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Integrity Medical Billing, Inc. - Blog 

Entry Date July 13, 2015

Questions about Aetna's chiropractic services? Check out Aetna's latest review on 03/20/2015, learn exactly what they are looking for to determine medical necessity. Just go to the following URL for all the information you need!!!

Entry date: Febuary 20, 2015

Commercial payers, unless otherwise requested within their guidelines (most do not), follow the same rule issued by HHS/OIG.

Updated Regulations:

In May 2014, the Department of Health and Human Services, Office of Inspector General (OIG) published a proposed rule updating its regulations. The proposed rule will authorize civil monetary penalties for “failure to report and return a known overpayment,” among other issues. The rule has outlined the penalty for failure to repor...t and return overpayment no longer than 60 days after the date the overpayment was identified, and characterizes it as a per day penalty with up to $10,000 for each day a practice fails to report and/or return a known overpayment. The final rule has not been determined, and there is speculation that Congress may convert the per day penalty to a “per item” or per service penalty. Either way, the assessment of a penalty of this magnitude could ruin a practice.

Entry date: February 7. 2015

An update has been established on ICD-10 :

CD-10 Compliance Date: October 1, 2015

About ICD-10

The transition to ICD-10 is required for everyone covered by the Health Insurance Portability Accountability Act (HIPAA). Please note, the change to ICD-10 does not affect CPT coding for outpatient procedures and physician services.

Road to 10: CMS Online Tool for Small Practices

Jump start your ICD-10 transition with Road to 10, an online resource built with input from providers in small practices.

“Road to 10” includes specialty references and helps providers build ICD-10 action plans tailored for their practice needs.

CMS Resources

Entry date: February 7, 2015

Pqrs updates were finalized on January 7, 2015 please read below to understand the update:

Physician Quality Reporting System

Physician Quality Reporting System (Physician Quality Reporting or PQRS) formerly known as the Physician Quality Reporting Initiative (PQRI)About PQRS

PQRS is a reporting program that uses a combination of incentive payments and negative payment adjustments to promote reporting of quality information by eligible professionals (EPs).

The program provides an incentive payment to practices with EPs (identified on claims by their individual National Provider Identifier [NPI] and Tax Identification Number [TIN]). EPs satisfactorily report data on quality measures for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare Secondary Payer).

Beginning in 2015, the program also applies a negative payment adjustment to EPs who do not satisfactorily report data on quality measures for covered professional services. This website serves as the primary and authoritative source for all publicly available information and CMS-supported educational and implementation support materials for PQRS.

Stay up to date on the latest news and updates by following us on Twitter.

Stay informed about the latest PQRS news by subscribing to the PQRS Listserv.

PQRS Quick Links

For step-by step instructions on how to implement PQRS, view the How to Get Started page. In addition, learn more about PQRS and how to participate by visiting the following pages:

• For information on how to select measures, review the Measures Codes page

• For information on reporting mechanisms, review the following pages:

o Registry Reporting page

o Medicare EHR Incentive Program Reporting page

o Group Practice Reporting Option page

o Qualified Clinical Data Registry (QCDR) page.

• For information on incentive payments, review the Analysis and Payment page

• For information on adjustments, review the Negative Payment Adjustment Information page

Help Desk

If you have questions or need assistance with PQRS reporting please contact the QualityNet Help Desk. The help desk is available Monday – Friday; 7:00 AM–7:00 PM CST:

Phone: 1-866-288-8912 TTY: 1-877-715-6222 Email:

Sign Up or Pre-Registration.

Individual EPs do not need to sign up or pre-register in order to participate in PQRS. However, to qualify for a PQRS incentive payment an EP must meet the criteria for satisfactory reporting specified by CMS for a particular reporting period. A revised List of Eligible Professionals who may participate in PQRS is available by clicking on this link.

Note: The PQRS program requirements and measure specifications for the current program year may be different from the PQRS program requirements and measure specifications for a prior year. EPs are responsible for ensuring that they are using the PQRS documents for the correct program year.

2014 PQRS

To participate in the 2014 PQRS, individual EPs may choose to report information on individual PQRS quality measures or measures groups using the following mechanisms: 

Individual EPs who meet the criteria for satisfactory submission of PQRS quality measures data via one of the reporting mechanisms above for services furnished during a 2014 reporting period will qualify to earn a PQRS incentive payment equal to 0.5% of their total estimated Medicare Part B Physician Fee Schedule (PFS) allowed charges for covered professional services furnished during that same reporting period.

A group practice may also potentially qualify to earn PQRS incentive payments equal to 0.5% of the group practice's total estimated Medicare Part B PFS allowed charges for covered professional services furnished during a 2014 PQRS reporting period based on the group practice meeting the criteria for satisfactory reporting specified by CMS.

To participate in the 2014 PQRS, group practices may choose to report information on individual PQRS quality measures using the following mechanisms:

(1) Qualified PQRS registry

(2) Web interface (for groups of 25+ only)

(3) Direct EHR using CEHRT

(4) CEHRT via Data Submission Vendor

(5) CG CAHPS via CMS-certified survey vendor (for groups of 25+ only)


If reporting for PQRS through another CMS program (such as the Medicare Shared Savings Program, Comprehensive Primary Care Initiative, Pioneer Accountable Care Organizations), please check the program’s requirements for information on how to report quality data to earn a PQRS incentive and/or avoid the PQRS negative payment adjustment. Please note, although CMS has attempted to align or adopt similar reporting requirements across programs, eligible professionals should look to the respective quality program to ensure they satisfy the PQRS, EHR Incentive Program, Value-Based Payment Modifier (VBM), etc. requirements of each of these programs.


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