most of the services provided to Medicare beneficiaries are to be bundled together and billed by SNFs under the Prospective Payment System (PPS) in one consolidated claim. The SNF concerned is then responsible to pay for contracted services out of the per diem rate that it earns for caring for a Medicare beneficiary. Eliminating Skilled Nursing Facilities (SNF) Medical Billing Complication While this imposition may have helped reduce potential fraud and abuse due to double billing by healthcare providers, SNFs have certainly had a hard time understanding: What services are covered under consolidated billing What is billable under Me

  The Trump Administration is taking aggressive actions and exercising regulatory flexibility to help healthcare providers contain the spread of the 2019 Novel Coronavirus Disease (COVID-19). CMS is empowered to take proactive steps through 1135 waivers as well as, where applicable, the authority granted under section 1812(f) of the Social Security Act (the Act) and rapidly expand the Administration’s aggressive efforts against COVID-19. As a result, the following blanket waivers are in effect, with a retroactive effective date of March 1, 2020, through the end of the emergency declaration. CMS is ending the specific emergency declaration blanket waivers for SNFs/NFs, inpatient hospices, ICF/IIDs, and ESRD facilities. CMS passed several temporary emergency declaration blanket waivers for SNFs which were intended to provide healthcare providers with extra flexibilities required to respond to the COVID-19 pandemic. Emergency Declaration Blanket Waivers for SNFs 3-Day Prior Hospitaliza

  During the Public Health Emergency (PHE), The Centers for Medicare & Medicaid Services (CMS) used a combination of emergency waivers, regulations, and sub-regulatory guidance to offer healthcare providers the flexibility needed to respond to the pandemic. In certain cases, these flexibilities suspended requirements in order to address acute and extraordinary circumstances. Now, CMS is taking steps to continue to protect nursing home residents’ health and safety by announcing guidance that restores certain minimum standards for compliance with CMS requirements. We shared a recent update on the removal of temporary emergency waivers for nursing homes, inpatient hospices, ICF/IIDs, and ESRD facilities. Emergency Waivers for Nursing Home Restoring these standards will be accomplished by phasing out some temporary emergency declaration waivers that have been in effect throughout the COVID-19 PHE. These temporary emergency waivers were designed to provide facilities with the flexib

  On 7th April 2022, in response to the COVID-19 PHE and under section 1135 of the Social Security Act, CMS passed several temporary emergency declaration blanket waivers which were intended to provide healthcare providers with extra flexibilities required to respond to the COVID-19 pandemic. While the waivers of regulatory requirements have provided flexibility in how nursing homes may operate, they have also removed the minimum standards for quality that help ensure residents’ health and safety are protected.  Declaration of Blanket Waivers Recently, CMS conducted some surveys that revealed significant concerns with resident care that are unrelated to infection control (e.g., abuse, weight loss, depression, pressure ulcers, etc.). Waiver of certain regulatory requirements may have contributed to these outcomes and raised the risk of other issues. For example, by waiving requirements for training, nurse aides and paid feeding assistants may not have received the necessary training

  Medicare Part A covers skilled nursing and rehabilitation care in a Skilled Nursing Facility (SNF) under certain conditions for a limited time. Coverage for care in SNFs is measured in ‘benefit periods’ or sometimes ‘spell of illness. In each benefit period, Medicare Part A covers up to 20 days in full. After that, Medicare Part A covers an additional 80 days with the beneficiary paying coinsurance for each day. After 100 days, the SNF coverage available during that benefit period is ‘exhausted,’ and the beneficiary pays for all care, except for certain Medicare Part B services. In this article, we shared Medicare SNF billing coverage for the year 2022, and also we bifurcated Medicare SNF billing coverage for Medicare part A, Medicare part B, Original Medicare, and Medicare Advantage (MA). Medicare SNF Billing Coverage Medicare Part A Coverage The SNF Prospective Payment System (PPS) pays for all SNF Part A inpatient services. Medicare Part A covers Medicare-certified SNF skill

  SNF Advanced Beneficiary Notice of Non-coverage Medicare requires SNFs to issue the SNF Advanced Beneficiary Notice of Non-coverage to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is not medically reasonable and necessary; or considered custodial. The SNFABN provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNFs must use the SNFABN when applicable for SNF Prospective Payment System services (Medicare Part A). SNFs will continue to use the ABN Form CMS-R-131 when applicable for Medicare Part B items and services. Form Filling Instructions for SNF Advanced Beneficiary Notice The SNFABN has 5 sections for completion i.e., header, body, option boxes, additional information, and signature & date.  Failure to use this notice or signific