Covid, OPPS and medical necessity certificates are reported here.
There is good news on the COVID-19 public health emergency (PHE) front. We now know the PHE will remain in effect at least until January 2023. But the Centers for Medicare & Medicaid Services (CMS) scared us last week by publishing a roadmap to ending the PHE. Some thought that this was the promised 60-day notice that the PHE would end in October, but this notice was simply an update of many of the CMS COVID-19 documents including as the listing of the waivers, but many contain added information on what will happen when the PHE does end. In addition, it was published 56 days prior to the next renewal date so it couldn’t possibly be considered 60-day notice. It is crucial that hospital compliance teams review this document to be prepared when the PHE finally is allowed to expire but until that time, you may continue to use the COVID-19 waivers for another few months.
On the good news front, you may have heard that the Food and Drug Administration (FDA) will now allow hearing aids to be sold over the counter and online. This is welcome news to many with hearing loss, as these devices currently are very expensive, costing thousands of dollars. But it will not be a free-for-all on Amazon and eBay. The devices will continue to be regulated by the FDA. The final rule is 200 pages so manufacturers will need to review that carefully and be sure their devices and marketing materials meet the FDA standards.
And in the same arena, in the Outpatient Prospective Payment System (OPPS) proposed rule, CMS is proposing to pay for some routine dental care. Now it would be great if they covered routine dental care for all Medicare patients, but their proposal is to only cover it when the dental care is, as they describe, inextricably linked to, and substantially related and integral to, the clinical success of other covered medical services. In lay terms, that means they will pay for it prior to a patient having a joint replacement or valve replacement or transplant. This is certainly a welcome start for patients and for surgeons. I expect that CMS will soon develop a process to allow dentists to submit claims for payment as most dentists have few or no dealings with Medicare.
Finally, starting Jan. 1, CMS is eliminating all certificates of medical necessity. These are required now for some durable medical equipment and oxygen and physicians universally hate them so this should come as a welcome relief.
But I suspect the DME, and oxygen companies won’t be as excited since they can use the certificate as documented proof the equipment is medically necessary. If a doctor just writes an oxygen order on a prescription pad, as appears to be allowed, the supplier is going to be less certain the patient meets the medical necessity requirements and if audited the suppliers are the ones that won’t get paid, not the doctor.
I am sure we will hear more on this as the new year approaches.
Programming note: Listen every Monday morning when Dr. Hirsch makes his Monday Rounds on Monitor Mondays 10 Eastern and sponsored by R1-RCM.
The Centers for Medicare & Medicaid Services (CMS) has the authority to recoup alleged overpayments from healthcare providers before the full adjudication of an appeal.
I know you are wondering, so I am happy to report that I just went a whole week without watching a webinar. But luckily, I
Please log in to your account to comment on this article.
Physician queries are essential for accurate documentation and claims data, but they are increasingly scrutinized by payors, leading to denials and revenue leakage. This webcast, led by industry expert Cheryl Ericson, RN, MS, CCDS, CDIP, provides actionable strategies to craft compliant queries, reduce denials, and enhance revenue integrity. Attendees will gain insights into clinical validation queries, how to avoid common pitfalls, and learn best practices to defend against query denials. Don’t miss this opportunity to refine your query process and protect your organization’s financial health.
Master the complexities of heart failure coding with this expert-led webcast by Emily Montemayor, CCS, CMBCS, COC, CPC, CPMA. Discover strategies to ensure compliance with ICD-10-CM guidelines, documentation integrity, and capture comorbidities like CKD and hypertension. Learn how to resolve coding challenges, improve documentation practices, and submit clean claims to minimize denials and safeguard your organization’s financial health. With practical insights and real-world examples, this session equips you to prevent revenue leakage, enhance compliance, and secure optimal reimbursement—all while supporting better patient outcomes.
Prepare your organization for the 2025 OPPS updates with expert insights from Tiffani Bouchard, CCS, CRCR, a Revenue Integrity Professional with over 30 years of experience. This webcast will address critical challenges in charge capture and coding, providing clarity on APC policies, C-APC packaging, exclusions, and payer-specific requirements. Attendees will learn actionable strategies to ensure compliance, optimize reimbursement, and mitigate risks of claim denials. Gain the knowledge needed to implement updates effectively, educate your team, and maintain seamless revenue cycle operations in the face of evolving OPPS complexities.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Dr. Ronald Hirsch dives into the basics of Medicare for clinicians to be successful as utilization review professionals. He’ll break down what Medicare does and doesn’t pay for, what services it provides and how hospitals get paid for providing those services – including both inpatient and outpatient. Learn how claims are prepared and how much patients must pay for their care. By attending our webcast, you will gain a new understanding of these issues and be better equipped to talk to patients, to their medical staff, and to their administrative team.
Hospitals face growing challenges in measuring observation metrics due to inconsistencies in classification, payer policies, and benchmarking practices. Join Tiffany Ferguson, LMSW, CMAC, ACM, and Anuja Mohla, DO, FACP, MBA, ACPA-C, CHCQM-PHYADV as they provide critical insights into refining observation metrics. This webcast will address key issues affecting observation data integrity and offer strategies for improving consistency in reporting. You will learn how to define meaningful metrics, clarify commonly misinterpreted terms, and apply best practices for benchmarking, and gain actionable strategies to enhance observation data reliability, mitigate financial risk, and drive better decision-making.
The 2025 Medicare Physician Fee Schedule brings significant changes to payment rates, coverage, and coding for physician services, impacting practices nationwide. Join Stanley Nachimson, MS., as he provides a comprehensive guide to understanding these updates, offering actionable insights on new Medicare-covered services, revised coding rules, and payment policies effective January 1. Learn how to adapt your practices to maintain compliance, maximize reimbursement, and plan for revenue in 2025. Whether you’re a physician, coder, or financial staff member, this session equips you with the tools to navigate Medicare’s evolving requirements confidently and efficiently.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Copyright © 2025 RACmonitor. Powered by MedLearn Media.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
