John Moody's Healthcare Compliance Issues Page

John Moody's
Healthcare Compliance Issues Page
(Last Updated 11/03/09 at 8:52 a.m.)

** John's Company - Healthcare Revenue Integrity Consulting **

Table of Contents

Outpatient Prospective Payment System (OPPS; APC)

Recovery Audit Contractor Program (RAC)

New ABN Guidelines/Forms

HIPAA Information

Hospital Issues

Laboratory Issues

National Coverage Determinations (non-Lab)/Clinical Trials

Other Resources on the Web

Additional Healthcare Compliance Links

APC OUTPATIENT PROSPECTIVE PAYMENT SYSTEM INFORMATION
CMS Hospital OPPS Overview Web Site Regulations and Notices Transmittals MLN (Medicare Learning Network) Matters Articles Addendum B Updates Page Device-Procedure Edits Page Pass-through Payment Device Program Memoranda (Historic)

CMS Recovery Audit Contractor Program
CMS Recovery Audit Contractor (RAC) Program Overview Web Site CMS RAC Recent Updates Region C RAC Web Site Region C Recovery Audit Contractor (RAC) is Connolly Healthcare. Region C consists of the states of: AL, AR, CO, FL, GA, LA, MS, NC, NM, OK, SC, TN, TX, VA, WV and the territories of Puerto Rico and U.S. Virgin Islands. Region C Approved Issues List

ABN INFORMATION
CMS Beneficiary Notices Initiative (BNI) ABN Forms, Instructions (Medicare Claims Processing Manual) 3/20/08

HIPAA INFORMATION
CMS HIPAA Web-Site HIPAA Healthcare EDI Code Set Lists 2/06/04

LABORATORY COMPLIANCE ISSUES
CMS Website: Clinical Laboratory Information for Medicare FDA Clinical Laboratory Improvement Act (CLIA) Web Site Added 12/20/06 Clinical Laboratory Related Transmittals American Red Cross Department of Reimbursement Policy and Provider Support Website 11/3/09 National Coverage Determinations (NCD) Information CMS Laboratory National Coverage Determinations (NCDs) Website"> 9/12/08 CMS Laboratory NCDs Alpha Listing 9/12/08 AB-02-134 Q & A on Implementation of NCDs for Clinical Laboratory Services 9/27/02 Final Rule Establishing National Coverage and Administrative Policies for Clinical Diagnostic Laboratory Services (Effective 11/25/2002) 11/21/2001 National Coverage Determinations (NCD)- Clinical Lab Testing (Part 1 of 3) National Coverage Determinations (NCD)- Clinical Lab Testing (Part 2 of 3) National Coverage Determinations (NCD)- Clinical Lab Testing (Part 3 of 3) Medical Necessity of Laboratory Test CMS (formerly HCFA) ABN Quick Reference Guide 9/03/01

LABORATORY COMPLIANCE ISSUES

CMS Website: Clinical Laboratory Information for Medicare
FDA Clinical Laboratory Improvement Act (CLIA) Web Site Added 12/20/06

Clinical Laboratory Related Transmittals
American Red Cross Department of Reimbursement Policy and Provider Support Website 11/3/09
National Coverage Determinations (NCD) Information
- CMS Laboratory National Coverage Determinations (NCDs) Website"> 9/12/08
- CMS Laboratory NCDs Alpha Listing 9/12/08
- AB-02-134 Q & A on Implementation of NCDs for Clinical Laboratory Services 9/27/02
- Final Rule Establishing National Coverage and Administrative Policies for Clinical Diagnostic Laboratory Services (Effective 11/25/2002) 11/21/2001
  National Coverage Determinations (NCD)- Clinical Lab Testing (Part 1 of 3)
  National Coverage Determinations (NCD)- Clinical Lab Testing (Part 2 of 3)
  National Coverage Determinations (NCD)- Clinical Lab Testing (Part 3 of 3)
Medical Necessity of Laboratory Test
CMS (formerly HCFA) ABN Quick Reference Guide 9/03/01

National Coverage Determinations/Clinical Trials (non-Laboratory)
Medicare Coverage Policy Website Updated for new CMS web site 12/20/05 Medicare Coverage Policy - What's New Updated for new CMS web site 12/20/05 Medicare Coverage of Clinical Trials: Medicare Learning Network: Coverage of Clinical Trial Services Q/A 4/26/01 Medicare Coverage Policy ~ Clinical Trials 11/27/00 FDA Clinical Trials Website 11/27/00 Office of Human Research Protections Website 7/5/01

National Coverage Determinations/Clinical Trials (non-Laboratory)

Medicare Coverage Policy Website Updated for new CMS web site 12/20/05
Medicare Coverage Policy - What's New Updated for new CMS web site 12/20/05
Medicare Coverage of Clinical Trials:
- Medicare Learning Network: Coverage of Clinical Trial Services Q/A 4/26/01
- Medicare Coverage Policy ~ Clinical Trials 11/27/00
- FDA Clinical Trials Website 11/27/00
Office of Human Research Protections Website 7/5/01

HOSPITAL COMPLIANCE ISSUES
CMS Acute Inpatient Hospital PPS Web site Added 10/17/08 IPPS Notices and Regulations Added 10/17/08 Acute IPPS Transmittals Added 10/17/08 CMS Inpatient Rehabilitation Facility (IRF) PPS Web Site Added 10/17/08 IRF Classification Criteria Added 10/17/08 IRVEN (Inpatient Rehabilitation Validation and Entry)Software Web Site Added 10/17/08 IRF PPS Transmittals Added 10/17/08 CMS Inpatient Psychiatric Facility (IPF) PPS Web Site Added 10/17/08 Code of Federal Regulations Related to Inpatient Psychiatric Care Added 10/17/08 IPF PPS Regulations Notices and Dupport Documentation Added 10/17/08 IPF PPS Notices and Regulations Added 10/17/08 IPF PPS Transmittals Added 10/17/08 CMS Hospital-Acquired Conditions (Present on Admission Indicator) Web Site Added 11/09/07 CMS Hospital Quality Initiatives Center SE0622 - Clarification of Medicare Payment Policy When Inpatient Admission Is Determined Not To Be Medically Necessary, Including the Use of Condition Code 44: "Inpatient Admission Changed to Outpatient" 04/08/06

HOSPITAL COMPLIANCE ISSUES

CMS Acute Inpatient Hospital PPS Web site Added 10/17/08

IPPS Notices and Regulations Added 10/17/08
Acute IPPS Transmittals Added 10/17/08

CMS Inpatient Rehabilitation Facility (IRF) PPS Web Site Added 10/17/08

IRF Classification Criteria Added 10/17/08
IRVEN (Inpatient Rehabilitation Validation and Entry)Software Web Site Added 10/17/08
IRF PPS Transmittals Added 10/17/08

CMS Inpatient Psychiatric Facility (IPF) PPS Web Site Added 10/17/08

Code of Federal Regulations Related to Inpatient Psychiatric Care Added 10/17/08
IPF PPS Regulations Notices and Dupport Documentation Added 10/17/08
IPF PPS Notices and Regulations Added 10/17/08
IPF PPS Transmittals Added 10/17/08

CMS Hospital-Acquired Conditions (Present on Admission Indicator) Web Site Added 11/09/07
CMS Hospital Quality Initiatives Center
SE0622 - Clarification of Medicare Payment Policy When Inpatient Admission Is Determined Not To Be Medically Necessary, Including the Use of Condition Code 44: "Inpatient Admission Changed to Outpatient" 04/08/06

OTHER RESOURCES ON THE INTERNET:
GPO Access (Federal Register) Advanced Search Alabama Medicare (Provider Page) Medicare News Line (Formerly MedicareFocus (AL) Medicare Special Bulletins with SB beside the month (AL) Alabama Part A Local Coverage Determinations (LCDs) National Coverage Determinations(NCDs) CMS Home Page CMS Web Site for HCPCS Updates (See Quarterly Updates Here) Medicare Payment Systems (Links to each System) 8/22/02 Physician Fee Schedule Web Site ("a" is original, check "b","c","d",etc. for updates) 11/09/06 CMS Website for National Correct Coding Initiative Edits - HOPPS CMS Website for Medically Unlikely Edits (MUE) 10/01/09 Update Posted Medicare/Medicaid Program Transmittals CMS Medlearn Matters articles CMS Online Manual System (Be sure to read the Introduction for cross-walk information from old paper-based manuals) Source for Medicare & Medicaid Paper-based Manuals Medicare's Regulations and Guidance Page HHS-OIG Home Page HHS-OIG Compliance Guidance Materials HHS-OIG Work Plan Page (2010 Work Plan Posted Now) 2009 Work Plan 2008 Work Plan 2007 Work Plan 2006 Work Plan HHS-OIG Advisory Opinions (Advisory Opinion(s) No. 09-16 Posted 9/24/09) HHS-OIG Advisory Opinion FAQ Federal Register Publication of OIG Special Advisory Bulletin on Contractual Joint Ventures 4/30/03 OIG Anti-Kickback/Safe-Harbor Information The False Claims Act OIG's Provider Self-Disclosure Protocol (.pdf format) FDA Information for Health Professionals Page FDA NDC Directory Web site Medicaid of Alabama Links ICD9 Code Listing Washington G-2 Reports

OTHER RESOURCES ON THE INTERNET:

Source for Medicare & Medicaid Paper-based Manuals

Medicare's Regulations and Guidance Page

HHS-OIG Advisory Opinion FAQ

Additional Healthcare Compliance Links

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DISCLAIMER: I am a not a lawyer or professional coder. While I have attempted to guarantee accuracy prior to providing the displayed information, I can only assure viewers of my good faith effort to provide accurate, timely information. Use of materials from this web page should be based on this disclaimer and YOUR best judgement.