I used to do a presentation that started with a slide that said, “If I had a crystal ball and could tell you the future of healthcare….” As I was writing this article, that slide kept popping into my mind. Man, if I had a crystal ball. This year has brought about a lot of changes that no one saw coming, and I wish I could predict what the next few years will bring, specifically from Medicare.
While I still do not have a crystal ball, I can share a few tools you should have in your Medicare tool belt that will help you be prepared for anything Medicare throws your way.
Medicare has finally rolled out the prior authorizations for several prosthetic codes. Phase 1 began in September in four states and for six procedure codes. Phase 2 will begin in December and will expand to all states and territories.
For prior authorization questions, visit cgsmedicare.com/jb/pubs/news/2020/03/cope16321.html.
To determine whether a prosthetic code is subject to prior authorization, visit cgsmedicare.com/medicare_dynamic/jb/pa/pa.aspx or med.noridianmedicare.com/web/jadme/cert-reviews/mr/pre-claim/required-programs/prior-authorization-for-llp
Audits were briefly suspended during the pandemic, but on August 3 pre- and post-payment audits resumed. We have seen an influx of audits in the past few months, which were not limited to Medicare. Checklists will help you prepare for audits, but do not wait for an audit to cross your desk to check your claims before you even bill the DME MAC. When used as part of your claims preparation process, checklists can help you to ensure your claims will pass an audit.
For a documentation checklist tool, visit cgsmedicare.com/jc/mr/documentation_checklists.html or med.noridianmedicare.com/web/jddme/policies/clinicians-corner/checklists.
Whether you’re looking for answers to questions about enrollment, coding, or same and similar items, this tool will become a favorite. The links provide telephone numbers and quick clicks to many useful websites at Noridian. Everything from claim status, eligibility, and same or similar to specific questions about claims and enrollment can be found. Some of my company’s favorite tools include the medically unlikely edit tool, appeals calculators, and the self-service portals.
Medicare Learning Network (MLN)
Another great tool we use in our practice is MLN Matters. MLN articles focus on Medicare policy, billing, and payment policy. They also have training tools you can use in your practice to teach the Learning Management System to staff members.
To read MLN articles, visit
This is a great tool that will help determine if a code is payable for your patient during an inpatient stay. If your patient is in a skilled nursing facility or hospice, or during a home health episode, simply enter the HCPCS code to check at: cgsmedicare.com/medicare_dynamic/jc/consbill/consbill/index.aspx
Without a functioning crystal ball, we cannot know the future. As the Greek philosopher Heraclitus said, “The only constant in life is change.” Knowing that there will always be change, all we can do is continue to learn and adapt. Luckily for us in O&P, the DME MACs provide us with some great tools to help in our adaptations. Check out these tools, build up that tool belt, and charge on with confidence that you are ready to take on any challenges you and your practice may face.
Erin Cammarata is president and owner of CBS Medical Billing and Consulting. She can be contacted at [email protected].