Shared Services – Truth In Billing

By Jana Weis, Principal, Gill Compliance Solutions, LLC.

As consultants in the healthcare industry, we are asked all kinds of questions on a daily basis.  Yet, if I were to add up the number of times clients ask about shared services, it would likely be on the top of the list.  Shared services seem like an easy concept, two providers’ participation in the care of a patient, right?  Well, almost right. 

Let’s first take into consideration the CMS language surrounding shared services:

Claims Adjudication and Payer Rules under ICD-10

Rayellen Kishbach's picture

Because we process thousands of LCDs updates weekly for our Coding Suite, we often get some insights that we can share. With the implementation of ICD-10, a significant drop off in the number of local coverage determinations (LCDs) and coverage articles published by the Medicare Administrative Contractors (MACs) has occurred. (See table in the white paper link below). While this may be partly due to MAC consolidation, it has left providers with less guidance than before about the proper coding and billing of covered services.

How health care economics teams communicate with payers (and other healthcare entities)

Rayellen Kishbach's picture

In January 2017, the FDA released draft guidance specifying the nature of communications between manufacturers and payers: The first draft guidance, entitled “Drug and Device Manufacturer Communications with Payers, Formulary Committees, and Similar Entities--Questions and Answers,” provides answers to common questions regarding communications of health care economic information (HCEI) about their approved prescription drugs to payers.

Keeping up with MS-DRG Revisions

Rayellen Kishbach's picture

CMS has issued two errata and correction notices for how MS-DRG logic functions in FY2017. These changes may impact payment. This article highlights a few examples.

It is important to note that CMS published v34 r2 in time for implementation on 10/1/2016, but the v34 r3 was released after claims for FY2017 had begun, so improper payments may have occurred.

Be Prepared for Changes in Billing Discarded Drugs/ Biologicals

Christina Panos's picture

By Christina Panos, RHIA, CTR

Original post on 6/9/2016 updated on 6/10/2016 to reflect announced delay.

The Centers for Medicare and Medicaid Services (CMS) has maintained a long-standing policy that provides payment for the discarded portion of single-use vials/packages.  While coverage is not changing, the associated drug wastage billing requirements are about to change.

Understanding non-covered codes – help for denials management and pre-payment review edits

Rayellen Kishbach's picture

Wouldn't it be great if there was just ONE LIST of procedure codes published somewhere by Medicare to identify non-covered services? Unfortunately, there isn’t one, but a quick review of the information that is provided by Medicare can get you there.

Supporting Compliance in the New World of Remote and Outsourced Coding & Billing.

Rayellen Kishbach's picture

According to a recent HIM Benchmark Report, HIM department managers equally ranked Coder Productivity, Quality, and Managing Financial Metrics as their biggest challenges, while that same report noted that close to 60% of HIM professionals outsource a portion of their coding needs. Even without direct outsourcing, we notice an increase in the opportunity to do coding and billing work remotely.

Understanding MS-DRG Grouping under ICD-10

Rayellen Kishbach's picture

Now that ICD-10 is in full swing, we are seeing a lot of activity with providers, payers, consultants and regulators who need to understand how Acute Inpatient and Long Term Care Hospital claims "behave" when the claim is coded in ICD-10. This includes both prospective and retrospective review of claims scenarios to understand MS-DRG grouping. This article offers a basic primer on MS-DRG grouping logic, and research techniques for using related MediRegs Coding Suite tools.

OIG Releases New Compliance Oversight Document for Health Care Governing Boards

Darci Friedman's picture

On April 20th, Daniel R. Levinson, the Inspector General for the Office of Inspector General ("OIG"), U.S. Department of Health and Human Services ("HHS") delivered an address at HCCA's 19th Annual Compliance Institute. He was his usual captivating, thoughtful self, delivering a few gems for those in attendance. One of those gems was that that day the OIG released a new document for the industry titled: Practical Guidance for Health Care Governing Boards on Compliance Oversight ("Practical Guidance").

OCR Releases a New Version of Guide to Privacy and Security of Electronic Health Information

Darci Friedman's picture

The Office of Civil Rights recently released Version 2.0 of its' Guide to Privacy and Security of Electronic Health Information ("Guide"). This new version of the Guide provides updated information about compliance with the Medicare & Medicaid Electronic Health Record (EHR) Incentive Programs' privacy and security requirements as well as the HIPAA Privacy, Security, and Breach Notification Rules. You can access the updated document on your MediRegs product, with the OCR data in the HIPAA Library.

Be There or Be Square: HCCA's Annual Compliance Institute

Darci Friedman's picture

HCCA's Annual Compliance Institute is just 25 days away! I attend the Compliance Institute every year, but this year I am really looking forward to it. Part of my eagerness is motivated by the fact that I write this from the greater Boston area. This has been a really rough winter for even the heartiest of New Englanders and it just seems as though there is no end in sight. It is a cold 21 degrees today. Brrrrr!  Lake Buena Vista, Florida - where this year's Compliance Institute is being held is projected to have a high in the mid-eighties today.  I'll take it!

Gain clarity into 2015 IPPS & OPPS Final Rules

Every year we provide in-depth learning covering both the Inpatient Hospital PPD (IPPSFinal Rule and the Outpatient Prospective Payment System (OPPS) Final Rule. This year we covered the important issues in these Final Rules, as well as provided practical suggestions for how providers should respond to the changes from these new Rules, in two online webinars.

Demystify IPPS with Our Improved Integrated MS-DRG Grouper and Calculator!

We are pleased to announce our new and improved provider-specific MS-DRG Grouper and Calculator, powered by New Health Analytics. Demystify payment under the Inpatient Prospective Payment System, and understand and compare payment for different MS-DRGs, or for the same MS-DRG over time.

Dateline San Diego: AHIMA: This is What is Happening in San Diego

Originally Posted in

Listen to the Talk Ten Tuesday Podcast

As always, AHIMA delivers a great convention filled with the latest and greatest industry knowledge and technology! Two of the greatest and most meaningful takeaways this year are related to Big Data and ICD-10, both of which tie nicely together.

ICD-10 Resources: Four Educational Webinar Replays

As we near the one-year mark to the updated ICD-10 deadline, we are continuing to provide ongoing educational resources to directly address the ongoing risks and challenges relating to the adoption of ICD-10 throughout your organization. Visit our online resource center to watch a replay of our four most recent ICD-10-related educational webinars:

New States Maintaining Separate Medicaid Sanction Lists

Don’t forget that Alaska, Louisiana, Minnesota, Missouri, North Carolina and North Dakota now maintain separate Medicaid exclusion and sanction lists. And if you're not staying up to date with your sanction screening, your organization is at risk for severe penalties. Sanction Screening Services (S3™) delivers the next generation of self-managed and full service sanction and exclusion checking with up-to-date state and federal databases.

How we can help you "Ramp Up" your ICD-10 Operations

Rayellen Kishbach's picture

On July 31, 2014, CMS announced that the U.S. Department of Health and Human Services (HHS) issued a rule finalizing Oct. 1, 2015 as the new compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10. According to CMS:

"This deadline allows providers, insurance companies and others in the health care industry time to ramp up their operations to ensure their systems and business processes are ready to go on Oct. 1, 2015."

How do Medical Review professionals keep up?

Rayellen Kishbach's picture

The ever-increasing pace of healthcare benefit and coverage policy change makes it harder than ever for medical review professionals to make quick, completely informed policy and reimbursement decisions. Without the right information and tools, your organization’s exposure to risk increases. This risk is multiplied when you have to monitor and comply with updates across multiple states.

Understand Local and National Coverage with MAC Coverage Articles

Rayellen Kishbach's picture

We know understanding Medicare coverage is a challenge, and we've just made this challenge easier by upgrading all of our health care products to include Medicare Administrative Contractor (MAC) Local Coverage Articles. These articles can provide a deeper explanation of the MAC Local Coverage Determination (LCD) logic, or explain special topics like non-covered services, self-administered drug lists, coding rules for National Coverage Determinations (NCDs) and more.

Demystify Inpatient Reimbursement with Simple Tools

Rayellen Kishbach's picture

Understanding the Inpatient Prospective Payment System can be quite a challenge (see below for key references!), but MediRegs subscribers can know right now with our MS-DRG electronic codebook, MS-DRG Grouper, and MS-DRG Calculator. We’ve recently released a significantly improved provider-specific MS-DRG calculator, powered by New Health Analytics. This calculator demonstrates MS-DRG payments under the Inpatient Prospective Payment System and includes the following enhancements:

Coding is easier with electronic references

Rayellen Kishbach's picture

Every day, I hear from clients who are frustrated by having to access so many different references, including payer websites, encoders, paper references, and the government websites. It is always rewarding to train new users on the Coding Suite, seeing the “Aha!” moments when they realize that they can get all of the information they need in one source.

Inpatient PPS Rule - Easier to Understand in E-Book Format

Rayellen Kishbach's picture

CMS has published the FY2015 IPPS Final Rule Rule, and MediRegs makes reading and understanding this rule easier with our electronic book version and payment data files. In this blog article, I will tell you where to find IPPS resources and what to expect in your product alerts.


For a quick review of the FY2015 IPPS Rule, check out the Presentation Slides from our FY2015 IPPS Final Review webinar.

ICD-10 Delay Provides Opportunity for Data-Based Assessment and Planning

Rayellen Kishbach's picture

By now, we all have come to realize that ICD-10 preparation is not a boiler-plate process; each organization has it's own unique challenges and opportunities. The delay gives every organization a chance to take a careful look at their own specifics - and a good place to start is the bottom line! Do you have a solid understanding of the payment impact your organization will face under ICD-10?

ICD-10-CM: Myths Gone Wild

As the ICD-10-CM implementation date nears, it seems that the buzz has heightened and along with the buzz comes half-truths and misconceptions.   A recent online article in Forbes’s magazine focused on coding.  The article, “Doctors Lag Far Behind On New Medicare Diagnosis Codes,” implies that ICD-10-CM codes are Medicare codes.  Because the United States uses ICD-9-CM (and eventually ICD-10-CM) in the billing process, we have ventured away from real reason we code:  to have an efficient, consistent system of capturing data that supports healthcare decision making in our country.   Do we ca

Maria Bounos from Wolters Kluwer joins "Talk Ten Tuesday" to discuss ICD-10: Now and Then

 Maria Bounos, RN, MPM, CPC-H, Practice Lead Coding and Reimbursement Products from Wolters Kluwer, will appear on’s “Talk Ten Tuesday” on October 14, 2013 at 10am EDT as part of an expert panel to discuss ICD-10: Now and Then. Register Now!

Government Shutdown

The content team at Wolters Kluwer Law & Business wanted to provide you with an update on the products, given the government shutdown.

Here is what the majorify of the government sites are stating: "Due to the lapse in government funding, only web sites supporting excepted functions will be updated unless otherwise funded. As a result, the information on this website may not be up to date, the transactions submitted via the website may not be processed, and the agency may not be able to respond to inquiries until appropriations are enacted. Updates regarding government operating status and resumption of normal operations can be found at" 

New York State Goes Paperless for Health Commerce System Accounts

The New York State Senate passed the Internet System for Tracking Over-Prescribing (“I-STOP”) Act in order to curb abuse and diversion of prescription drugs.  The program requires prescribers to review the patient’s recent history of controlled substance prescriptions, which offers providers more information to exercise professional judgment in treating patients.  Starting on August 27, 2013, any New York State (NYS) licensed prescriber who holds a valid DEA registration must consult New York’s online Prescription Monitoring Program (PMP) Registry prior to prescribing Schedule II, III or IV

OIG Work Plan To Be Released in January 2014!!

The Office of the Inspector General has just announced that its annual Work Plan will not be released in the Fall!  The Work Plan is usually released in early October.  But now, the OIG says the "Work Plan will next appear in January 2014. This change from the usual October release will better align with priorities OIG has set for the coming year, a time of continuing fiscal challenges."

Is ICD-10 really needed in the US?

Key industry players, such as the AMA and MGMA, have questioned whether we really need ICD-10-CM in this country.  They seem to think there will be no benefit to clinicians with the upcoming change in the diagnosis coding system.  I think they’re wrong.  The current system hasn’t been overhauled since 1979.  It’s been updated every year but it can’t move forward to work in the electronic environment and it can’t capture information about current day medical practice.  It’s pretty hard to describe cutting edge medicine with a 34 year old system. 

Medicare and Inpatient Consultations

CMS made a major blooper in their announcement about a new set of claims edits designed to keep providers from reporting new patient evaluation and management (E/M) services more frequently than allowed. But the good news is that they have fixed the edits and you should not run into any problems with them as long as you are following correct E/M coding guidelines. On May 3 CMS issued Transmittal 1231, which explained the new edits. The Transmittal listed the codes that CMS considered to be new patient services.

New OIG Self-Disclosure Form Online Follows Updated Protocol

Today, the OIG launched an online submission process for the Self-Disclosure Protocol ("SDP").  The SDP is a mechanism for providers to voluntarily disclose evidence of potential fraud to the OIG and have the opportunity to avoid the costs and disruptions associated with a government-directed investigation and civil or administrative litigation.  This new online form comes just a few months after the OIG issued an updated SDP on April 17, 2013.  In the updated SDP, the OIG reviews the benefits of disclosure:

AHIMA ICD-10 and Computer Assisted Coding Summit – Our Takeaways

We just got back from the AHIMA ICD-10 and Computer Assisted Coding Summit, and wanted to share our experience.
In the sessions, during social time, and while interacting with attendees, we heard deep and intelligent conversations about the readiness assessment process, education approaches, and implementation strategies. We are pleased that the “wait and see” attitude so prominent last year seems to have shifted to “let’s get this done!”

Navigating the Diabetes Self-Management Training (DSMT) Reimbursement Maze (Webinar Replay)

View a replay of the the Navigating the Diabetes Self-Management Training (DSMT) Reimbursement Maze webinar. This replay will give you an overview of Diabetes Self-Management Training (DSMT) Coding and Coverage. Review practices for overcoming reimbursement obstacles faced by pharmacies, solo practices and other providers, along with ways to Improve Profitability of AADE programs.

The Medical Record – Best Evidence in Response to Audits (Webinar Replay)

View a replay of the the Medical Record – Best Evidence in Response to Audits webinar. Third party recovery audits have increased significantly over the past several years putting facility and provider revenue at greater risk. During this audit activity, it is the medical record that is being scrutinized – it can either be a facility’s best defense or its worst.

MEGA HIPAA Can Be An Opportunity!

We all know Compliance Officers are more than busy and redoing HIPAA is not always on the front burner.

But given MEGA HIPAA, we all must revisit and enhance our HIPAA programs. This is a perfect time to consider the basics of your program.

Think about it this way: what trends or situations are happening in your organization that might drive basic changes or expansion of your HIPAA program?

It’s not long, but here is my list:

  • Purchase of Physician Practices

Beyond HIPAA: Developing Your Information Security Program

Trust is essential to realizing the benefits that technology is bringing to the healthcare world. With the confidence that healthcare organizations will handle information about them fairly and responsibly, patients are becoming more interested and adept at participating in their healthcare, including having access to their private health information.

Absorbing the Changes for Behavioral Health

2013 marked a significant year for coding changes for psychiatry and psychology. As with other specialties, the AMA provided a clear division of coding for psychotherapy services as opposed to medical management of patient problems.

CMS has adopted most of the new coding regulations put forth by the AMA yet, many state Medicaid plans have narrowed the scope of coverage within the code series.


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