SCGhealth Blog

CMS about to crack down on billing for drug tests

Monday, April 23, 2018

By Marla Durben Hirsch, contributing writer

If you bill for specimen validity testing done in conjunction with drug testing, heads up: the Centers for Medicare & Medicaid (CMS) has taken the rather unusual step of issuing a “reminder” on how to do so correctly. 

Specimen validity testing is used to analyze urine specimens and determine whether they’ve been adulterated or tampered with. 

In a new Special Edition MLN Matters article, issued on March 29, 2018, CMS reiterates Medicare’s policies regarding correct coding and instructions for billing specimen validity testing when done as part of drug testing. 

The article, SE18001, first lays down the groundwork: Services that Medicare pays for must be reasonable and necessary, and clinical lab services must be ordered and used by the physician who is treating the patient or by a qualified ancillary practitioner. Current coding for testing for “drugs of abuse” relies on (1) screening (known as presumptive testing, CPT codes 80305- 80307) and (2) quantitative or “definitive” testing that identifies the specific drug and quantity of it in the patient (HCPCS codes G0480-G0483). Only one code from each code range may be reported per date of service. 

There’s also a definitive drug testing code, G0659, that was created to recognize labs that are performing a less sophisticated version of these tests. The work performed in this test approximates the work performed in CPT code 80307. 

Importantly, “providers performing validity testing on urine specimens utilized for drug testing shall not separately bill the validity testing.” 

The agency stresses that this is not a policy change, but serves as a reminder of Medicare requirements. CMS implores providers to “please make sure your billing staffs are aware of these instructions.”

Topic a New Sore Spot for CMS

SE18001 itself doesn’t state why it issued this particular reminder, but a quick look at the references at the end of the article reveals what’s going on. The Department of Health and Human Services’ Office of Inspector General (OIG) recently reported that CMS had improperly paid 4,480 labs and physician offices a whopping $66.3 million for these tests from 2014 to part of 2016. 

Even after CMS updated its automated system edits to identify and prevent these improper payments in 2016, OIG still identified $1.8 million in improper payments from April 1 through December 31 of that year. 

OIG also found that at this rate, CMS would lose $12.1 million due to such improper payments over a five-year period. Ouch. 

What physicians can expect 

While the OIG has had lab testing (and lab/physician deals) in its cross hairs for years, this is yet another lab testing issue that will now come under increased scrutiny. 

And while this reminder about urine testing may be spurred by the OIG report, it’s also likely due in part to the fact that more physicians are conducting or ordering these tests in light of the current focus on opioid addiction and substance abuse disorders. This also puts more pressure on CMS to pay for them correctly. 

If you have billed for these tests in the past, expect your Medicare Administrative Contractor to take another look at those claims. The OIG specifically recommended that CMS instruct the Medicare contractors to recover the improper payments. You may want to conduct a self audit and double check that you complied with these billing rules. 

And if you currently bill for these tests, make sure that you’re doing so correctly. CMS will be taking a closer look at them. And the fact that CMS just issued a “reminder” indicates that CMS expects everyone to know the drill. 

2018 SCG Health QCDR Measures Sneak Peak

Wednesday, April 11, 2018

By Audrey Landers

Last week the 2017 MIPS reporting period finally came to a close, which means it’s time to ramp up our 2018 enrollment! SCG Health has been approved as a Qualified Clinical Data Registry (QCDR) for the 2018 reporting year. To help you meet your reporting goals while providing high quality healthcare, we have created the following six measures which will be available for the 2018 reporting year:

SCG1: Evaluation of High Risk Pain Medications for MME
The United States is in the midst of an opioid epidemic and we believe physicians should be doing all they can to help bring it under control. This includes assessing and recording the dosage of those prescribed high-risk medications such as opiates, benzodiazepines, anti-spastics and NSAIDS. 

SCG2: Outcome Assessment for Patients Prescribed Ankle Orthosis for Ambulation and Functional Improvement
This outcome measure encourages quality care by allowing the patient’s recovery to affect the final score. The only way for performance to be met in this measure is to document a significant improvement in ankle function, or to confirm that there is no problem with function.

SCG3: outcome Assessment for Patients Prescribed Foot Orthosis for Ambulation and Functional Improvement
Similarly to SCG2, this outcome measure’s score relies on patient recovery. The only way for performance to be met in this measure is to document a significant improvement in foot function, or to confirm that there is no problem with function. 

SCG4: Prevention of Antibiotic or Herbal Supplement Impairment of Anesthesia
Many consumers may not be aware that herbal supplements, which are often marketed as being natural and healthy, can have negative interactions with other medications. Because of this, patients may not mention supplements when listing current medications or may be vague saying “I take a vitamin.” Physicians should have a checklist that includes discussing discussing prescribed medications, antibiotic medications and specific herbal supplements, possible complications from combinations of antibiotics or herbal supplements with anesthesia, and ensuring that the surgical team is included with anesthesia impairment prevention and management. 

SCG5: Improvement in Quality of Life from Partial Foot, Prosthetics
This measure was created to help physicians quantify how much a patient’s life has been improved by a prosthetic, with the score being based on patient questionnaires. Performance is met if a patient reports that their quality of life has improved or remains the same.

SCG6: Outcome of High Risk Pain Medications Prescribed in the Last Six Months
SCG Health created this measure to help physicians remain aware of the over prescription of dangerous medications such as opioids, benzodiazepines, anti-spastics, and NSAIDS. In order for performance to be met, a patient’s polypharmacy evaluation must result in some sort of prescription change, whether it be a reduction in the number of medications, a change to a different pain management medication or a change in dose or frequency.

If you don’t think you fit these measures, don’t fret! We’ve licensed 21 measures from seven other QCDRs that you may be able to use. Here’s a sneak peak of what other kinds of measures we have to offer:

  • MA3 Corneal Abrasion
  • ACS18 Patient Frailty Evaluation
  • AQI51 Assessment of Patients for Obstructive Sleep Apnea
  • CDR2 Diabetic Foot Ulcer (DFU) Healing or Closure
  • CODE7 Improved Functional Outcome Assessment for Knee Replacement
  • MEX1 Heel Pain Treatment Outcome for Adults
  • MSSIC1 Pre-Surgical Screening for Depression

A full list of all the great measures we are offering in 2018 can be found here.

OIG to CMS: We’re Worried About How You Review Extrapolation

Monday, February 26, 2018

By Marla Durben Hirsch

Physicians may soon see some welcome relief when it comes to dealing with denied Medicare claims and overpayment demands involving statistical sampling, also known as extrapolation. The Office of the Inspector General (OIG) announced this month that is has added to its work plan a review of how the government is applying “statistical methods” during the Medicare fee-for-service administrative appeal process. 

Medicare program integrity contractors are authorized to use statistical sampling to determine how much a provider had been overpaid. 

Statistical sampling applies the rate of billing errors found in a sample of claims to a similar total group of claims. Medicare auditors use this methodology regularly.

However, providers often disagree with the calculated result and challenge these statistical estimates by using Medicare’s five step administrative appeals process. According to the OIG’s announcement, if an extrapolation estimate is overturned during this process, the provider is liable for any overpayment upheld in the sample, but not the full extrapolated total. The OIG acknowledges that the difference is “often substantial.” 

The first two levels of appeal, conducted by Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) “play a critical role in deciding which extrapolations will be upheld.” Evidently the OIG has determined that these contractors may be dropping the ball and has decided to review whether they are “reviewing statistical estimates in an appropriate and consistent manner.” 

In other words, the OIG knows that mistakes can be made when applying extrapolation and wants to make sure that they’re being caught. The errors include:

  • The underlying audit that the sampling is based on is wrong. For instance, the audit used the wrong codes or wrong error rate in determining whether there was any overpayment.
  • The rules of extrapolation weren’t followed. For example, it’s only supposed to be used in certain situations, such as when there is a sustained or high level of payment errors.
  • The sample wasn’t valid. For instance, the sample may have been too small.
  • The government made a math error.

In addition, the government is supposed to give the provider a report of the extrapolation so that the provider can review it but that doesn’t always occur or is provided late, so that the provider must file an appeal before having had a chance to see if the calculations are correct. 

The OIG probably has two objectives here. It not only wants to ensure that the appeals process is working correctly, but also to reduce the logjam of appeals currently choking the appeals process

The OIG has previously reported that providers are more likely to have an adverse determination overturned only after getting to the third level of appeal, the administrative law judge (ALJ) level, which is the first stage independent of the Centers for Medicare and Medicaid Services and the first stage which allows hearings. The OIG found fully favorable results in just 20 percent of cases decided at the QIC level of appeal, compared to a fully favorable result 56 percent of the time at the ALJ level. 

Why this review is important to physicians
This new review is good news for physicians and other providers, and could have a major impact. It may uncover inconsistencies and other issues with the way that MACs and QICs currently handle extrapolation appeals and could ultimately lead to improvements in not only the use of extrapolation but also the appeals process itself. 

It may mean that fewer sampling mistakes will be made so fewer appeals will need to be filed, and if an appeal is filed, a mistake may be caught sooner on appeal.

It may also raise awareness among physicians that they should not take extrapolation calculations at face value but review them carefully and challenge them if necessary.

KNOW QPP Enrollment Deadline Extended!

Wednesday, February 14, 2018

By Audrey Landers

Enrollment for 2017 KNOW QPP was originally going to end today, but we realized that some of you were heartbroken at the thought of missing the deadline! Worry not, we’re officially extending our enrollment until March 1, 2018 at 7:00 PM EST.

You’ve got more than enough time to let us help you avoid a penalty, or maybe even get a bonus!

2017 Subscription Options

 90 Days of Data


 90+ Days of Data
       2018 Reporting Prep      


If you have any questions, don’t be afraid to ask Gina or give us a call at 888-886-8054

To make sure we are there whenever you need us, we will be keeping extended hours until the end of MIPS reporting season on March 31. You'll be able to get ahold of us from 7 AM to 7 PM Monday through Saturday.

Gimme 15 Minutes- Attesting to Advancing Care Information (Meaningful Use) and Improvement Activities

Friday, January 19, 2018

By Audrey Landers

Join us on Monday, January 29, 2018 at 12:30 PM EST for a free webinar event about the ACI attestation.

SCG Health founder and CEO Jennifer Searfoss will be demonstrating how to use the Centers for Medicare and Medicaid Service’s (CMS) newly updated website to attest to their 2017 data for the Merit-based Incentive Payment System.

If you want to do some reading beforehand, you can read our blog post which explains what attestation means and its importance. 

If you are interested in this free event, you can register here. After registering, you will receive an email about how to access the webinar.

Won’t be available for the event? No worries! All our past webinars are posted to our YouTube channel. Keep an eye on our events schedule so you can keep your calendar free for the next one.

No Show Fees- Medicare and Medicaid’s Contradictory Policies

Wednesday, January 17, 2018

By Audrey Landers

Missed appointments, or “No Shows” as they are known among physicians, are a long-standing problem. Approximately 19% of patients will be no-shows, leaving an average of $195 worth of missed revenue per patient. The most popular way to encourage patients to show up and recoup losses from those who don’t is to charge for missed appointments. This is fine…if the patient is covered by Medicare. If they have Medicaid it’s another story. 

Rules for Medicaid:
Federal regulations dating back to 2004 state that physicians who participate in Medicaid must accept Medicaid reimbursement as “payment in full” (42 C.F.R. §447.15). The Centers for Medicare and Medicaid (CMS) has interpreted this to mean that physicians may not charge Medicaid patients no-show fees, stating that missed business opportunities are a part of being in business and therefore should not be charged for. This policy is completely different from the one they have for Medicare.

Rules for Medicare:
Medicare’s rules for no-show fees are fairly straightforward. Any physician who accepts Medicare may charge missed appointment fees to Medicare patients so long as they meet the following requirements:

  • The missed appointment policy must apply equally to all patients
  • The patient must be made aware of the policy beforehand
  • The fee amount must be the same for all patients
  • Medicare may not be billed, instead the physician must bill the patient directly

A full explanation of the policy can be found in Chapter 1, section 30.3.13 of the Medicare Claims Processing Manual. This policy became first became effective in October of 2007. 

CMS considers the no show fee to be a charge for a missed business opportunity, rather than a service. This is completely contrary to the previously stated opinion that, when referring to Medicaid patients, missed opportunities are an unavoidable part of doing business.

Another issue is to be had with the main rule in the Medicare policy, specifically their rule stating that the missed appointment policy must apply equally to all patients. If the policy must apply to all patients, does that prohibit physicians who see both Medicare and Medicaid patients from having a no-show fee? 

SCG Health believes strongly that policies should be clear and leave no room for confusion. While we don’t necessarily have an opinion either way whether or not no-show fees should be allowed, we do hope that CMS will clarify their contradictory policies so that there is no confusion about what is and is not allowed.

SCG Health Mail Bag- Billing for Non-Covered Services

Monday, January 08, 2018

By Audrey Landers

One of the most important parts of what we do at SCG Health is client education. We are always eager to answer questions and help our clients navigate the sometimes murky waters of the medical industry. Recently, we received this interesting question:

“We are participating in Medicare and submit claims with the GA modifier for non-covered charges would fall under the “frequency limits.” Do we have to accept Medicare allowance, or can we bill the member our full charge for a non-covered service if an Advanced Benefit Notice is signed? “

Imange from

There are a few different components to this question, so let’s break them down. 

Depending on the case an Advanced Benefit Notice (ABN) may not be necessary. ABNs only apply to services that could be covered by Medicare, but the provider has reason to believe the claim may be denied. For example: the Centers for Medicare and Medicaid Services (CMS) may deny a claim for a service that is not medically necessary. In this case however, frequency limits draw a clear boundary set by Congress for what is and isn’t covered. You are not required to submit the claim to Medicare because it is an excluded service. You could use a (now retired) Notice of Exclusion from Medicare Benefits (NEMB). 

The difference between these forms is small but significant:

  • ABN- Informs the patient that Medicare may or may not pay for the service they receive, and if Medicare does not pay then the patient will be responsible.

  • NEMB- Informs the patient that Medicare will not pay for the requested service, and the responsibility of payment will fall on the patient.

On both these forms, you will write in an estimated cost for the patient to review. Whatever you write in this section is the appropriate amount to charge. The key is that the patient is given advanced notice of what to expect.

We think the real question here is “what amount should we use as the estimated cost on either an NEMB or ABN?”

The answer is that you should use the self-pay rate (not the actual and usual charge) for any service that Medicare will not charge. You should treat them as any other patient who is paying for a service completely out-of-pocket. Of course, we are assuming here that your self-pay rate is higher than the Medicare allowable.

We take great pride in being helpful and informative, if you have any questions, you can ask us or click the “Gina, Help Me!” tab at the top of our website.

We hope you will take the time to learn more about our educational services and view our events calendar. SCG Health typically holds one free webinar each week, so be sure to check the calendar for events you are interested in.

Share your EMR Information- Prevention of Information Blocking Attestation

Monday, November 27, 2017

By Audrey Landers, Intern

Part of getting the highest score possible in the Advancing Care Information (ACI) category of the Merit-based Incentive Payment system (MIPS) is using your certified electronic medical record technology to exchange electronic health information. The Center for Medicare & Medicaid (CMS) understands that sometimes there may be circumstances that are beyond a MIPS eligible clinician’s control that may hinder their ability to do this, therefore you must show that you have acted in good faith to share health information when appropriate. CMS intends to focus on the individual clinician’s circumstances in order to determine whether a good faith effort was made.

All MIPS eligible clinicians will be required to attest to statements about the implementation and use of certified electronic medical record technology. If you are reporting as a group, every single MIPS eligible clinician must attest. If any member does not attest, the whole group will fail the meet the attestation requirement.

There are three statements that each MIPS eligible clinician must attest to:

Statement 1: I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified electronic medical record technology.

Statement one is mostly an umbrella statement, with the other two statements going into further detail. With this first statement, you must be ready to demonstrate that you have not knowingly restricted access to your certified electronic medical record technology.

Statement 2: I implemented technologies, standards, policies, practices, and agreements reasonably calculated to ensure, to the greatest extent practicable and permitted by law, that the certified electronic medical record technology was, at all relevant times:

  • Connected in accordance with applicable law

  • Compliant with all standards applicable to the exchange of information, including the standards, implementation specifications, and certification criteria in regulation

  • Implemented in a manner that allowed for timely access by patients to their electronic health information (including the ability to view, download, and transmit this information)

  • Implemented in a manner that allowed for the timely, secure, and trusted bidirectional exchange of structured electronic health information with other health care providers as defined by law

Statement two is about the interoperability of certified electronic medical record technology. Specifically, this statement confirms that you reasonably implement corresponding technologies, standards, practices, and policies as well as agreeing not to restrict appropriate access to your certified electronic medical record technology’s information. CMS does not expect individual clinicians to have a complete understanding of the technical details as long as a good faith effort is shown to comply with this statement.

Statement 3: I responded in good faith and in a timely manner to requests to retrieve or exchange electronic health information, including from patients, health care providers and other persons, regardless of the requestor’s affiliation or technology vendor.

Statement three focuses on the use of certified electronic medical record technology and the steps taken to exchange appropriate information in a timely manner. You may attest to statement three even if you have restricted information, as long as there was a good reason. For example, in the cases of certified electronic medical record technology maintenance or a security concern, functionality may be reasonably restricted in ways that are narrowly tailored to the situation and show a good faith effort to minimize the impact of loss of functionality for patients and other clinicians.

For more information about the prevention of information blocking attestation, please see CMS’ official fact sheet.

Emergency Measures and MIPS- Auto Designation

Wednesday, November 15, 2017

By Audrey Landers, Intern

If you are a clinician in an area that has experienced an extreme, uncontrollable natural disaster, you will no longer be required to apply for a hardship exception for the first Merit-based Incentive Payment System (MIPS) reporting year. This decision was triggered by the devastating effect of Hurricanes Harvey, Irma and Maria.

Previously, clinicians were asked to apply for a hardship exemption for the first MIPS reporting year by December 31, 2017 in order to be reweighted for Advacing Care Information (ACI) only. The Center for Medicare & Medicaid Services (CMS) has issued an interim final rule which implements an automatic reweighting system for all categories of MIPS for clinicians in areas that are suffering from an uncontrollable disaster. This interim rule is intended to take some burden off of clinicians in hard-hit areas and allow them to focus on quality care and repairs to facilities. In order to be eligible for this automatic reweighting, your facility must be located in an area that has been heavily affected by a disaster that could not be avoided. CMS gives a tornado or fire destroying the only facility in which a clinician practices as an example of an unavoidable disaster.

If you are not eligible for automatic reweighting be feel that you need it, you may still apply no later than December 31, 2017. To find out if you are eligible, you can see a list of requirements on 

Areas eligible for automatic reweighting:

  • All 67 counties in Florida.
  • All 159 counties in Georgia.
  • The following parishes of Louisiana; Acadia; Allen; Assumption; Beauregard; Calcasieu; Cameron; De Soto; Iberia; Jefferson Davis; Lafayette; Lafourche; Natchitoches; Plaquemines; Rapides; Red River; Sabine; St. Charles; St. Mary; Vermilion; and Vernon.
  • All 78 municipios in Puerto Rico.
  • The following counties of South Carolina: Allendale; Anderson; Bamberg; Barnwell; Beaufort; Berkeley; Charleston; Colleton; Dorchester; Edgefield; Georgetown; Hampton; Jasper; McCormick; Oconee; and Pickens.
  • The following counties in Texas: Aransas; Austin; Bastrop; Bee; Bexar; Brazoria; Burleson; Caldwell; Calhoun; Chambers; Colorado; Comal; Dallas; Dewitt; Fayette; Fort Bend; Galveston; Goliad; Gonzales; Grimes; Guadalupe; Hardin; Harris; Jackson; Jasper; Jefferson; Jim Wells; Karnes; Kleberg; Lavaca; Lee; Liberty; Madison; Matagorda; Milam; Montgomery; Newton; Nueces; Orange; Polk; Refugio; Sabine; San Augustine; San Jacinto; San Patricio; Tarrant; Travis; Tyler; Victoria; Walker; Waller; Washington; and Wharton.
  • All of the U.S. Virgin Islands. 

This list may be updated, please see CMS’ website for the most current list of impacted areas.

New Secure Medicare Cards - What They Mean for You

Wednesday, November 01, 2017

By Audrey Landers, Intern

In April 2018, the Centers for Medicare & Medicaid Services (CMS) will be rolling out brand new ID cards without Social Security Numbers (SSN). This change is being made in reaction to the Medicare Access and CHIP Reauthorization Act (MACRA) which requires that SSNs be removed from Medicare cards by April of 2019. 

In order to help protect Medicare beneficiaries from identity theft, the SSN-based Health Insurance Claim Number (HICN) will be replaced by new Medicare Beneficiary Identifiers (MBI). These MBIs will be randomly generated 11-character alphanumeric codes with no specific meaning.

Source: Center for Medicare and Medicaid Services

CMS will be allowing an adjustment period from April 1, 2018 to December 31, 2019. SCG Health recommends that practitioners use this time to test, collect data from, and perfect their document management system (DMS) and claims submission system as well as remind patients of the change. During this time period, both the HICN as well as the new MBIs may be used to submit claims. Your practice will be expected to be able to use MBI exclusively by January 1, 2020 with limited exceptions. These exceptions include:

  • Appeals
  • Claim status query (Date of service before 1/1/2020)
  • Span-date claims (DOS before 1/1/2020)
  • Home health claims & Requests for Anticipated Payments (DOS before 1/1/2020)

Even when these exceptions apply, you are urged to use the new MBIs when possible.

Getting Ready
In order to be prepared for the transition period, your DMS and claims submission systems must be ready to accept MBIs no later than April 1, 2018. CMS is currently running a television ad campaign discussing the new cards and you can help spread awareness by making information about the new cards available in your offices. CMS suggests displaying posters and putting out pamphlets in waiting areas as well as discussing the new cards directly with your patients. They should be aware that the cards will be sent out automatically starting April 1, 2018 and all Medicare beneficiaries should have new cards by April 1, 2019. There is nothing they need to do to get a new card. You should also take the opportunity to keep your patients from getting scammed during the transition period by making sure they are aware of the following:

  • CMS will never call a beneficiary, nor will they ever ask for their SSN.
  • The new Medicare cards are free, CMS will never ask a beneficiary for payment for a new card.
  • If a beneficiary receives a phone call from someone who asks for their MBI, SSN or for payment, they should hang up immediately and call 1-800-MEDICARE
For more information on the new Medicare cards, you can visit CMS’s New Medicare Card Overview.

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