This week’s updates include identifying "No Documentation" medical necessity denials for claims flagged for Recovery Auditor review; Shared System Enhancement 2015 Analysis and Design HUOPCUT hospice period and Health Maintenance Organization processing; and more!
The 2016 OPPS final rule includes the first negative payment update for the system. CMS finalized its proposal to reduce the conversion factor by 2% to account for its overestimation of dollars for packaged labs built into the 2014 APC rates, despite congressional and provider pressure to not proceed with this payment reduction.
On November 16, 2015, CMS released a final rule that bundles acute-care payments for knee and hip replacement surgeries, the most common type of inpatient surgeries for Medicare beneficiaries, with some 400,000 performed in 2004.
Per CPT1, modifier -52 is used when a service or procedure is partially reduced or eliminated at the provider's discretion. Such a situation is identified by using the service's usual HCPCS/CPT code and adding modifier -52, signifying that the service is reduced.
