FYI
- For Your Information
Healthcare policies change quickly. Proposals are always on
the horizon. FYI will be updated regularly to give you the
latest information that we get that may be pertinent to your
business. Check back frequently "for your information".
December 27, 2011
Article: CMS Will Not Provide Interim Feedback Reports for Determining if Individual Providers will Incur the 1% 2012 ERx Penalty for Medicare Part B Fee Schedule Services
Despite CMS indicating in their 9/6/11 final E-Prescribe rules that providers would receive an interim feedback report to know in advance if they would receive the 1% ERx penalty adjustment as of 1/1/2012, CMS announced 12/20/11 these reports were not "technically feasible" for them to provide.
In addition, CMS has NOT processed the ERx exemption requests which providers could apply for using the Communication Support Page up until 11/8/11. CMS indicates the volume of these requests was too great. The ONLY email notices thus far sent to providers as a result of their exemption request filings, were sent to providers from QualityNet on 12/9/11. The email notified providers they would not be penalized as of 1/1/2012; BUT WAS NOT due to the actual exemption request reason the provider filed. The email was sent to providers whose actual data had been reviewed for the period 1/1/11 thru 6/30/11 based on the Name/NPI/TIN listed in the exemption request; and determined they were already exempt from the penalty (no filing of an exemption request was required). The email sent to providers was VERY confusing. Here is what the email said:
"Thank you for submitting a request for a significant hardship exemption from the 2012 electronic prescribing (eRx) payment adjustment. Our records indicate that you submitted one or more requests for a significant hardship exemption to the 2012 eRx payment adjustment. This formal notification is to inform you that the 2012 eRx payment adjustment, which will result in a 1.0 percent reduction on an eligible professional’s 2012 Medicare Part B physician fee schedule covered professional services, does NOT apply to you based on the identifying information received in your hardship request. Therefore, your request(s) for a significant hardship exemption to the 2012 eRx payment adjustment will be disregarded.
If you received the above email...GREAT!! If you did not, then you will NOT receive any notification as to your penalty status that kicks in as of 1/1/2012, although CMS says they contunue to work on a method for notifying providers. At this late date, do not hold your breath.
Instead, your first indication as to receiving the 1% penalty will occur when you start receiving your 2012 Medicare remittances. On 12/21/11, CMS posted an article describing the remittance and remark codes that will indicate the 1% penalty has been applied. To read the Medlearn article, click here.
If the exemption request you filed on the Communication Support Page is ultimately approved by CMS after 1/1/2012, any claims where the penalty applied would then need to be re-processed thus creating further chaos to your patient account reconciliation. The MedLearn article also describes the remittance and remark codes you will see when the ERx penalty is subsequently adjusted.
November 9, 2011
Article: CMS Now Providing List of Providers Who Have Been Sent Letters for Medicare Revalidation
In response to provider requests, CMS has now posted a listing of providers who have been sent a request to revalidate their Medicare enrollment information. The list contains the name and national provider identifier (NPI) of each provider sent a letter, as well as the date the letter was sent. CMS indicates they will update this list monthly. It is anticipated Medicare contractors will also start posting lists specific to their jurisdictions in the future; but for now, please access the CMS listing to insure you have not missed receiving the very important revalidation letter!
For additional information about the national revalidation project, please see the articles posted below this one dated 11/2/11 and 10/9/11.
To view the list posted to the CMS website 11/8/11 Click Here. Scroll down to the download section and click on the “Revalidation Phase 1 Listing”.
NOTE: You will need to widen each column in the spreadsheet to view the contents. In addition, the list is large and is not formatted in an efficient alpha or numeric format. You will need to use your find function to more easily navigate the list for your specific provider NPIs.
If you discover a provider NPI on the list but have not received the revalidation letter, you should contact the customer service area of your Medicare contractor. Remember, you only have 60 days to respond to the letter before your payments may be held and your provider number deactivated.
November 3, 2011
Article: Advanced Diagnostic Imaging - BE PROACTIVE - Please Insure Your Accreditation Organization Has Your Provider/Supplier NPIs and Has Transmitted Them in Their Files to CMS
As of 1/1/2012 the techincal component (TC) of an advanced diagnostic imaging service (MRI, CT, Nucelar Medicine, & PET) will not be paid unless you are accredited for the specific modalities. An important part of the ability to still be paid is also related to your accreditation organization having your provider NPIs to transmit to CMS for upload to the PECOS system to insure correct claims processing as of 1/1/2012.
Prior to 8/1/11 CMS was going to require providers to submit a Medicare enrollment application (with your NPI) to include a new specialty code 95 as an ADI designation to insure correct claims processing. However, a revision to CMS transmittal 380 changed all that as of 8/1/11.
Your accredtation organization must provide your group and individual NPIs to CMS as part of your accreditation file. If you were accredited prior to 8/1/11, you may never have provided the NPIs to the accreditation organization. The organizations are providing outreach via mail and on their websites to acquire the NPIs; but if you have missed the mailing or have not noticed changes to their websites, your NPI data may not be in the posession of the accreditation organization for forwarding to CMS.
Please be proactive and contact your accreditation organization!! Make sure to provide your group NPI(s) as well as the NPI(s) of your individual providers who will be billing for the TC as the rendering provider.
The clock is ticking to 1/1/2012. Denials due to this issue could be significant if NPI data is not made available to CMS as part of your accreditation information. Please be sure to be proactive and contact your accreditation organization.
November 2, 2011
Article: CMS Extends Revalidation Process From March 2013 to March 2015
As the article below this one in the "FYI" section, dated 10/9/11 describes, enrollment revalidation for all Medicare providers and suppliers will be required if your enrollment was originally processed prior to 3/25/2011. Where CMS was planning to have Medicare contractors complete this daunting task (1.5 million providers & suppliers nationally)by March, 2013, yesterday CMS quietly revised their original revalidation MedLearn notice to extend the revalidation period through March, 2015.
As stated in the revised Medlearn article, SE 1126, "CMS has reevaluated the revalidation requirement in the Affordable Care Act, and believes it affords the flexibility to extend the revalidation period for another 2 years. This will allow for a smoother process for providers and contractors. Revalidation notices to providers and suppliers will now be sent through March of 2015."
NOTE: If you have already received a revalidation notice you must still submit the enrollment document(s) within 60 days. Revalidation is not being delayed. CMS is just extending the period during which the process will take place.
To read the entire Medlearn Matters SE1126 document regarding revalidation click here.
October 9, 2011
Article: ALL Medicare Providers, Suppliers, or Organizations Required to Revalidate Enrollment Between Now & March 2013
As a result of a section in the Patient Protection and Affordable Care Act ALL providers, suppliers, or organizations will be required to revalidate their Medicare enrollments.
The only providers, suppliers, or organizations excluded are those who newly enrolled or revalidated an enrollment AFTER 3-23-2011.
ALL providers, suppliers, or organizations enrolled PRIOR to 3-23-2011 will receive a letter from the Medicare contractor requesting revalidation. The requests will be mailed in several phases during the period now and March, 2013.
CMS recently indicated NO revalidation requests would be made between now and the end of 2011 unless the provider does not currently have an enrollment record in the national Medicare enrollment database called PECOS. That however, may not be the case with all Medicare contractors.
On 9-29-11, First Coast Service Options (the Medicare contractor for Florida and Puerto Rico) sent revalidation request letters to 10,600 individual providers in this jurisdiction. Other contractors nationally have done the same. Many of the providers receiving letters do have an existing PECOS record; but that is a moot point.
When these letters are received, THEY MUST be acted on without delay. IF the provider does not submit a revalidation within 60 days of the date of the letter, the provider payments will be held and ultimately the provider number will be deactivated. PLEASE NOTIFY ALL AREAS WITHIN YOUR BUSINESS WHERE MAIL FROM A MEDICARE CONTRACTOR MAY BE RECEIVED TO BE ON THE LOOKOUT FOR THESE LETTERS STARTING NOW AND CONTINUING UP UNTIL MARCH, 2013. In an attempt to insure providers receive these letters, Medicare contractors will send the letter to ANY address they may have on file for the provider, so do not be surprised if these letters are received at multiple addresses in your enrollment files.
PLEASE CLICK THE LINK BELOW TO SEE WHAT THE FIRST COAST LETTER LOOKS LIKE – THE LETTER WILL BE DELIVERED IN A YELLOW ENVELOPE. OTHER MEDICARE CONTRACTORS WILL BE USING THE SAME OR VERY SIMILAR FORMAT AND PROCEDURE.
Actual First Coast Revalidation Letter
Where the revalidations may be submitted using paper applications, I highly recommend, if possible, using the internet PECOS system instead. At the present time, internet PECOS is quicker for ultimately receiving final approval for enrollments.
NOTE: In order for providers to use internet PECOS for INDIVIDUAL enrollments, the provider MUST have a WORKING Login (User ID & Password) for the INDIVIDUAL provider NPI file.
CMS is working with Medicare contractors to develop the phases for this massive revalidation project that will start in greater earnest in 2012. Certain PECOS updates scheduled for the end of January, 2012 are being worked on to create even more efficiency in the PECOS enrollment system including electronic signatures.
No information has been made available at the present time as to when letters for revalidating GROUP enrollments will be issued so sit tight on that piece for right now.
Where you are not precluded from submitting revalidations proactively (before letters are received for individuals or your group enrollment) CMS and the Medicare contractors are requesting this NOT be done due to the potential of overwhelming contractor enrollment departments. They are asking you to wait until the revalidation letter is received.
At the present time, knowing that further information about the process as well as potential enrollment enhancements will be forthcoming in 2012, I agree with the CMS and contractor request.
October 9, 2011
Article: CMS Fixes Error in Communication Support Page for Entry of 15 Digit EHR Certification Number
For those providers applying for an EHR Exemption for the 2012 E-Prescribe penalty, a major error in entry of your 15 digit EHR Certification Number at the Communication Support Page was noted 9/28/11. (See article below posted 9/29/11)
The data field for entry of your 15 digit number was fixed as of 9/30/11. However, meaningful communication from CMS regarding this issue and fix has been non-existent. In addition, for those provders who may have submitted exemption requests with faulty numbers prior to the fix, meaningful communication advising providers what action to take has also been non-existent not only from CMS but from QualityNet too.
The only email communication received by Physicians First from a CMS official says ” I am told that the help desk(QualityNet) will contact and work with anyone who submitted a faulty application but also that if you felt that you might have submitted a faulty application you could be proactive and call Q net”
Emails sent to QualityNet by Physicians First have gone unanswered which is not the usual standard for QualityNet. One client who did contact QualityNet verbally indicated the representative confided that QualityNet was equally confused as to what was occurring and what the resolutions would be.
IF you believe you may have been affected by the data entry error for the 15 digit number, I would recommend you contact QualityNet and ask for email confirmation as to their advice. Other organizations have posted information indicating CMS verbally advised them you could resubmit your EHR exemption request; but thus far there is no documentation to support this CMS advice.
Here is the contact info for QualityNet:
Phone: 866-288-8912 and Email:qnetsupport@sdps.org
September 29, 2011
Article: Major Issue Identified with Communication Support Page for Entry of EHR Certification# When Applying for EHR Exemption Request for Avoiding the 2012 E-prescribe Medicare Penalty
If you are applying for an EHR exemption for your providers to avoid the 2012 E-prescribe penalty, a problem with data entry in the Communication Support Page website has been identified and may not be fixed anytime soon. Your deadline for filing an exemption request to avoid the 2012 penalty is 11/1/11.
The problem is in the data entry field for the ONC Certification# which is a required data entry field. ONC Certification numbers for EHR products are 15 digits in length. The data entry field only allows a maximum of 13 digits!!
In an email 9/28/11, CMS confirmed the issue and indicated they are working as quickly as possible to fix it. However, the indication from QualityNet (and confirmed by CMS) is the "fix" may occur too close to the filing deadline of 11/1/11 which is rapidly approaching. You want to file your EHR exemption as quickly as possible in hopes that CMS will finalize and approve the exemption with plenty of time before the 1/1/2012 penalty is implemented.
Here is what CMS and QualityNet have identified as your "workaround" to use when applying for your EHR exemption. The "workaround" instructions are quoted directly from the email received by Physicians First from QualityNet.
Recorded Issue Resolution:
CMS is currently researching and working on a fix for the ONC # field on the Communications Support Page. However, due to the time it is taking to release a fix, and with the deadline for requesting a hardship exemption fast approaching, CMS is providing the following work around for eligible professionals to request the hardship exemption for the EHR. CMS is asking providers to enter the LAST 13 digits of the ONC number in the ONC number field, then enter the complete ONC number in the Justification for action field on the Communication Support Page form. Also enter the complete justification for the hardship exemption they are applying.
To link to the Communication Support Page click here.
The ONC Certification# for your EHR product MUST be obtained from the Certified Health IT Product List (CHPL List). To link to the CHPL list website click here.
August 25, 2011
Article: CMS Releases Revised Enrollment Forms & One New Form - Mandated for use as of 11/1/2011
On 8/23/11, CMS formally announced the release of revised enrollment forms for the Medicare Program. In actuality, the new forms were quietly released by CMS in July, 2011; and many of you may have already started using the new forms.
CAUTION:You should still download and save the new forms by clicking the link below. Since the release of the new forms in July, several errors were noted and brought to the attention of CMS. The forms released 8/23/11 have corrected these errors.
The oldest enrollment forms with a date of "(02/08)(EF 07/09)" in the lower left corner of the forms will no longer be accepted by Medicare contractors as of 11/1/11. You MUST begin using these new forms no later than 11/1/11.
If you are one of the small number of providers who only need to enroll for the purpose of ordering/referring services for Medicare beneficiaries, there is a new form, the 855O, which is now mandated for use for that specific type of enrollment.
To Access the New and Revised forms Click Here.
June 19, 2011
Article: CMS adds EPrescribe FAQ document to Website-Note Ability to EPrescribe Over the Counter Medications & DME Supplies
On 6/16/11 CMS posted a frequently asked question (FAQ) document to their website specific to EPrescribe.
Please NOTE questions #10632 & #10636 on page 4. Time is short to meet the 10 EPrescribe encounters required by 6/30/11; but perhaps the over the counter medications & DME supply opportunities might help in your final push to avoid the 2012 penalty!
Click here to download the FAQ document.
June 6, 2011
Article: CMS Issues Proposed Rule Regarding Electronic Prescribing & Penalties for 2012
On May 26, 2011 CMS issued a proposed rule regarding the ERx incentive program and addressing many of the concerns echoed by providers concerned about being unnecessarily penalized starting in 2012. The details of the rule are more extensive than what can be typed in this article space. Therefore, Physicians First, Inc. has drafted an explanatory document regarding the details of the proposed rule for your reference. To read the details click here.
In addition, CMS has scheduled a free audio call regarding the ERx proposal for June 21, 2011 from 1:30PM-3PM (Eastern). You must register for the call. To register click here.
May 17, 2011
Article: HUGE NEWS on Advanced Diagnostic Accreditation Enrollment Requirements!!
An Open Door Forum call with CMS has just concluded. During the call CMS announced you WILL NOT be required to make a change of any kind to your enrollment with Medicare in order to continue billing for the TC of advanced diagnostic imaging services as of 1/1/2012. YOU WILL, HOWEVER STILL NEED TO BE ACCREDITED BY ONE OF THE CONTRACTED ACCREDITATION ORGANIZATIONS.
Prior to today's announcement, CMS was going to require you to do an enrollment update to add the specialty designation code 95. This specialty designation has now been made invalid.
Prior to today's call, the enrollment would also have required you to list the CPT codes used in your billing for the TC for advanced diagnostic services AND you would have been required to list the model number of the specific equipment. None of this will now be required. IF you already have an enrollment record; and IF you are validly accredited, your information to continue billing for the TC as of 1/1/2012 will be extracted by CMS from the actual accrediting organization.
CMS is still planning on revising the 855I and 855B enrollment documents (both paper and PECOS). Where the original release date was expected to be July, 2011, this date is no longer firm. Ultimately, the new forms will require only a "check box" of some sort to indicate you provide advanced diagnostic imaging services if you are doing a new enrollment.
CMS is still working on questions related to billing for both the TC and professional component in the same claim for advanced diagnostic imaging services, and will announce further details regarding this during a future open door forum call.
March 27, 2011
Article: CMS Posts Selected Screen Shots of the Medicare EHR Attestation Process
Attestation for the Medicare EHR Incentive Program will formally become available as of April 18, 2011. CMS has posted a document providing print screens of some of the screens you will be completing during the process. The document does not include every screen you will encounter during attestation; but it does provide an overview. CMS will be presenting audio programs in the near future to address the attestation process in greater detail. Dates for the programs have not yet been announced.
Click Here to Review the Selected Screen Shot Preview Document
March 27, 2011
Article: CMS Issues Instructions for Paying Medicare Enrollment Fees
On 3/24/11, CMS provided instructions via their email listserv for payment of the Medicare enrollment application fees that started 3/25/11.
Remember, these fees are not applicable to physicians, non-physician practitioners, and physician or NPP organizations (see article below posted 3/8/11); HOWEVER, they are applicable IF you are newly enrolling for or revalidating a DME provider number.
The fee for 2011 is $505.00. Where CMS originally indicated a paper check could be sent to the Medicare contractor with your enrollment documents, their new instructions now require the use of only the new Pay.gov website for processing checks, debit card, and credit cards. You will NOT be able to send a paper check with your enrollment documents.
To pay the fee, you would go to the website Pay.gov. Once there, type CMS in the search box under “Find Public Forms” and click the “GO” button. Click on the “CMS Medicare Application Fee” link. Once your transaction is complete, you will receive a payment confirmation. Where Medicare contractors will have access to the Pay.gov files to confirm your payment, CMS highly recommends attaching a copy of the payment confirmation with the enrollment documents forwarded to the Medicare contractor.
To read the entire CMS email regarding payment of the application fees, Click Here
March 8, 2011
Article: New Enrollment Screening Rules & Application Fees Effective 3/25/2011
The Affordable Care Act required increased enrollment screening as well as application fees for Medicare, Medicaid, and CHIP. On 2/2/11, CMS published the final rules related to these new regulations. Where physicians, non-physician practitioners, and group practices are exempt from the increased screening rules and fees, the fine print in the regulation indicates physicians/physician groups who are also dually enrolled as DME providers will be affected by these new regulations and fees. Listed below are highlights of the new rules and effects on those providers who are also enrolled as DME providers.
1. Effective 3/25/11, new rules for enrollment screening will apply to all providers who are newly enrolling or revalidating their enrollments. The level of screening will depend on the risk category the provider type has been placed in – Low, Moderate or High
Physicians, NPPs, and physician groups are considered low risk, and screening procedures will not change from the current standards used by Medicare, Medicaid, and CHIP.
HOWEVER, DME is considered high risk. If a physician/physician group also has a separate enrollment for DME, the revalidation for the DME enrollment (required every 3 years) or a new DME enrollment will be subject to the high risk screening procedures.
Effective 3/25/11 high risk will require a site visit as well as (probably within the next 60 days) a fingerprint-based criminal background check for direct or indirect owners with a greater than 5% ownership interest. This will not be required for directors, officers, or managing employees. CMS is working to develop relationships with entities that will provide the electronic channeling of these background checks and will provide further detail as soon as available.
2. Application fees will also be assessed effective 3/25/11 for new enrollees or providers revalidating enrollments. Again, physicians, NPPs, and physician groups are exempt from the application fees.
HOWEVER, once again, DME is not exempt. If as a physician/physician group you are newly applying for a DME provider number or revalidating your DME enrollment, you will be required to pay an application fee. The fee for 2011 is $505.00; AND if you have a DME number for additional locations, the fee would apply to EACH location you are enrolling or revalidating.
The application fee will change on an annual basis adjusted as a result of the Consumer Price Index (CPI).
3. Application fees must be received by the contractor at the time of filing your applications (whether paper or PECOS). All application fees must be submitted via paper check, until the Centers for Medicare & Medicaid Services (CMS) specifies a mechanism for submitting electronic funds at a future date. Processing of the application will not occur until such time as your check has cleared. If you fail to submit the fee with the application(s), the application will be rejected. If the enrollment is for a revalidation, and the fee is not submitted, you could run the risk of a billing number revocation.
4. If you feel the fee will present a hardship, you may file a hardship exemption request. There is no specific form or format for the hardship exemption request. Attach a letter to your application requesting the exemption. A decision is supposed to be rendered by the contractor regarding the hardship within 60 days. HOWEVER, CMS recommends you still submit the application fee with your hardship exemption request to prevent further delay of your application processing if the exemption is denied.
If you would like to review the final rules published in the Federal Register 2/2/11 Click Here
February 24, 2011
Article: Reprocessing 2010 Claims Affected by the Affordable Care Act
The Patient Protection and Affordable Care Act (PPACA) – The Healthcare Reform Act - was signed into law in March of 2010 and mandated certain revisions that affected areas in the Medicare fee schedule such as relative values (practice expense, malpractice, and geographic values) for billing codes. The law made these revisions retroactive to January 1, 2010. As a result, CMS had to revamp the allowed amounts in the Physician Medicare Fee Schedule. The allowed amounts for many billing codes increased as a result of these changes; BUT your claims had already been processed and paid at the lower amounts by the time CMS implemented the new fee schedules on 6/1/10. Underpaid claims for dates of service 1/1/10 thru 5/31/10 were supposed to be re-processed. HOWEVER, CMS then had to set aside these fee schedules in order to implement the congressionally mandated fee schedules as of 7/2/10 that resulted from the dollar conversion chaos of 2010. Reprocessing of the underpaid claims then came to a screeching halt. To make matters worse funding for the re-processing of these claims was not made available by Congress until 2011.
On 2/8/11, CMS posted a public notice indicating claims re-processing should begin “over the next several weeks”. In an open door forum 2/22/11, CMS indicated the reprocessing should start within “2 weeks”. Here are some other disclosures made by CMS during the open door forum call:
1. This is a huge project involving hundreds of millions of claims nationally. Time frame for completion will be “quite a bit longer” than 3 months or perhaps even 6 months.
2. A CMS priority is to insure normal claims processing for existing claims is not negatively impacted.
3. Medicare contractors are submitting plans to CMS to indicate the approach they will use for the re-processing to insure organization and to prevent jeopardizing normal claims processing. In all likelihood, Medicare contractors will re-process claims based on date of service by month (for example, start with January 2010 dates of service claims and move forward to February, 2010, March, etc.)
4. Providers should not resubmit claims. The claims would be denied as duplicates. As long as the charge for services in your original claim was at or above the new allowed amount, the claim will be reprocessed.
5. If your charge was below the allowed amount, the claim cannot be reprocessed. For these claims you would need to contact your Medicare contractor and complete the manual process for re-opening the claim.
6. As claims for a provider are re-processed, they will aggregate in the system and will be paid at the time your next scheduled payment is due. Payment for the claims will be noted in your Medicare remittance. By aggregating claims and releasing them at the time of your next scheduled normal claims payment time, this should prevent multiple checks for small amounts being issued.
February 16, 2011
Article: FLORIDA PROVIDERS - The Medicare Contractor, First Coast Service Options, will transition to the HIGLAS system starting 3/11/11 - Payment "dark days" will occur
The Medicare contractor will transition to HIGLAS (Healthcare Integrated General ledger Accounting System) starting March 11th. HIGLAS is an accounting system where claims payment calculations, provider and benficiary withholdings, and payment offsets occur. The transition should be completed and HIGLAS will be fully operational as of 3/14/11.
During the transition, however, Medicare payments cannot be made (claims processing is not affected). As a result of the "dark days" for payment during the transition, the contractor will "sweep the payment floor" over a two day period, March 8-9, 2011. Sweeping the floor means your claims approved for payment will be paid earlier than the law normally allows. As a result, you will see much higher payments coming in for this two day period; but then, your payments over the next 10-14 days will be less when the "payment floor" rules become effective again following HIGLAS transition.
First Coast has been conducting many free webinars regarding this topic; and they have also posted a helpful explanatory document at their website.
Click Here to View the First Coast Document
February 14, 2011
Article: New CMS Signature Requirements for Clinical Laboratory Paper Requisitions
A new provision for Medicare 2011 was tucked into the final rules published by CMS 11/29/10. The rule became effective January 1, 2011; but CMS has postponed compliance and enforcement until April 1, 2011 to give providers more time to understand and prepare for the rule.
The rule requires an original signature on any paper requisition for clinical laboratory tests ordered by a physician or qualified non-physician practitioner. Without an original signature on the paper forms, clinical labs will not be able to bill for their lab services. Signature stamps are not acceptable. Exceptions to this rule would be for lab tests ordered via phone or submitted electronically.
Please review your operational procedures in place for paper requisitions. If a Medicare beneficiary presents themselves to a clinical lab for tests, and the paper form is not signed, there is a high likelihood the clinical lab would need to refuse service since their payment is predicated on having a signed form. Delayed lab tests could adversely affect patient outcomes; and test samples drawn at your office will not last if you have to take additional time to chase a provider down for a signature!!
February 5, 2011
Article: New Home Health Face to Face Encounter Requirement for Home Health Certification for Medicare Part B Patients
This new requirement for a documented face to face encounter is a result of the Affordable Care Act, and became effective January 1, 2011. Enforcement for compliance will begin 4/1/11.
Unfortunately, the provider community does not seem to be aware of the new regulation, and Home Health Agencies are struggling to meet the new regulation so they may bill for home health services.
A physician is the only person who may CERTIFY a home health plan of care; BUT the documentation required for the face to face encounter may be performed by the physician or by a non-physician practitioner (i.e ARNP or PA) who is employed or duly collaborating with the physician.
The face to face encounter must occur within the 90 days prior to the start of home health care (unless a new patient condition occurred during this 90 days affecting the home health plan of care and certification), or within 30 days after the start of care. The documentation of the face to face encounter MUST be part of the home health certification form, or as an addendum to it. The documentation MUST include how the patient's clinical condition, as seen during the encounter, supports the patient's homebound status and need for skilled care.
Since many patients may be attended to in an acute care setting, such as a hospital, by someone other than the patient's regular attending physician (such as by a hospitalist), the rule now allows the hospitalist to develop the plan of care, certify the plan of care, and provide documentation of their face to face encounter to support the service.Thus, this would allow the hospitalist to be able to bill for the home health ceritifcation (G0180)which was precluded in the past. A hospital discharge summary DOES NOT qualify as documentation of the face to face encounter.
The only provider who may bill for home health certification (G0180) is a physician and ONLY the physician who actually signs the home health certification. Thus, if the hospitalist orders the home health and provides documentation of the face to face encounter BUT leaves the signing of the home health cerififcation to the regular attending physician, the hospitalist MAY NOT bill G0180!!
Click here to read the Medlearn article for further detail about this regulation.
Click here for further CMS Q&A about the rule and clarifications
In the middle of the site click on "Home Health Face-to Face Encounter FAQs" in the "Spotlight" section.
January 21, 2011
Article: New CMS 855B & 855I Enrollment Forms to be Released - Groups Billing for the TC of Advanced Diagnostic Imaging (ADI) Services Will Need to Complete an Enrollment Adding the New Specialty Designation for Accreditation in Order to Maintain Claims Payment as of 1/1/2012
As of 1/1/2012, if you are providing the technical component (TC) of an advanced diagnostic imaging (ADI) service you must be accredited by a CMS designated organization in order to continue being paid for the TC in the Medicare Part B program. An ADI is defined as:
MRI, CT, Nuclear Medicine, and Positron Emission Tomography (PET).
In a CMS transmittal, #7175, 10/29/10, CMS announced a new specialty designation code, 95, which is described as “Advanced Diagnostic Imaging Accreditation”. As a result of this transmittal, Physicians First, Inc. made inquiry to CMS to ask if groups would be required to complete a Medicare enrollment to add this specialty code to their enrollment files. Just today, CMS has responded with further information which is outlined below.
1. Yes, groups will be required to complete an enrollment to add the specialty code.
2. CMS will be releasing revised forms, CMS 855B (for groups) and CMS 855I (for sole provider-corporations, as applicable) to accommodate changes in the forms required to add the specialty code. The revised forms and further instructions are expected to be released by July, 2011.
3. Both revised forms will include a new section to include the specialty designation, 95. In addition, you will need to list the specific ADI CPT codes that you will be billing.
4. CMS contracted accrediting organizations (AOs) submit monthly reports to CMS that list the suppliers/groups who have been or are accredited. In addition, the AOs provide CMS with the beginning and end date of the accreditation and the respective modalities for which the supplier has received accreditation.
5. CMS has posted a revised list of codes subject to the ADI accreditation requirement BUT DO NOT assume the list is comprehensive. If you are providing MRI, CT, Nuclear, or PET services, you are required to obtain the accreditation even if your billing code(s) is/are not on the list. Click here for the ADI Code List
6. Do not delay becoming accredited. The process may take anywhere from 6-9 months and the AOs may very well be backlogged. Click Here for More Information on the Accreditation Organizations
November 28, 2010
Article: Status of the Dollar Conversion Factor Issues for Medicare Payments
As Congress reconvenes on 11/29/10 for the remainder of their "lame duck" session, here is where we stand regarding the Medicare dollar conversion factor. Without congressional action on two fronts, the dollar conversion factor will drop by approximately 23% as of 12/1/10; and will further drop by another approximately 7%, to a staggering low figure of $25.5217, as of 1/1/2011.
So what did Congress do prior to their Thanksgiving recess?
On 11/18/10 the Senate unanimously passed HR 5712 that would freeze Medicare payments at their current levels through 12/31/10. However, the bill must now go to the House of Representatives for a final vote of approval. The earliest this vote could occur would be 11/29/10. It is anticipated the House will approve the bill; but it is not a given until that vote occurs.
As a result of the mid term elections, Congress is now more focused on making sure new legislation is paid for instead of continuing to add to the federal deficit. Interestingly, the freeze through 12/31/10 would be paid for as a result of anticipated savings in 2011 Medicare resulting from the new multiple procedural payment reductions (MPPR) for physical therapy services. So, thank a physical therapist for the payment reprieve the next time you meet one!! The MPPR for PT services was supposed to be 25% as of 2011; but the bill passed by the Senate referenced above (HR 5712), also included an amendment to decrease the reduction to 20%.
Next, is anything being done about the pay decrease due 1/1/2011?
On 11/18/10, the House introduced a bill, HR 6427, called "Medicare Physician Payment Update Extension Act". The bill has been referred to committee so it is not close to a vote by either the House or Senate at this point. The bill provides for a 1% update to the conversion factor in Medicare for 2011. However, what conversion factor would be used for the 1% update? There have been many dollar conversion factors in 2010. Would the 1% be applied to:
The original dollar conversion factor for 2010 - $28.3868?
The dollar conversion factor in place 1/1/10-5/31/10 - $36.0846?
The dollar conversion factor resulting from healthcare reform changes as of 6/1/10 - $36.0791? OR
The dollar conversion factor with the 2.2% increase approved by Congress in July, 2010? This dollar conversion factor of $36.8729 was authorized only for the period 6/1/10 thru 11/30/10.
An interesting question without an answer at this point.
The window of opportunity for the House and Senate to fully act on all issues is narrowing. They will reconvene 11/29/10; but unless they pass a federal budget for 2011 for the ENTIRE government, ALL funding for the ENTIRE government expires at the end of the first week of December; and technically Congress could leave town until 1/1/2011! No one expects this to happen; but in the healthcare community we have come to expect the unexpected. There are many issues requiring the attention of the House and Senate that go beyond the "Doc Fix". Will there be enough time to address all the issues before the House and Senate sessions end for 2010; and they all head home for the holiday recess? Stay tuned!
August 18, 2010
Article: CMS Announces Projected Dates for Payment of 2009 EPrescribe and PQRI Bonuses
CMS announced during an audio conference on 8/17/10 their expected dates for distributing bonus payments for the 2009 E-Prescribe and PQRI programs.
EPrescribe bonuses will be distributed starting approximately 9/21/10 and concluding approximately 10/22/10.
PQRI bonuses will be distributed starting approximately 10/25/10 and concluding approximately 11/12/10.
These bonus payments will be distributed via the Medicare contractors and will be noted in your Medicare remittance.
CMS indicated the availability of feedback reports for both programs should also be available as close to the pay dates as possible.
In addition to the information about the 2009 bonuses, CMS also stated some technical difficulties in analysis of data occurred with 2008 PQRI bonus determinations. Specifically, there were some issues with calculating Medicare allowed amounts for eligible professionals. This problem also impacted some of the qualtiy data codes that were processed. As a result of correction of these technical issues, 889 more eligible professionals nationally will have additional money paid to them for the 2008 PQRI reporting period. These additional payments will be distributed starting 8/25/10 and will conclude on 9/17/10.
July 18, 2010
Article: 2012 Penalties for not E-Prescribing in Medicare Would be Based On Analyzing Provider Data for the Period 1/1/2011 through 6/30/2011
If you have not implemented E-Prescribing in your practice, you should not put it off any longer.
As of 1/1/2012 Medicare allowed amounts for individual providers will decrease by 1% if providers are not "successfully" e-prescribing for Medicare patients. Where this may seem like a long way off, CMS recently proposed the determination of whether the penalty will be imposed would be based on analyzing provider data for the period 1/1/2011 through 6/30/2011.
For claims based submission of the E-Prescribe measure, CMS would look at services billed by the provider. If there were 100 services billed where the E-Prescribe measure applied, 10 of those claims must have the code for E-Prescribing reported or the penalty would be imposed. For registry based or EHR reporting of E-Prescribe, these qualified registries or EHR vendors would need to download data to CMS during the period 7/1/2011 through 8/19/2011. The same 100 encounter rule with the minimum 10 reporting would be applied in these situations to avoid the penalty in 2012.
Exemptions to the penalty would apply if:
The provider is of a type who does not have prescribing privileges, or
Data analysis indicates there were less than 100 applicable cases where E-Prescribe should have been reported, or
Less than 10% of the providers Medicare allowed amounts are applicable for E-Prescribing reporting.
Keep in mind also that penalties for not successfully e-prescribing increase as of 2013 to 1.5% and 2% as of 2014 and beyond.
To review the E-Prescribing reporting measure specification click here
To review all information related to the CMS E-Prescribe program click here
July 11, 2010
Article: Medicare Contractor Mailings to Providers Who Bill for Advanced Diagnostic Imaging Services Will Start in August, 2010
Any provider/supplier who bills globally or for the technical component of advanced diagnostic imaging services (CT, MRI, and nuclear medicine services, such as PET) must be accredited by 1/1/2012 in order to continue furnishing these services (see article 1/26/2010 posted below in the FYI section of this website).
CMS notified Medicare contractors on 7/2/2010 to send letters starting in August 2010 to providers/suppliers billing for these services as a reminder of this requirement. If you have billed any of the CPT codes in the list referenced below, you will receive a letter. A total of 5 letters will be sent to providers/suppliers from August through October, 2010 and during January, April, and July of 2011. Since accreditation may take as long as 9 months and more as the deadline approaches, please get started with the process now.
Click Here to See the List of CPT Codes & the Sample Letter to be Sent
July 2, 2010
Article: Office of Inspector General (OIG) Issues Policy Related to Waiving Medicare Cost Sharing Amounts Due to Retroactive Pay Increases
2010 has been a tumultuous year thus far for payments in the Medicare system. As a result of changes in federal legislation, claims already processed for payment to you in the Medicare program, retroactive to even January 1, 2010, may now result in re-processing at a higher payment rate. This means that Medicare beneficiaries may now owe you more for their cost sharing portion as a result of the adjustments to Medicare allowed amounts. Some of the amounts owed may be very small; and thus, not deemed worthy by your practice for billing.
Federal law prohibits a routine write off of these types of balances. However, as a result of the retroactive issues resulting from the multiple fee schedule changes in 2010, the OIG has issued a policy to allow you to write off the balances without fear of violations of the law.
The policy is not, however, without parameters that must be followed; and is subject to the following conditions:
1. The policy only applies to claims affected by retroactive pay increase for claims already processed.
2. The policy only applies to cost sharing amounts affected.
3. Providers must apply the waiver uniformly across all affected beneficiaries, waivers cannot be advertised or used in any solicitation, and the waiver cannot be used as a condition to provide service.
To read the OIG policy click here.
May 22, 2010
Article: Status of the 21.2% Decrease to Medicare Payments Set to Take Affect 6/1/10
Unless Congress takes action, Medicare reimbursements will decrease by 21.2% as of 6/1/10. At this point the House is set to vote sometime the week of 5/24/10 on a bill that will stave off the decrease and make certain adjustments to Medicare reimbursements through the end of 2013. The bill DOES NOT however ultimately eliminate the Sustainable Growth Rate (SGR) formula that is the source of Medicare payment declines. If the House passes the bill, the Senate would still have to pass the bill and the President would have to sign the bill prior to 5/31/10. There is not much time for all this to take place prior to Congress taking their Memorial Day recess from 5/31/10 through 6/6/10.
If the bill passes as currently written, here is what would happen to the dollar conversion factor in the Medicare program:
A 1.3% Medicare payment update for the remainder of 2010
A 1% payment update in 2011
Updates for 2012 and 2013 would be based on two separate expenditure targets. One target would be for Evaluation and Management and Preventive Services. The second target would be for all other physician services. The bill guarantees that the payment update for 2012 and 2013 cannot be below 0%.
As of 2014 the SGR formula kicks back in; and unless Congress fixes the SGR formula, payments could go down in 2014 by 37%. In addition, the price tag at that point for fixing SGR would increase to $500 billion dollars!
With the small window of time between 5/24/10 and 5/31/10 for the bill to be passed by the House and Senate and signed in to law by the President, be prepared for CMS to potentially put a hold on claims as in the past several months.
May 22, 2010
Article: New Fee Schedules for Medicare Will Be Implemented 6/1/10
The healthcare reform legislation passed in March of this year mandates several provisions in the Medicare program that are retroactive to January 1, 2010. As a result of the changes, CMS has had to revamp the allowed amounts in the Physician Medicare Fee Schedule. New fee schedules have been posted to the Medicare contractor websites and will be implemented as of 6/1/10 for processing of all claims with dates of service 1/1/10 through 12/31/10.
Changes in the fee schedule are related to practice expense relative values, geographic values, and malpractice relative values. As a result of these changes, the dollar conversion factor has also decreased by 0.015% which represents a change from $36.0846 to $36.0791. This does not mean ALL your Medicare allowed amounts will decrease. Certain codes may in fact see increases. An increase or decrease is dependent on the specific billing code. You will need to download the new fee schedule and compare the allowed amounts to the old fee schedule.
Since the new fee schedules are retroacvtive to January 1st, many claims in the Medicare system have already been paid at incorrect rates. CMS issued an email on 5/13/10 related to the re-processing of claims. At this point, CMS is still working on the best method to use in addressing the claims payment problem. Below is quoted from their email:
"We continue to work on the best way to address the many claims that are paid at the rates that were in place before the current corrections and updates are made. Please be on the alert for further information about how CMS will address past claims. Until then, providers should NOT resubmit previously-processed claims affected by the payment changes, as it is likely that these resubmissions may be denied as duplicate claims."
To access the new fee schedules for Florida payment localities click here.
BE CAREFUL in the fee schedule you choose. Look for a PDF file specific to your payment locality that has a "modified date" of 5/18/10. So many fee schedules have been posted in 2010 it is easy to pick the wrong one!!
To view the CMS Medlearn article outlining the changes to the fee schedule and other relevant provisions click here
May 8, 2010
Article: Multiple Procedure Payment Reduction for the Technical Component (TC) of Certain Diagnostic Imaging Services Increases from 25% to 50% as of July 6, 2010
The rule to implement a 25% reduction to the TC for certain diagnostic imaging services was originally implemented in the Medicare program in 2006. Under the rule, IF you provide specific imaging services to "contiguous" body areas within the same family of codes to the same patient at the same session, the TC for the code(s)is reduced by 25%. The first code with the highest TC value is not reduced; but the TC of all other codes billed within the same family of codes at the same session is reduced by 25%. This rule has no effect on the professional component billing (modifier 26).
Unfortunately, a provision in the new healthcare reform bill will now increase the TC reduction to 50% starting July 6, 2010!!
There are 11 families of codes where the rule applies. To refresh your memory as to the codes, the code families, and the rule, click on the link below for the original CMS MedLearn article from 2006. The codes and family of codes have not changed.
Click here for MedLearn Article
May 7, 2010
Article: New Timely Claims Filing Rules for Medicare
The healthcare reform bill signed in to law in March of this year mandates new timely filing rules for Medicare claims. The effective date of the new rule is January 1, 2010, and claim denials subject to the rule will start October 4, 2010.
Claims for Medicare services must now be filed no greater than one year after the date of service or they will be denied for timely filing limits.
Claims with dates of service prior to October 1, 2009 will still be subject to the old filing rules.
Claims with dates of service October 1, 2009 thru December 31, 2009 must be received no later than December 31, 2010 or they will deny.
Claims with dates of service on or after January 1, 2010 must be received within the one year period or they will deny.
As stipulated in the rule, there is only one exception where timely filing could be argued. You would need to prove there was "an error or misrepresentation of an employee, Medicare contractor, or agent of the Department that was performing Medicare functions and acting within the scope of its authority."
May 6, 2010
Article: CMS Changes Claims Rejection Date for Ordering/Referring and Adds Other Requirements Due to Healthcare Reform Bill Legislative Requirements
On May 5, 2010 CMS publsihed an interim final rule in the Federal Register to implement certain requirements in the health care reform act (Patient Protection and Affordable Care Act aka PPACA) as of July 6, 2010. If you would like to read the actual rule click here.
The rule changes the date requiring providers enrollment records to be in the PECOS system for services ordered or referred from 1/3/2011 to 7/6/2010. In addition, home health services are now added to the list of potential claims rejections if ordered or referred by providers whose enrollment is not in PECOS.
Obviously the provider community is upset. CMS has been asked for clarification regarding this apsect of the rule and thus far has been fairly silent although today they have indicated further details will be discussed during a national audio call related to provider enrollment on May 19, 2010. CMS indicates they will release details of the call in an email to the provider community later today.
The rule also stipulates the legal name and NPI must be submitted for all claims for Medicare and Medicaid; but this has not been an issue for providers who have been mandated to do so since 2008.
The final issue stipulated in this new rule is the requirement for providers to maintain documentation for 7 years for any item ordered or referred related to DME, laboratory, imaging, specialist, or home health services. Failure to maintain the documentation and/or to release the documentation, if requested, would result in revocation of Medicare billing privileges.
May 4, 2010
Article: CMS Releases New CMS 588 Form for Electronic Funds Transfer Enrollment
CMS posted a new CMS 588 form to their website with an effective date of 4/1/10. The form is used to newly enroll with Medicare for EFT or to change your existing EFT information. CMS has not specifically stated when the new form will be mandated for use but rumor has it the mandatory date will be 1/1/2011.
Click Here to View the New Form
Some of the changes noted in the new form compared to the old one are as follows:
A specific question is asked if you have had a change of practice location. If you indicate a change has occurred, be prepared to submit a CMS form to change your enrollment information.
As the "Account Holder" you will need to enter your full address (be sure your address is up to date in your Medicare enrollment file).
You will no longer have to enter the name of the Medicare contractor in the Authorization Section. This has been an area many people frequently overlook or enter incorrectly resulting in letters of development.
March 26, 2010
Article: Medicare Contractors to Hold Claims for Ten Business Days Starting 4/1/10
The Senate today failed to pass legislation, a part of which would have continued a freeze on Medicare payments for 30 more days. Congress is now leaving for the Spring Recess and will not return until 4/12/10. As a result, the 21.2% decrease to Medicare reimbursements will take effect 4/1/10. Another vote on the issue is scheduled to take place when the Senate returns on 4/12/10. In anticipation of a fix, CMS has instructed Medicare contractors to hold payment for claims with dates of service 4/1/10 and after for 10 business days. Since electronic claims are currently held for payment for 14 calendar days, it is hoped that cash flow issues to providers will be minimized.
Below is the actual text from an email sent by CMS to the provider community today.
"The Centers for Medicare & Medicaid Services (CMS) is working with Congress, health care providers, and the beneficiary community to avoid disruption in the delivery of health care services and payment of claims for physicians, non-physician practitioners, and other providers of services paid under the Medicare Physician Fee Schedule (MPFS). As you are aware, the Temporary Extension Act of 2010, enacted on March 2, 2010, extended the zero percent (0%) update to the 2010 MPFS through March 31, 2010.
CMS believes Congress is working to avert the negative update that will take effect April 1. Consequently, CMS has instructed its contractors to hold claims containing services paid under the MPFS (including anesthesia services) for the first 10 business days of April. This hold will only affect claims with dates of service April 1, 2010, and forward. In addition, the hold should have minimum impact on provider cash flow because, under the current law, clean electronic claims are not paid any sooner than 14 calendar days (29 for paper claims) after the date of receipt."
March 15, 2010
Article: CMS Clarifies Signature Requirements - "Legible", "Illegible", and Electronic
In October, 2009 (see FYI article below dated 10/8/09) the Centers for Medicare and Medicaid Services (CMS) and the Office of Inspector General (OIG) clarified that providers
of Medicare services must comply with signature legibility requirements outlined in the Medicare Carrier Internet-only manual, Publication 100-08, Chapter 3, Section 3.4.1.1 B. This section stipulates and CMS has stated that "Medicare requires a legible identifier for services provided/ordered. The method used shall be hand written or an electronic signature (stamp signatures are not acceptable) to sign an order or other medical record documentation for medical review purposes. (The only exception is that facsimiles of original written or electronic signatures are acceptable for the certifications of terminal illness for hospice.)The legible identifier (signature) requirement applies to documentation for any service performed and billed to Medicare. The purpose of a rendering/treating/ordering practitioner’s signature in patients’ medical records, operative reports, orders, test findings, etc., is to support that the services have been accurately and completely
documented, reviewed and authenticated."
On 3/9/10, an article was posted to the Florida Medicare contractor website outlining clarifications from CMS regarding "legible", "illegible", and electronic signatures. It is very important for you to read and comply with these requirements. Record reviews by contractors or other entities, are being very strict in enforcement; AND money will be recouped if signature requirements are not followed.
Click Here to Read the Recent CMS Clarifications
February 26, 2010
Article: Medicare Contractors to Hold Claims for Ten Business Days Starting 3/1/10
Congress has failed to stave off the 21.2% decrease to Medicare reimbursements slated, by law, to take effect 3/1/10. The Senate will not reconvene again until Tuesday, March 2nd. It is hoped that some temporary fix to eliminate the Medicare cut will be approved next week. In anticipation of a fix, CMS has instructed Medicare contractors to hold payment for claims with dates of service 3/1/10 and after for 10 business days. Since electronic claims are currently held for payment for 14 calendar days, it is hoped that cash flow issues to providers will be minimized.
Below is the actual text from an email sent by CMS to the provider community.
"The Centers for Medicare & Medicaid Services (CMS) is working with Congress, health care providers, and the beneficiary community to avoid disruption in the delivery of health care services and payment of claims for physicians, non-physician practitioners, and other providers of services paid under the Medicare physician fee schedule. As you are aware, the Department of Defense Appropriations Act of 2010 provided a zero percent (0%) update to the 2010 MPFS effective for dates of service January 1, 2010, through February 28, 2010.
We believe Congress is working to avoid the negative update that will take effect March 1. Consequently, CMS has instructed its contractors to hold claims containing services paid under the MPFS for the first 10 business days of March. The holding of MPFS claims will only affect claims with dates of service March 1, 2010, and forward. This hold should have a minimum impact on provider cash flow because, under current law, clean electronic claims are not paid any sooner than 14 calendar days (29 for paper claims) after the date of receipt. Be on the alert for more information about the 2010 Medicare Physician Fee Schedule Update."
February 25, 2010
Article: CMS Publishes MLN Matters Article with Q&A for Consult Coding
CMS has just released a MLN article with Q&A related to the elimination of consult coding in Medicare that became effective January 1, 2010. Noteworthy in the article is their clarification that NO crosswalk exists for former inpatient consult codes 99251-99255 to the inpatient codes now to be used, 99221-99223. In addition, they clarify a physician may bill the subsequent hospital visit codes, for example 99231 or 99232 if their initial consultative service does not meet the documentation requirement for the 99221-99223. CMS also points out they have notified Medicare contractors to "not find fault" if providers bill the subsequent hospital visit code as their initial inpatient consult. The only time a provider would use the E/M unspecified code, 99499, is if there is absolutely NO CPT code that describes the service rendered (this should be rare).
To read the full MLN Matters article Click Here
February 23, 2010
Article: Medicare Claims Crossover to Supplemental Payer Problem
The Center for Medicare Medicaid Services (CMS) recently sent an email to providers nationally identifying an issue with crossover claims to supplemental payers for both Medicare Part A and Part B. The problem started 1/5/2010 and has now been resolved. Unfortunately, your Medicare remittance advice may erroneously have posted that a crossover occurred when it did not.
Where CMS was able to provide a fix for Part A claims to automatically correct the error and reprocess claims to supplements, they have NOT been able to do so for Medicare Part B claims crossovers. Part B providers will need to check their remittances with an issue date of 1/5/2010 thru 2/12/2010 to identify certain claims criteria that will require you to take manual action to crossover the claim to the supplement. To read the full CMS email and the criteria to look for click here
January 26, 2010
Article: CMS Announces Organizations Approved for Accrediting the TC of Advanced Diagnostic Imaging Services
As of 1/1/2012, if you are providing the technical component (TC) of an “advanced imaging service” you must be accredited by a designated organization in order to be paid for the TC. An "advanced imaging service" is defined as MRI, CT, nuclear medicine, and positron emission tomography (PET).
In the federal register today, 1/26/10, CMS announced approval of three organizations to provide the accreditation services.
NOTE: If you are already accredited AND the accrediting organization (AO) happens to be one designated by CMS, your accreditation will remain in effect. If the AO is not approved by CMS, then you will need to pursue accreditation through one of the approved organizations!
Only three organizations applied to CMS for approval at this point in time. All three have been designated by CMS. The organizations are:
American College of Radiology (ACR) Click Here to View the ACR Website
Intersocietal Accreditation Commission (IAC) Click Here to View the IAC Website
The Joint Commission (TJC) Click Here to View the TJC Website
Click Here to Read the Federal Register Posting 1-26-10
November 24, 2009
Article: CMS Delays Phase 2 Date for Claims Rejections If Individual Medicare Enrollments Are Not In PECOS
CMS sent an email to their listserv late on 11-23-09 indicating a delay for implementation of Phase 2 of the change requests for individual providers in the Medicare program who order or supply DME.
(See the article posted 10-21-09 in the FYI section of the Physicians First website for further detail about the original change requests)
Instead of denying claims as of 1/4/2010 if an individual provider enrollment is not in PECOS, claims will not deny until 4/5/2010. This will give providers affected by the rules more time to get enrollments submitted and processed.
Click Here to View the Text of the CMS Email 11-23-09
October 22, 2009
Article: Medicare Part A & B Deductibles Increase for 2010
The Department of Health & Human Services announced today in the federal register the premiums and deductibles for Medicare part A & B for 2010.
The Medicare Part B deductible for 2010 will be $155.00. In 2008 and 2009 the deductible was $135.00.
The inpatient hospital deductible for Medicare Part A will increase from $1068.00 in 2009 to $1100.00 for 2010.
The standard Medicare Part B monthly premium in 2010 is $110.50. In 2009 the standard monthly premium was $96.40. Medicare Part B premiums are adjusted based on income so the monthly premium of $110.50 is the base rate and would increase accordingly based on the beneficiary income whether filing taxes individually or jointly.
October 21, 2009
Article: ALERT!!! All Providers Who Order or Supply DME
If your physicians or other providers are ordering or supplying DME supplies for Medicare Part B beneficiaries, your claims will be denied as of January 4, 2010 IF the INDIVIDUAL PROVIDER’S’s Medicare Part B enrollment IS NOT IN PECOS.
What does this mean?
PECOS is the Provider Enrollment Chain & Ownership System implemented by the Center for Medicare-Medicaid Services (CMS) in November, 2003. It is a national database of ALL enrollments for ALL Medicare Part B providers. If you enrolled as an individual provider with Medicare Part B prior to November 2003 and have not made changes to your enrollment, YOU ARE NOT IN PECOS.
Where you are validly enrolled with Medicare Part B, your information is simply part of your actual Medicare contractor’s local (state) enrollment file. Your enrollment information does not become a part of PECOS unless you make a change to your information or you REVALIDATE your individual information with your Medicare Part B contractor.
Can you call your Medicare Part B contractor to find out if you are in PECOS?
Unfortunately, the answer to that question is “no”. Customer service personnel at the Medicare contractors do not have access to the PECOS system.
If your providers individually enrolled with Medicare Part B prior to 2004, I would strongly recommend that you revalidate your individual Medicare enrollment information NOW in order to avoid denials of your claims for DME services as of 1/4/2010 or to avoid the DME supplier you send your patients to receiving denials. To revalidate your enrollment you must complete the CMS 855I form; and you MUST use the latest version of the form which was revised in July, 2009. You complete the form by checking the box “revalidation” and completing the document as though you are newly enrolling. In addition, if you are a member of a group practice, you also need to complete the CMS 855R in order to re-verify your reassignment to your group.
PLEASE NOTE: The enrollment is sent to your Medicare Part B contractor and NOT to the DME contractor.
As a warning to providers, DME contractors started checking claims received as of 10/5/09 to see if ordering providers are in PECOS. If you are not in PECOS, you will start receiving warning messages regarding this from the DME contractor (or you might receive a note from your local DME supplier that they are receiving the warning).
During this warning phase, 10/5/2009 – 1/3/2010, if the DMEPOS supplier claim is an ANSI X12N 837P standard electronic claim, the DMEPOS supplier will receive a warning message on the Common Electronic Data Interchange (CEDI) GenResponse Report.
If the DMEPOS supplier claim is a paper CMS-1500 claim, the DMEPOS supplier will not receive a warning and will not know that the claim did not pass these edits!!
During this phase claims will continue to be paid.
As of 1/4/2010, claims will be denied, IF THE INDIVDUAL PROVIDER IS NOT IN PECOS!!!
The concept of revalidation is one that CMS now requires all suppliers and individuals to complete every 5 years. Getting started by revalidating NOW will not only prevent the potential for the denial of DME claims; but it will insure your peace of mind for the next 5 years!!
October 16, 2009
Article: PQRI Bonuses for 2007 Re-Run and 2008 - CMS Offers Alternate Method for Obtaining Individual Feedback Reports
Bonuses for the 2008 PQRI program have started being paid as of 10/12/09. The payments will be issued to you by your Medicare contractor in the same manner you receive other Medicare payments. If you receive an electronic remittance, you will note a remark code "LS" which designates the payment is a "Lump Sum". If you receive a paper remittance, the payment will be described as "This is a PQRI incentive payment". Medicare contractors will continue to release the 2008 bonuses through the end of October.
Bonuses for the 2007 Re-Run will start to be released by the Medicare contractors as of November, 2009.
Feedback reports for 2008 PQRI will not be available until 10/30/09. As a group practice you will still need to obtain the full report for all individual providers by registering in the IACS system. However, CMS now has an option available where any individual provider may request their indivudal PQRI report. As of 10/19/09, an individual provider may call their Medicare contractor to request the report. The provider will be required to provide identifying information as well as an email address. The PQRI report will be forwarded to the provider via email within 30 days. Click Here for the Medlearn Article About This New Option
Click Here to Download and Print a New CMS Guide to Understand the Feedback Report
October 8, 2009
Article: Signature Requirements in the Medicare Program Clarified
The Center for Medicare and Medicaid Services (CMS) and the Office of Inspector General (OIG) have clarified that all providers must comply with signature requirements for ALL services that are billed to the Medicare program. If records are requested for review, and the signature requirement is not met, this error will result in an overpayment and recoupment of funds. The link to the following article was posted by the Florida Medicare contractor BUT applies to ALL providers nationwide as quoted in the article directly from the internet only Medicare Carrier Manual.
Click Here to Read the Article
October 6, 2009
Article: New Website Tool Compares Federal & State Privacy Laws
The Agency for Healthcare Administration (AHCA) in Florida has launched a new website that serves as a crosswalk to enable providers and consumers to search for federal laws related to privacy and security. The search will not only allow you to obtain federal laws; but it then crosswlaks to applicable state laws in Florida. For you Non-Floridians, you might still find the site helpful as a quicker search for the federal rules.
Click Here to View the Site
September 15, 2009
Article: New Enhancements to the NPPES System Will Affect You the Next Time You Login
On September 13, 2009 enhancements were made to the National Plan & Provider Enumeration System (NPPES). This is the system where all NPI data is housed and where you apply for new NPIs, change information in existing files, and search for NPIs. The next time you login to your NPI file, whether individual or organization, you will be required to select five (5) secret questions and answers. These questions and answers will be saved and used for verification purposes when you login to a file to reset your password. (CMS recommends that users change their passwords periodically for security purposes.)
As a second enhancement, the system will not allow a password to be changed more than once within a 24 hour period.
As a reminder, it is VERY important for providers and organizations to maintain accurate information in their NPI files. In fact, technically, the NPI rules require any changes to be made within 30 days. If you have changed locations or made other changes to your individual or business information, UPDATE your files!! If you have misplaced your User ID & Password login information, contact NPPES directly at 1-800-465-3203. If you are not the contact person in the NPI file, NPPES will require the provider (for an individual NPI file) to be the caller and to provide identifying information. For an organization NPI file, if you are not the contact person listed in the file, the authorized official would need to call; and again, be prepared to provide identifying information for the business.
September-8-2009
Article: CMS Revises 855B and 855I Medicare Enrollment Forms
Revisions to the CMS 855B and CMS 855I were posted by CMS in August 2009. The changes to the forms are minor and should not cause confusion. What will happen, however, is the eventual return of the old forms by the Medicare contractors if used for enrollments in the future. CMS has not issued a mandatory date for use of the new forms. It is recommended that you download the new forms now and start using them.
The forms may be accessed at the CMS forms website:
NOTE: When you do the lookup for the forms at the CMS website you will note under the “revision” column the date is 02/2008. However, download the forms and you will note in the lower left hand corner: (02/08)(EF 07/09). The “EF 07/09” indicates you have the most current form.
First Coast Service Options, the Florida Medicare contractor, posted a summary document of the form changes. Click Here for the Summary Document
September 4, 2009
Article: CMS Issues Guidelines and Codes for Swine Flu Vaccine and Administration
CMS has published a Medlearn article regarding billing for the administration of the swine flu (H1N1) vaccine. The vaccine is expected to be available in Mid-October, and will be provided to physicians at no cost via your state health departments. Since the vaccine is free to providers, you will not be allowed to bill for the actual vaccine even though CMS has created a new "G" code for same (G9142). You may bill for the administration of the vaccine (even if more than one shot is required). The new code for administration is G9141. You should use the diagnosis code V04.81. Payment for the administration will be the same as for flu and pneumonia vaccines (G0008 & G0009). Deductible and co-pays for the H1N1 vaccine are waived.
Click Here to Read the Medlearn Article
Click Here for the 2009 Pay Rates for 2009
Click Here for State Information Regarding Vaccine
August 26, 2009
Article: Medicare Part B Claims Editing for Ordering/Referring Providers Expanding as of 10/5/09 As of 5/23/08 when a physician or supplier bills Medicare for a service that is the result of an order or referral, the name & NPI of the ordering/referring provider must be entered in the claim.
As of 10/5/09 the editing for this requirement will be expanded to insure the ordering/referring provider is validly enrolled in the Medicare program and is specialty eligbile to order or refer. Initially, if there is an issue, your claim will be paid; but an error message (M68) will indicate to you in your remittance that a problem exists with the provider.
CMS announced yesterday that, effective 1/1/2010, claims will be denied payment if there is an issue with the enrollment and eligibility of the ordering/referring provider. To read the Medlearn article related to this new editing: Click Here
July 6, 2009
Article: CMS Publishes PROPOSED 2010 Medicare Rules - Consult Coding Would Be Eliminated!
On July 1, 2009 CMS issued the proposed rules for the 2010 Medicare program. The proposed rule changes are extensive; but perhaps the biggest bombshell is the proposal to eliminate the use of consultation codes (99241-99245 and 99251-99255) for Medicare beneficiaries. Office and other outpatient consults would now be billed using new patient office codes (99201-99205) or established office codes (99211-99215). Less clear, as the rule is not written particularly well, is what will happen with inpatient consults. CMS appears to say the attending physician for an inpatient would bill an initial inpatient admission code, 99221-99223, BUT would be required to use a new modifier (yet to be disclosed) to indicate the physician is the attending. Consultants would then be able to bill 99221-99223 for their initial work up of the patient. It appears, however, that the consultants reimbursement would have a high likelihood of being denied IF the attending physician forgot to bill the initial admission with the new modifier. This could be a huge change for 2010 that could cost practices significant revenue if all providers involved in the care of the patient are not coding correctly; and could significantly increase the administrative burden in the appeals process for an initial consultation. CMS will accept comments regarding the proposed rules until 8/31/09. Final rules will be published some time in November, 2009.
May 26, 2009
Article: FTC Requirement for Red Flag Rules for Identity Theft Protection Compliance Date Now Moved to 8/1/09
The federal trade commission originally published the Red Flag rules in the federal register 11/9/07. Click here for link to rules
Much disagreement has occurred as to whether physician practices are considered “creditors” under the rule and are required to comply. Unfortunately, the consistent answer from the FTC has been “yes”. As the FTC has stated: “When a physician submits a claim to an insurance carrier first and then bills any remaining unpaid amounts to the patient – whether he/she does so as a courtesy to the patient or because he/she is required to do so as a matter of contractual or state law – the physician is deferring the consumer’s payment of his or her share of the claim (i.e., the physician is billing the patient after having provided the patient with medical services).”
Your practice will be required to develop an identity theft prevention program that contains "reasonable policies and procedures" to achieve the following goals:
1. Identify relevant indicators of a possible risk of identity theft (“Red Flags”)
2. Detect Red Flags
3. Prevent and mitigate identity theft
4. Train employees on detecting the Red Flags
5. Update the identity theft prevention program on an annual basis
Even with your HIPAA Privacy compliance plans in place, Identity Theft rises to some different areas for compliance with the new Federal Red Flag Rules.
The FTC website has a great deal of information you may find helpful including a step by step process for completing your plan: Click Here for the FTC website for Red Flag Information and Compliance Plan Tool.
The AMA has also posted helpful information and resources to their website: Click here for the AMA Resource site
April 17, 2009
Article: CMS revises CR 6310 - New Transmittal 289 - Non-Compliance for Failing to Report Practice Location Changes Now Even More Confusing!
CMS Change Request 6310 was first issued to Medicare contractors 3/13/09 to implement new enrollment rules as of 4/1/09. These were the rules published in the federal register 11/08 with an effective date of 1/1/09.
One of the new rules requires providers to notify enrollment of practice location ”changes” within 30 days rather than the old 90 days.
CR 6310 originally instructed contractors that they “shall” assess an overpayment back to 1/1/09 if a practice was not compliant with the 30 day rule.
In addition the rule said contractors “shall” revoke billing privileges if someone was non-compliant.
In CMS enrollment rules that became effective 8/26/08, if a provider whose billing privileges were revoked due to this type of non-compliance occurred, they would not be allowed to re-enroll for 1 year.
Needless to say this type of punishment would really adversely affect businesses. Actually it would put them out of business once and for all!
On 4/15/09, CMS reissued CR 6310. The language now reads that a contractor “may” assess the re-payment and revoke billing privileges. Where it is a nice wording change it still leaves the issue unsettled. It appears that the decision will be left to Medicare contractors nationally which means different actions may be taken by different contractors making it even more of a mess!
April 16, 2009
Article: Internet PECOS Individual Enrollment Issue Remains Up in the Air (See Article Posted 4/7/09)
CMS has still not provided a final answer to the Internet PECOS issue related to the missing data entry field for the Medicare PTAN reassignment. In fact, the only response received since 4/7/09 when CMS indicated they were working on the issue was an email with the following statement: "When a provider goes to work for an organization, he is working for the organization as a whole, therefore when the provider submits a CMS 855R he is reassigning to the organization and not to a PTAN. Therefore, if an organization has more that one PTAN the provider should be reassigned to all PTANs on the file."
Unfortunately, this answer only serves to confuse the true meaning and validity of the meaning of reassignment.
Interestingly, CMS announced earlier this week that changes will be made to the PECOS system. The announcement is as follows:
"The Centers for Medicare & Medicaid Services (CMS) will be making changes at its Data Center that will affect the Provider Enrollment, Chain and Ownership System (PECOS). As a result, physicians, non-physician practitioners, and provider and supplier organizations will not be able to access Internet-based PECOS from 9:00 p.m. Eastern Time on Thursday, April 16, until 9:00 a.m. Eastern Time on Monday, April 20. We apologize for any inconvenience this may cause."
April 7, 2009
Article: Issue Identified with Internet PECOS for Individuals
Thanks to the documentation provided by a very large group yesterday to Physicians First, an issue with Internet PECOS for Individual Medicare enrollment hs been identified.
When doing online enrollment, internet PECOS does not have a required field to enter the group Medicare PTAN for reassignment of benefits. As a result, practices have been receiving letters of development or have given up entirely attempting to do online individual enrollment.
Documentation of the issue has been forwarded to CMS, and they indicate they are working to correct the problem.
April 3, 2009
Article: CMS Revises Change Request 6310 to Allow for Out of State Bank with EFT
CMS has removed the language from change request (CR) 6310 prohibiting the out of state bank for EFT. Notification of the change has been sent to all Medicare contractors nationally.
Per CMS: CR 6310, Transmittal 286, issued on March 13, 2009, is reissued to remove the provision in Business Requirement 6310.6 that deals with electronic funds transfers (EFT). The same provision has also been removed from the manual instruction document. All other information remains the same.
There is no news to report on the other two items of concern (see FYI Article Posted 4/1/09.)
To read CR 6310 in entirety click here
April 1, 2009
Article: URGENT!!-New Medicare Enrollment Rules Could Cost You Not Only Revenue But Revocation of Billing Privileges
CMS issued a change request to Medicare contractors nationally (CR 6310) with an implementation date of 4/1/09. The wording of the CR has allowed contractors nationally to make interpretations that are of significant concern to the enrollment process, your revenue stream, and even maintaining your billing privileges in the Medicare program.
Physicians First was able to learn yesterday from a source at First Coast Service Options (Florida Medicare contractor)the following enrollment rules are in place as of 4/1/09.
1. The billing/effective date of an enrollment will be the later of the date of filing or start date. NO retroactive billing for 30 days will be allowed unless there is documentation submitted with the enrollment to justify why the enrollment was not filed timely.
2. An out of state bank will not be allowed for EFT.
3. If a practice fails to notify the contractor of a practice location change within a 30 day time frame, your billing privileges will be revoked. There will be no appeal rights and you will not be allowed to re-enroll for 1 year.
Physicians First has been in communication with the AMA, National MGMA, as well as the head of the CMS Physician Regulatory Issues Team; and they are working to try to resolve these major issues. In the meantime be sure that you are abiding by the enrollment rules to stave off revenue losses and the potential for revocation of your Medicare billing privileges!!
Information is also starting to trickle out that other Medicare contractors nationally are starting to interpret CR 6310 and to implemnent the same changes as those implemented by First Coast.
February 27, 2009
Article: National Plan and Provider Enumeration System (NPPES) Enhancements on 3/7/09
The NPPES system will undergo system maintenance on 3/7/09. Neither NPPES nor the NPI Registry will be available on that day. After the update, the following enhancements will be in place:
• NPPES application help page will be revised to be consistent with the revised application/change form updated 11-08 (CMS form 10114)
• If NPPES resets your password, you will be required to change the password following the reset. The user will be redirected to the password reset page in order to change to a password of your choosing. Passwords must be a minimum of 8 characters.
• The "doing business as" (DBA) search feature will be restored.
• NPI Registry will be updated daily.
• NPI Registry will display information in capital letters. This change, however, does not affect how information in the actual NPI file is displayed.
February 19, 2009
Article: CMS Discloses CPT II Coding Issue for 2009 PQRI
CMS posted an article to their PQRI website disclosing a technical problem identified in the reporting of 20 quality data codes (QDCs) used for reporting 13 quality measures in the 2009 PQRI program. All of the QDC codes affected are new codes for 2009 in the PQRI program. Line items of claims where these codes have been submitted have been denied by all Medicare contractors nationally as unprocessable. A correction to the issue is expected "within the next 3 weeks".
Click here to download the CMS article identifying the issue, the codes affected, CMS recommendations for provider action, and CMS's action to mitigate a detrimental affect for your bonus payment for 2009.
January 9, 2009
Article: Update to the Initial Preventive Physical Exam (IPPE) Benefit for Medicare Beneficiaries
As of 1/1/09:
A. Beneficiaries may receive this benefit up to 12 months after the date their Medicare eligibility begins (previously 6 months).
B. The deductible is waived for the IPPE. Patient must still pay 20% co-pay.
C. The mandatory requirement for the screening EKG is removed. The screening is optional and is permitted as a one time screening service as a result of a referral arising out of the IPPE. The deductible and 20% co-pay does apply to the EKG (not new).
D. The IPPE must now include measurement of body mass index.
E. The IPPE must now include end of life planning.
Published rules make it clear that CPT 99201-99215 may be reported on the same day as IPPE so long as the service is medically necessary and separate and identifiable from the IPPE. The 25 modifier would need to be added following the 99201-99215 service.
Go to the "Documents" section of the Physicians First Inc. website to download the CMS 2009 IPPE Quick Reference Form for the NEW 2009 CODES and other IPPE information. There is also a download there for the CMS 2009 Quick Reference Guide for ALL Medicare Preventive Services.
December 20, 2008
Article: New Medicare Provider Enrollment Rules Effective 1/1/09
The effective date of enrollment (whether a new enrollment or change) will be the later of:
Date of filing the application (date defined as date when the contractor receives a signed app) that is subsequently approved OR
Date a supplier first started rendering services at a location.
This new rule could dramatically affect your revenue stream. Retroactive billing for services will be limited to only 30 days!!
Example:
You started rendering services 2/1/09.
You did not file immediately & the signed enrollment is not received by the contractor until 4/1/09.
The enrollment is finalized 6/1/09.
Your effective date is, therefore, 4/1/09.
You are allowed to bill for 30 days retroactive to effective date (3/1/09).
Services 2/1/09-2/28/09 cannot be billed.
Services 3/1/09-3/31/09 may be billed.
Medicare contractors may not actually implement these rules until March or April of 2009. Contractors cannot implement the rules until they receive actual instructions from CMS. CMS indicated this may not take place until March or April 2009. HOWEVER, remember…the EFFECTIVE date of the rule is 1/1/09.
Example:
You file an application 2/5/09.
The contractor receives instructions from CMS 4/1/09. Your application is not yet finalized.
Because your filing was after 1/1/09, the new rules will be in effect.
December 15, 2008
Article: Maintaining Ordering/Referring Documentation Inlcuding the NPI
New CMS rules effective 1/1/09 requires that ordering/referring documentation, including the NPI, must be maintained for 7 years. The original proposal by CMS was going to be 10 years.
Maintaining this type of documentation has been required for some time and was based on the date of payment for the service. Now, the date will be based on date of service. The documentation can be maintained electronically or offsite as long as easily accessible.
December 8, 2008
Article: New Physician Resource Use Feeback (PRUF) Program to be implemented by CMS in 2009
Legislation passed by Congress mandates the Secretary of Health & Human Services to implement the PRUF program as of 1/1/09. Under this program physicians and/or groups will be provided confidential reports outlining their use of resources (costs) expended for the care of Medicare patients.
Providers will be compared to others in their specialty and geographic area. Falling above the 90th percentile compared to a peer group will be considered an outlier. A low cost provider would be below the 10th percentile.
Data used in the reports is acquired by analyzing claims data 2004-2007. Determining a physician's cost efficiency is based on several factors including diagnosis & procedure codes, dates & site of service, & payment amounts.
Phase 1 of the program will focus on the following conditions: CHF, COPD, Prostate cancer, Cholecystitis, Coronary artery disease with acute MI, Hip fracture, Community acquired pneumonia, and UTI.
Phase 1 will focus on the following specialties: Internal Medicine, Cardiology, Gastroenterology, General Practice, Orthopedic Surgery, Medical Oncology, Urology, Pulmonology, Family Practice, and Primary Care.
Even though the program is being implemented 1/1/09, reports will not quickly be forthcoming. A test phase for the program using Baltimore and Boston was conducted in 2008. The first reports were provided to participants in these areas as of August and September 2008. CMS is still receiving feedback from this test phase. Look for further details in 2009.
October 31, 2008
Article: CMS Posts Final Rules for 2009 on Display
The 2009 final rules are now on display as of 10-30-08. Final publication in the federal register will come at a later date. If you would like to view the 1400+ page document, click here.
The dollar conversion factor for 2009 will decrease from $38.0870 to $36.0666. This decrease occurred as a result of applying budget neutrality adjustments to the dollar conversion factor rather than by decreasing the work relative values as has occurred in 2007 and 2008. Now that the work relative values have been restored to the CPT codes, the news for reimbursement for evaluation and management codes is not as bad as it may sound. Most of these codes will increase in 2009. Codes that will be hit the hardest by the dollar conversion factor decrease will be the ones that do not have any or very little work relative value assigned (for example, certain diagnostic services.) Click below to view the document from the final rules listing the national average payment expected for select CPT codes (remember, these amounts are not accurate for the actual allowed amount as they are not adjusted for a specific geographic locality):
Click here for 2008 vs 2009 Allowed Amounts for Selected Codes
October 24, 2008
Article: Signature Requirements for Medicare
Click Here for the Medlearn Article
As quoted from the article:
"The Centers for Medicare & Medicaid Services (CMS) has taken this step to ensure accurate application of Medicare's program requirements throughout the nation. CMS has identified problems of noncompliance with existing statutes, regulations, rules, and other systematic problems relating to standards of practice for a valid physician's signature on medical orders and related medical documents."
The SE0829 article relates to CMS change request 5971 with an original release date of 3/28/08, effective date of 9/3/07, and implementation date of 4/28/08.
The use of stamped signatures is prohibited in ALL medical records and orders.
This includes hospice orders and home health certification or other plans of care.
These requirements are intended to apply all providers/suppliers.
Hand written, electronic signatures or facsimiles of original written or electronic signatures are acceptable.
Medicare contractors require a legible identifier for services provided/ordered. When documentation is for medical review purposes, the only acceptable method of documenting the provider signature is by written or an electronic signature. Again, stamp signatures are not acceptable to sign an order or other medical record documentation for medical review purposes.
October 15, 2008
Article: Medicare Payments Reduced as of 10/1/08 if Provider Has Overdue Taxes
The General Accounting Office (GAO) found that over 21,000 of the physicians, health professionals, and suppliers paid under Medicare Part B during the first 9 months of calendar year 2005 had tax debts totaling over $1 billion. Government authority to collect these debts was authorized by the Taxpayer Relief Act of 1997 and a subsequent congressional mandate in Sec. 189 of the recent MIPPA legislation.
CMS will implement the Federal Payment Levy Program (FPLP) to collect overdue taxes owed by providers and suppliers enrolled in Medicare Part A and Part B.
Payments subject to the levy will be reduced by 15 percent, or the exact amount of tax owed if it is less than 15 percent of the payment. The levy is continuous until the overdue taxes are paid in full, or other arrangements are made to satisfy the debt.
When such adjustments occur, your Medicare remittance advice will reflect the code of 'WU' in the PLB03-1 data field. In addition, a 10 digit toll-free IRS number (1-800-829-3903) will appear in the PLB03-2 data field. Should this happen to you, note that under current privacy rules and regulations, only the IRS may discuss the tax issue with you. Thus, if you have questions, contact the IRS at the toll-free number instead of contacting your Medicare contractor.
NOTE: AT THE CURRENT TIME, the levy cannot occur if you are an individual who has reassigned benefits to a group practice. CMS is considering a proposal to revoke Medicare billing privileges when individuals have reassigned benefits. They are also considering revoking billing privileges to an organization/group IF the organization/group has providers in default with the IRS who have reassigned benefits.
October 1, 2008
Article: New Authentication Requirements When Contacting Medicare Customer Service or Using the IVR - Effective 3-1-09
As of 3/1/09 you will be asked to provide 3 authentication requirements in the following order when contacting Medicare. Be sure your staff members have this information readily available:
NPI
Medicare PTAN
Last 5 digits of Tax ID#
September 22, 2008
Article: CMS Announces Medicare Part A & B Deductibles, Premiums, and Other Part A Beneficiary Expenses for 2009
CMS made the announcement on 9/19/08:
2009 Medicare Part B deductible will remain the same as 2008 at $135.00.
2009 Monthly Part B premium will remain the same as 2008 - $96.40 per month. Increases in the monthly premium will continue based on individual or joint income.
2009 Medicare Part A deductible increases from $1,024 to $1,068. Deductible is incurred for each inpatient stay up to 60 days.
2009 Medicare Part A - inpatient for days 61-90. Increases from $256/day to $267/day.
2009 Medicare Part A - inpatient beyond the 90th day in a benefit period. Increases from $512/day to $534/day.
2009 Medicare Part A - daily co-insurance for the 21st-100th day in a skilled nursing facility increases from $128 to $133.50.
99% of Medicare beneficiaries do not have to pay a premium for Medicare Part A as they have contributed to social security or are the spouse or widow of someone who qualifies. If a premium does have to be paid, it will increase by $20 in 2009 to $443 per month.
September 3, 2008
Article: CMS Announces that Eligible Professionals Are Exempt From Meeting Accreditation & Quality Standards for DME Enrollment
The Medicare Improvements for Patients & Providers Act (MIPPA) enacted by Congress 7/15/08 contained language to allow the Secretary of Health & Human Services to exempt "eligible professionals" from the requirements for DME quality standards and mandatory accreditation if the Secretary felt that these standards did not apply to these providers. CMS announced the good news today that eligible professionals (EPs) are exempt until further notice. The following providers are now exempt: MD, DO, Podiatrists, physical/occupational therapy, speech language, optometrists, opticians, audiologists, orthotists, prosthetists, physician assistant, nurse practitioners, nurse specialists, anesthetists, dietitians social workers, psychologists.
Without this exemption providers were required to be accredited and in compliance with standards no later than 9/30/09 or risk revocation of DME billing numbers. New DME enrollees have had the mandate in place since 3/1/08. Accreditation takes approximately 9 months to complete not to mention the expense being in excess of $3,000.
CMS will be publishing "at some point in 2009" a notice of proposed rulemaking for standards & accreditation BUT ONLY for orthotists and prosthetists. ALL OTHERS continue to be exempt for the forseeable future.
CMS assured those listening to the call they have put the NSC (National Supplier Clearinghouse) on notice as to this exemption to insure that new enrollments will no longer be denied without accreditation.
July 21, 2008
Article: CMS Issues New Enrollment Rules Effective August 26, 2008
CMS recently published new enrollment rules in the Federal Register. Below are some of the highlights:
1. If you receive a letter of development from your Medicare contractor during the enrollment process, you will only have 30 days to respond (rather than the current 60 days).
2. CMS has made it clear that a new enrollment, revalidation, or change in enrollment mandates conversion to EFT.
3. If your enrollment is denied or Medicare billing privileges are revoked, you have the right to a first level of appeal, called reconsideration. The appeal decision is rendered in 60 days; and the decision is rendered by a hearing officer not involved in the original determination. If you lose the reconsideration, you may appeal to an ALJ.
4. Medicare contractors may revoke your Medicare billing privileges if you bill for services (3 times) that could not have been rendered to a beneficiary. If your number is revoked (and you lose the appeals process), you may not apply for reinstatement for up to 3 years!
5. Revalidation of Medicare enrollment for all providers and organizations is required every 5 years. You may voluntarily revalidate your information or you may wait for communication from the Medicare contractor. If you fail to revalidate your enrollment information within the 60 day required period communicated by the carrier, your Medicare billing privileges will be revoked. The contractor has the discretion in this instance to NOT allow reapplication and reinstatement for up to one year.
Click Here to Read the Rules in the Federal Register
July 17, 2008
Article: CMS Issues PQRI Bonus Payments for Reporting in 2007 - To Acquire Data You Must be Registered in IACS
CMS issued a press release 7/15/08 indicating PQRI bonus payments for 2007 had been issued. Approximately 56,700 eligible professionals nationally qualified for the bonus payment. The average individual payment was over $600. The average group practice payment was $4,700.
In order to acquire individual data for the providers who participated in PQRI, you are required to register in the IACS system (Individuals Authorized Access to CMS Systems). This is the same system that utlimately will be used for electronic Medicare Provider Enrollment.
Individual providers (those who do not reassign benefits to another party) will be able to register fairly quickly since the system will only look to verify their individual identity for security purposes. The downside for individuals though....if your individual Medicare enrollment data is not in PECOS (Provider Enrollment and Chain Ownership system), you will be required to revlaidate your Medicare enrollment, a process that will take time.
For a group practice, a delegated authority model is used for registry in IACS. The group assigns a security official, user group administrator, and end users. This process may take up to two weeks for final verification.
If all of this sounds confusing, CMS recently held an audio call with step by step instructions provided in a detailed powerpoint program.
Click here to Download the Power Point Program
PLEASE NOTE: Once you register in IACS you are required to change your password every 60 days!!
July 16, 2008
Article: House and Senate Override President Bush's Veto of HR 6331-Pay Cut Averted-Guaranteed Increase of 1.1% for 2009
In emergency votes last night both the House and Senate voted to override President Bush's veto of the Medicare bill HR 6331. The bill now becomes law guaranteeing your Medicare payments will stay the same for the remainder of 2008 and providing a 1.1% increase for 2009.
CMS issued their first statement today to explain how Medicare contractors will deal with system changes and paying claims with dates of service 7/1/08 and after.
Click Here to Read the CMS Statement
July 11, 2008
Article: Senate Passes HR 6331 to Stave off Medicare Cuts, but Presidential Veto is Likely This Weekend
The Senate passed HR 6331 on July 8th by a vote of 69-30. Because contentious portions related to Medicare Advantage Plans remain in the legislation, a Bush administration official indicated on 7/11/08 the President is likely to veto the bill as early as this weekend. Due to the margins by which the House and Senate passed the bill, there is a strong likelihood that Congress can override the veto (although the administration would need only three votes to change the override in the Senate). That override process, however, has to start in the House of Representatives; and at the earliest, would begin July 15th.
CMS has no choice but to implement the law as it stands for 7/1/08, and it would seem that the 10.6% reduction in claims payment will start when CMS is forced to release claims from the claims processing system on July 15th.
In preparation for this, Medicare contractors nationally have started posting the revised Medicare Physician Fee Schedules to their websites.
June 26, 2008
Article: Senate Fails to Pass Bill That Would Stave Off 10.6% Medicare Pay Decrease as of 7/1/08
HR 6331 was defeated in the Senate today with no hope of another vote until after the July 4th Congressional recess. If the bill had passed, it may still have been met with a veto by Presdient Bush due to certain parts of the legislation related to Medicare Advantage Plans. When Congress reconvenes on July 7th, the bill may come up for another vote.
So What Does This Mean to You Now?
1. For claims with dates of service 7/1/08 and after, the allowed amount for services paid under the Medicare Physician Fee Schedule will decrease by 10.6%
2. CMS, however, has indicated they will instruct carriers to hold all claims with dates of service 7/1/08 and after for the first 10 business days of July in the hope that Congress will be able to pass legislation on their return to Washington DC. Hopes, however, become slim since Congress needs to act and the President would need to sign the bill with a very short window of opportunity. As of 7/15/08, CMS will have no choice under the existing law but to relase the claims for payment at the lower amount.
3. Keep in mind too that the ability to use the KX modifier for a therapy cap exception also sunsets as of 6/30/08.
If Congress is able to pass a bill that the President will sign, the original legislation would have maintained allowed amounts at their pre 7/1/08 levels through the remainder of 2008; and the dollar conversion factor would increase by 1.1% for 2009. If Congress makes their legislation retroactive to 7/1/08, CMS indicates they are prepared to retroactively reprocess "most" claims at the correct allowed amounts.
All of this creates a great adminstrative burden to medical businesses where the potential for having to reconcile two different claims may be unavoidable not to mention the sudden revenue decrease by 10.6% with Medicare and other managed care contracts with rates that are tied to the Medicare Fee Schedule.
June 10, 2008
Article: CMS Announces Orgnaization NPIs Will be De-Activated if IRS Legal Business Name and NPI Files Do Not Match!!
Per CMS: "In an effort to ensure that the data submitted to the National Plan and Provider Enumeration System (NPPES) for organization health care providers is accurate, CMS initiated an NPPES-IRS data match to ensure that the legal business name (LBN) and employer identification number (EIN) in NPPES are consistent with IRS data.
This week, CMS will mail out letters to organization health care providers that have an EIN/LBN combination in NPPES that are different from the information maintained by the IRS. These letters request that the health care providers review and update their LBN and/or EIN in NPPES. If health care providers can not furnish data that are consistent with the IRS, we will deactivate the National Provider Identifier in NPPES. CMS will continue to match these health care provider data in NPPES against IRS data to ensure the accuracy of NPPES data."
Please call the IRS and ask them to fax you a letter to confirm your tax id number and how your name for your business is listed in the IRS files. The number is 866-860-4259. The IRS has been doing this constantly for people for Medicare enrollment over the past two years. They will fax it to you the same day!
Once you get the letter, log in to your business NPI file and enter your business name EXACTLY as listed in the IRS file.
Keep the letter from the IRS. You will need it in the future for Medicare enrollment when you are forced to revalidate your group information. You will also need the letter in order to register to access PQRI information for your individual providers.
June 2, 2008
Article: CMS Rescinds the Recent "Incident to" Policy Transmittal 87 - CR 5288
On May 30 CMS announced the decision to rescind their transmittal on incident-to billing guidance due to take effect 6/2/08. CMS received many complaints from the AMA, MGMA, and 30 other physician specialty organizations prompting them to rescind the transmittal. CMS also announced its intention to release a new transmittal at a future date.
May 20, 2008
Article: Medicare Competitive Bidding Program for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)!
This new program starts 7/1/08 in 10 areas. As of 2009, 70 other areas are added.
If Medicare beneficiaries live in or travel to a designated area, they must receive DMEPOS from a contracted/accredited supplier or risk paying out of pocket.
For providers, if you have a DMERC billing number and want to continue to bill for DME supplies, you will need to be accredited as of September 30, 2009 or your number will be revoked. Becoming accredited currently takes, on average, 4-6 months and CMS expects the process to become more prolonged as more and more suppliers awarded contracts are required to be accredited too. The cost of the accreditation process is on average $3000 and escalates considerably depending on the number of locations you have.
Please take time to read information below and visit the CMS website link.
Article 1
Article 2
Article 3
Beneficiary Fact Sheet
CMS DMEPOS Website
May 9, 2008
Article: CMS Issues "Incident to" Policy Update 5/2/08 and Dramatically Changes the Landscape for Compliance
Change request 5288 clarifies CMS "incident to" policy and is effective 6/2/08. In a dramatic change, the policy now specifically states "contractors shall not pay for services incident to a physician's/NPP service unless there is documentation authorizing the subsequent service". They further state, "The authorization may be an order which may be part of the care plan. The authorization does not have to be in any specific form. The authorization will not be on the claim and therefore, will be identified only when the record is reviewed."
The policy gives wide latitude to Medicare contractors in other areas for compliance with the rule when records are reviewed. You would be wise to read the entire change request and MedLearn article for the full scope of clarifications!
Click Here to Read the Change Request 5288
Click Here to Read the Medlearn Summary Article
May 6, 2008
Article: Medicare Provider Authentication as of May 23, 2008
As of 5/23/08 when contacting Medicare customer service or using the IVR you will be required to provide BOTH the Medicare PTAN and the NPI.
For written inquiries, including fax and email, you will be required to have the provider name, and either the PTAN or NPI. Make sure your staff members have all these numbers readily available!
Click here to read the Medlearn Article SE0814 regarding these new requirements
April 30, 2008
Article: CMS Posts and Reviews New PQRI Alternative Reporting Methods, Reporting Periods, and Use of Data Registries
The Medicare, Medicaid, SCHIP Extension Act of 2007 (MMSEA) required CMS to develop new approaches for PQRI reporting in 2008. CMS has recently posted the summary document related to the changes. In addition, CMS held the first national audio session 4-30-08 to provide greater detail for the provider community.
Click Here for the Summary Document
If you were unable to listen in to the 4-30-08 CMS audio:
Click Here for the CMS Powerpoint Educational Document
April 15, 2008
Article: CMS Issues Clarifications for Prolonged Service Codes (99354-99359) Effective 6-2-08
CMS issued CR 5972 to clarify prolonged service coding. The CR also includes very specific examples of billable and non-billable scenarios. Reading the entire document is recommended. Below are a few highlights of the document.
1. Prolonged service codes are payable by Medicare only for face to face time (99354-99357). Non face to face prolonged service codes are not payable (99358-99359).
2. Time spent reviewing charts or a discussion with house medical staff is not face to face time with the patient and may not be counted toward prolonged service.
3. Documentation to support prolonged service should include start time and end time.
4. Prolonged service codes may be used with the greater than 50% rule for counseling/coordination of care (see examples in the CMS document).
Here is a billable example from the CMS document: A physician performed an office visit to an established patient that was predominantly counseling, spending 75 minutes (direct face-to-face) with the patient. The physician should report CPT code 99215 and one unit of code 99354
Click Here for CMS CR 5972
April 1, 2008
Article: CMS Issues Clarifications for Discharge Day Management Coding (99238, 99239) & Death Pronouncement - Effective 4-1-08
CMS issued change request 5794 to clarify aspects of discharge coding. Below are some of the relevant points made in the document.
1. Discharge day management (99238, 99239) is a face to face E/M service between the attending physician and the patient. Only the attending physician of record (or physician acting on behalf of the attending physician) may bill the discharge day management code.
2. Other providers managing concurrent problems may only bill a subsequent hospital visit code for a final visit (99231-99233).
3. The date used for the discharge visit code should be the date the actual service was rendered even if it occurs on a different date than the actual discharge.
4. Only one discharge management code is payable per patient hospital stay.
5. The physician who personally performs the death pronouncement of a patient may bill using the discharge management code even if paperwork is delayed to a subsequent date.
Click Here to read the full CMS CR 5794
March 14, 2008
Article: CMS Posts New ABN (Advance Beneficiary Notice)
CMS implemented the new ABN as of 3/3/08. A 6 month transition period will be allowed for implementing the new form. As of 9/1/08 the new form is mandated for use.
The new form replaces the current General Use ABN (Form 131-G) as well as the Lab ABN (Form 131-L). In addition, you may also use the new ABN in place of the Notice of Exclusion from Medicare Benefits form (NEMB).
In essence the new ABN is "one stop shopping". Note there is a mandatory requirement to enter a cost estimate for the beneficiary. Benficiaries may also elect not to have a claim filed to Medicare. A copy of the ABN must also be provided to the beneficiary.
Click here for the New ABN
Click here for the ABN Instructions
Click Here for CMS FAQs
A Spanish version of the form will be posted by CMS in the near future.
February 23, 2008
Article: Changes to the Medigap Crossover Process
If you start receiving more frequent error messages with Medigap crossovers, such as MA19 - "Information was not sent to the Medigap insurer due to incorrect/invalid information you submitted concerning the insurer", you are probably experiencing issues with the new crossover process and the new ID numbers assigned to the Medigap plans. The transition to this new process started 10/1/07.
Instead of having the Medicare carriers crossover claims to Medigap, the system is now handled by the Coordination of Benefits Contractor (COBC).
The prior Medigap ID numbers for these health plans are in the process of being replaced with what is called the COBA identifier. The COBA identifiers assigned are in the range 55000 to 55999.
In order to find the new COBA number for a plan, you will need to access the CMS crosswalk list of Medigap ID to COBA ID for the specific Medigap plan. Click Here
then scroll down and click on "Medigap Claim Based COBA IDs for Billing Purposes"
NOTE: The list is limited at this point, but keep checking frequently for updates.
Instructions for formatting the new numbers are as follows:
A. 1500 Paper Claim
Enter the new assigned 5-digit COBA ID in block 9-D of the CMS-1500 claim form.
B. Electronic Billing
Enter the COBA ID left-justified in field NM109 of the NM1 segment within the 2330B loop and followed by spaces.
December 20, 2007
Article: Congress Approves Measure to Avert 10.1% Conversion Factor Decrease for Medicare BUT Only for 6 Months!!
On 12/19/07 the House approved a Senate amendment to temporarily stave off the 10.1% decrease to the dollar CF and instead increase the conversion factor by 0.5%. However, this (and other measures passed) will expire as of 6/30/08 unless Congress takes further action.
In order for this measure to technically take effect, the President must sign the bill in time for CMS to update reimbursement files so carriers may publish the new fee schedules. It is expected that President Bush will sign the bill in time.
Note, however, that your reimbursements will still, in the majortiy, be less than last year. Why? The bill does not alter (just like last year) the 11.94% reduction in the work relative values for ALL codes in order to maintain budget neutrality!
Other items in the bill that are extended through 6/30/08:
1. Continue the therapy cap exception process.
2. Continue the 5% bonus payment to physician shortage areas.
3. Continue the geographic practice cost indice floor of 1.0.
4. Continue to allow independent laboratories to bill Medicare directly for the technical component of certain pathology services.
So the drama is over for 2007; but we have more drama that will occur in a short six months! If Congress does not act by 7/1/08, reimbursements would plummet as the 10.1% decrease to the CF would then be back!!
November 2, 2007
Article: Dollar Conversion Factor Plunges to New Lows in CMS Final Rules for 2008!
CMS posted the final rules for 2008 on 11/1/07. The document is for viewing purposes only and will not be published in the federal register until 11/27/07.
The shocking news is the dollar conversion factor is reduced by 10.1% rather than the expected 9.9% AND the budget neutrality work adjustor has risen to 11.94% from the 2007 10.1%.
The dollar conversion factor will fall from $37.8975 to $34.0682 in 2008 unless congress intervenes. The dollar conversion factor back in 1999 was $34.7315; and consider this...when RBRVS was first implemented in 1992, the CF was $31.001. Certainly not good news for medical businesses who, in the 15 years since RBRVS became the payment methodology in the Medicare system, have seen their operating expenses mushroom!
If you would like to view the CMS document to review other final rules for 2008 prior to the 11/27/07 federal register publication, Click Here
July 17, 2007
Article: CMS Posts Notice that Clearinghouses May Be Stripping NPIs From Your Claims
CMS posted an email notice today stating the following:
"It has come to the attention of CMS that some Clearinghouses are stripping the NPI prior to submission of the claim to Medicare. This will adversely affect Eligible Professionals in that these claims will not count toward PQRI participation."
Another issue is that you may not be aware the stripping has occurred. The clearinghouse may strip the NPI, the Medicare claims system crosswalks and finds your NPI to match your current legacy number; and your Medicare remittance lists your NPI leading you to believe everything is ok!! You must confirm (and get it documented) what your clearinghouse is doing. For those clearinghouses not able to correct their ways, CMS's only recommendation is to find another one! (Not necessarily and easy task or even possible).
July 2, 2007
Article: Are You Violating CMS Rules If You Charge a Medicare Beneficiary for a Missed Appointment?
You will be happy to know that the answer is a definite no!
CMS posted this confirmation on 6/29/07 in their CR 5613, Transmittal 1279. Here is the quote from the CMS transmittal:
"CMS's policy is to allow physicians and suppliers to charge Medicare beneficiaries for missed appointments, provided that they do not discriminate against Medicare beneficiaries but also charge non-Medicare patients for missed appointments. The charge for a missed appointment is not a charge for a service itself (to which the assignment and limiting charge provisions apply), but rather is a charge for a missed business opportunity. Therefore, if a physician's or supplier's missed appointment policy applies equally to all patients (Medicare and non-Medicare), then the Medicare law and regulations do not preclude the physician or supplier from charging the Medicare patient directly."
May 15, 2007
Article: What is a PTAN and why is it an important term as of 5/23/07
PTAN stands for Provider Transaction Access Number. Currently your PTAN=Your Current Medicare Provider Number.
As of 5/23/07, when you contact the Medicare IVR system, Medicare Customer Service, or written inquiry areas, instead of being asked to provide your Medicare provider number as the authentication element, you will be asked to provide your PTAN. Again, for now, the PTAN is your Medicare provider number.
However, at the point where the NPI becomes the required number for transactions, the PTAN will be a new number assigned specifically as the authentication element required for carrier communications. When new enrollments or changes to a provider enrollment are finalized, carrier enrollment letters will confirm the assignment of the NPI in the enrollment AND will include a specific PTAN number.
April 18, 2007
Article: CMS Contingency plan for the NPI IS NOT an invitation to STOP moving forward with the mandatory date of 5-23-07 and testing of the NPI!!
Industry confusion abounds since CMS announced a "contingency" plan for the NPI. CMS has stated they do not have the authority to change the NPI deadline date of 5-23-07. One mandate still in place, per CMS, is you MUST have your NPI no later than 5-23-07. Currently 85% of those expected to apply for an individual or organization NPI have done so. Lots of people out there are still not compliant with even that piece! What CMS has done with the issuance of their "contingency plan" is to say you may continue to submit your transactions using the "dual use" approach (listing both your existing legacy numbers and NPI) until 5-23-08. The original law stated that as of 5-23-07 NPI ONLY would be required for use in transactions. HOWEVER, between now and 5-23-08, if you find a covered entity not compliant with allowing for the use of the NPI, testing, etc. and moving with a plan toward NPI only, CMS wants to hear from you so they may pursue complaints to insure that covered entitites have a contingency plan in place and are moving forward toward compliance with the NPI ONLY in transactions. To file a complaint you will do so through ASET (Administrative Simplification Enforcement Tool).
Click here to Access the ASET website
Regretfully, CMS is still not saying when the long awaited Data Dissemination proposed rule will be issued. As they have been saying since the Fall of 2005, "it is still in final clearance"!!
March 9, 2007
Article: CMS Forms for Medicare Enrollment-Ability to Complete and Save Online Expected End of April, 2007
Shortly after the inception of the new Medicare enrollment forms in May, 2006, the ability to complete the forms online became available since the forms could be saved in a pdf (Adobe) file. However, without having the entire Adobe suite package, you have not been able to enter data to the forms and save them which causes great inconvenience for the online completion. CMS has been working with Adobe regarding this issue and now expects to have the "save" capability available as of the end of April, 2007.
Certain deficiencies in the formatting of the forms (see FYI article posted 7/9/06) have also been corrected.
February 23, 2007
Article: CMS posts proposed new Advanced Beneficiary Notice (ABN)
Changes to the ABN were posted by CMS today in the federal register with a 60 day comment period. The new form will probably go into effect June, 2007. CMS states basic content of the form remains the same BUT the changes to the new form incorporate:
1. more user friendly language
2. combining the two previous ABNS (General and Lab) into one form
3. adding the 1-800 MEDICARE number to the form
4. adding information about a beneficiary's right to demand Medicare be billed
5. increasing beneficiary selection options from 2 to 3 to allow beneficiaries to pay out of pocket
6. allowing a place for other insurance information to be recorded AND
7. describing the significance of the signature.
Click here to see the proposed new form
February 3, 2007
Article: Nine (9) Digit Zip Code for CERTAIN Zip Codes Required in Medicare Claims Processing as of 10/1/07
CMS has discovered that certain 5 digit zip codes are causing incorrect payments when services cross payment localities. As of 10/1/07 IF you do not submit claims for CERTAIN zip codes as 9 digit codes, your claims will be denied as unprocessable. REMEMBER, THIS DOES NOT AFFECT ALL ZIP CODES. To see if you will be affected by any zip codes in your state Click Here and Pay Specific Attention to Table 1
January 12, 2007
Article: Conversion Factor for 2008
Maintaining the dollar conversion factor at the 2006 level for 2007 Medicare payment calculations still DOES NOT fix the formula used for calculating the CF in subsequent years.
In fact, the bill passed by Congress on 12/8/06 specifically states that the calculation of the CF for 2008 will be computed as if the computation used for 2007 never occurred.
Translated, this means that the 2008 CF computation will use the ORIGINAL calculated dollar conversion factor for 2007 of $35.9848.
Concerns regarding this provision of the law are already being expressed with a
projection that the CF for 2008 will be reduced by anywhere from 7-10%.
January 2, 2007
Article: CMS Adds 4 New "Q" Codes to Establish Separate Payment for Sodium Hyaluronate Products - Effective 1/1/07 for Medicare
These codes were added by CMS 12/22/06 with an effective date of 1/1/07. The intent was to establish separate payment for products that have entered the market since October, 2003. In addition, certain of the "J" codes for these drugs have been deleted or discontinued for payment as of 1/1/07.
The "J" codes deleted from the HCPCS level II book as of 1/1/07 are J7317 and J7320.
The new codes and payment amounts thru 3/31/07 are:
Q4083 - Hyaluronan or Derivative, Hyalgan or Supartz, for intra-articular injection, per dose - $105.558
Q4084 - Hyaluronan or Derivative, Synvisc, for intra-articular injection, per dose -$198.089
Q4085 - Hyaluronan or Derivative, Euflexxa, for intra-articular injection, per dose - $115.155
Q4086 - Hyaluronan or Derivative, Orthovisc, for intra-articular injection, per dose - $200.541
NOTE: J7319 is a new HCPCS level II code for 2007 describing the above products but CANNOT be used for Medicare billing purposes.
December 21, 2006
Article: President Bush Signs the 2006 Tax Relief & Healthcare Bill December 20, 2006
The congressional legislation that averts certain payment issues in the Medicare program for 2007 has now been signed into law. Now that the bill has been signed, CMS can start to issue revised fee schedules and other carrier instructions for provisions in the law. For a summary of the provisions of the law and other relevant aspects, (drafted by Physicians First, Inc.), Click Here
November 2, 2006
Article: CMS Posts Final 2007 Rules for Viewing
CMS has posted the document for viewing the final rules for 2007. The dollar conversion factor is posted as being $35.9848 - a 5% decrease. CMS is also applying approximately a 10.1% decrease to work relative values for codes in order to maintain budget neutrality!!Despite increases in relative values for E/M services, not all E/M services are seeing payment increases; but there are some increases noted (by doing manual calculations) for 99213, 99214, 99251, 99253, 99254, 99221, 99223, 99232, and 99233.
Unfortunately the rule also includes the dreaded imaging reductions. Quoted here is what the press release from CMS states "Consistent with requirements of the DRA (Deficit Reduction Act), the final rule caps payment rates for imaging services under the physician fee schedule at the amount paid for the same services when performed in hospital outpatient departments. The final rule includes a list of codes to which the outpatient prospective payment system (OPPS) cap would apply. The rule also finalizes a policy of reducing by 25 percent the payment for the technical component of multiple imaging procedures on contiguous body parts. CMS will apply the multiple imaging reductions first, followed by the OPPS imaging cap, if applicable."
If you would like to download the document for viewing (it is over 1000 pages but gives you the information needed including RVUs) Click Here
October 11, 2006
Article: Medicare Premiums & Deductibles for 2007
Part A Premium: $410 (paid by about 1% of beneficiaries
Part A Deductible: $992
Part B Standard Premium: $93.50 (5.6% increase)
Part B Deductible: $131 (increased from $124)
In addition, starting in 2007, approximately 4% of Medicare Part B enrollees with higher incomes will pay a higher Part B premium based on their income. The income related Part B premiums for 2007 will be $106.00, $124.70, $143.40, or $162.10, depending on the extent to which an individual beneficiary's income exceeds $80,000 (or a married couple's income exceeds $160,000).
Source: Medicare Fact Sheet, CMS Media Affairs, September 12, 2006
October 5, 2006
Article: Medicare Diagnosis Code Requirements for Flu and Pneumonia Vaccines
Effective for services on or after 10/1/06 the following diagnosis codes are required for flu and pneumonia vaccines:
V06.6 must be used when flu and/or pneumonia vaccines are given during the same encounter.
Use V03.82 if the claim is only for pneumonia.
Use V04.81 if the claim is only for flu vaccine.
Note that CPT code 90660 may be reported for flu vaccine.
August 18, 2006
Article: ALERT!! 9 Day Medicare Pay Hold - Check With Your IT Department and/or Software Vendors to Prevent Payment Problems Once the Hold is Over!!!
During the period 9/22/06-9/30/06 Medicare will not issue any payments for your claims. The only processing of claims that you receive will be for denials. During this hold period Medicare normally would issue up to 6 payments to you so the hold is significant! In addition, since Medicare has a 15 day "floor" period as part of the existing pay rules (claim submitted today, clean claim right away as a claim to pay, payment is held until day 15), this hold on your payments will actually affect you for up to a 24 day period.
When your payments start again as of 10/2/06 MEDICARE WILL ISSUE ONLY ONE CHECK OR EFT FOR ALL PAYMENTS YOU SHOULD HAVE RECEIVED DURING THE HOLD. FOR THOSE OF YOU RECEIVING ELECTRONIC REMITTANCE, THIS FILE COULD BE HUGE!! CHECK WITH YOUR IT AND/OR VENDORS TO BE SURE THAT YOUR SYSTEM WILL NOT TIME OUT OR REJECT THE SIZE OF THE FILE.
DO NOT stop sending claims to the carrier during the hold period. If you do, you will continue to be affected with prolonging receipt of your payments. Claims received during the hold period will be dated accordingly, and after the hold ceases, the carriers will reset their claims processing time clock BACK to the norm.
August 15, 2006
Article: Conversion to the New ICD-10 Diagnosis Coding System - 2009 or 2012- This Should Concern You!!
There are certain competing Congressional bills that, if finally adopted, would require you to retire the use of the ICD-9 diagnosis code set and implement the completely revised and expanded ICD-10 code set as of 2009 or 2012. The problems ICD-10 expands from 24,000 codes in ICD-9 to approximately 207,000 codes in ICD-10. Specificity for certain code categories may expand to 6 digits and the codes start with an alpha character. The expense to this form of code set would be enormous from a software update perspective and forms revision. Training time for doctors and other staff would also be enormous. As health plans convert their systems to accept these codes, it is expected that plan premiums would increase as a result. Medical Associations are working to prevent the implementation from ccurring in 2009; but the code set will eventually be implemented and that could be as of 2012. The final date will not be known until Congress reconvenes in September and irons out the final bill. Stay tuned.
To view the latest information about ICD-10 AND to review the actual codes online Click Here
August 2, 2006
Article: Transfer of Care vs Consult-Medical Associations Ask For CMS Clarification
In December, 2005 CMS issued transmittal 788 to carriers and updated the carrier manual to reflect revisions to consult rules. (A summary of the new and revised rules is posted for download in the "Documents" section of this website). What started to surface over the past many months is the CMS language related to transfer of care. CMS rules used to say that a transfer of care only occurred (and precluded use of a consult code) when total care for the patient had been transferred to the consultant (an unlikely prospect). The language now references that a transfer of care occurs when the management of a particular condition occurs. This has caused great concern as to the appropriate use of consult codes in the physician community. The Physicians Regulatory Issues Team (PRIT) is working with CMS to clarify the definition of a "transfer of care". We will update this issue as it plays out or you can follow any PRIT updates by checking their website. Click Here to Access the Prit Active Issues Page
July 31, 2006
Article: Commission Releases First List of Certified EMRs (electronic medical records)
The Certification Commission for Healthcare Information Technology (CCHIT) recently released their first list of "certified" products for EMRs. CCHIT is a private non-profit company that has received some funding from the federal government agency, Health and Human Services (HHS), in order to review EMR products to encourage physician practices to invest in these systems. The list certifies 18 EMR products. To review the list and to access other information about CCHIT Click Here
July 9, 2006
Article: CMS Posts Enrollment Forms You May Complete On Your Computer
CMS has posted the enrollment forms in PDF format. You may save the forms on your computer and complete the forms online. Remember, electronic submission to carriers is not possible. That will happen in the distant future!
The forms do have some issues; BUT it still adds a convenience.
Here are the current problems:
You can enter your data but you cannot save it. You may only print the form.
With both the 855B and 855I forms -Section 1A - Basic Information -You are able to check the appropriate box, such as new enrollee, revalidate, etc; but you are not able to enter Medicare PIN or NPI number.
In "effective date of termination" in this section you are unable to enter the date.
855I Section 2 - Identifying information - You are unable to enter the SS#
855R - Section 1 - Basic Information - In each area where you enter an effective date, the font size is quite large!
Despite these errors, completing the forms is a bit easier even if the data error areas must be filled in after the documents are printed. Look for CMS to correct these format errors.
If you would like to download and save the PDF files, Click here for the 855I Click here for the 855B Click here for the 855R
July 9, 2006
Article: CMS Instructs Carriers to PAY for E/M with 25 Modifier on Same Day as Minor Procedure Even if SAME Diagnosis is Used
CMS has released a revision to the carrier manual as well as a Medlearn article once again clarifying the use of the 25 modifier to pay an E/M service on the same day as a procedural service. In the past, countless practices have indicated that the E/M was denied even when the 25 modifier was used when their diagnosis code was the same or similar to the diagnosis used for the procedure. Even since 1992 CMS has indicated that the diagnosis code COULD be the same or similar and CPT also made the definition change years ago. Despite that though problems have remained.
Now, however, we have this change with an effective date of 6/1/06 and an implementation date of 8/20/06 that stipulates claims with an EM with the 25 modifier SHOULD be paid on the same day as the procedural service even IF the diagnosis is the same or similar. No documentation needs to be submitted with the claim.
HOWEVER, since the Office of Inspector General found in a random review that physicians frequently DO NOT document the "separate and identifiable" nature of the E/M service when using the 25 modifier, PLEASE make sure that they as well as Non-Physician Practitioners understand the documentation need.
This should help those of you, however, who have been getting denials from the carrier when your diagnosis was the same or similar and you did have the supporting documentation. Many of you in the past often said to me that you lost these arguments with the carriers even on appeal!!
Click Here for Medlearn Article to Support Your Appeal!
May 29, 2006
Article: Is Documenting "Seen and Examined" Sufficient Physician Documentation to Justify Billing a Shared/Split Hospital Visit Under the Physician Medicare Provider Number?
ANSWER: Check with your Medicare carrier policy area. Here is what First Coast Service Options, the Florida Medicare carrier had to say:
"A split/shared E/M visit is defined by Medicare as a medically necessary encounter with a patient where a physician and a qualified non-physician practitioner in the same group practice each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, exam, or medical decision-making components of an E/M service. Selection of the appropriate E/M code to bill is based upon the combined documentation of the physician and the non-physician practitioner.
While, in the strictest sense, "patient seen and examined" would appear to indicate that the physician had a face-to-face encounter with the patient, the physical findings elicited through the examination are not documented. Thus, the medical necessity for the physician portion of the split/shared visit is not evidenced in the documentation.
Furthermore, selection of the appropriate E/M code for the visit would, in such a case, be based solely on the NPP's documentation, since there are no physical findings recorded on which to base the level of the exam.
Therefore, it is important for the physician to document the findings from the exam, in addition to noting that the patient was "...seen and examined."
May 17, 2006
Article: NPI is NOT required for Biliing Company in New CMS 855 Enrollment Forms!
You may have noted in the new CMS 855I Medicare enrollment form the area requiring entry of a NPI for a billing company. The same entry requirement is not found in the CMS 855B. Since billing companies do not meet the definition for a health care provider who would be required or even eligible to apply for a NPI, quite a stir was caused with the release of the new forms. As of yesterday, CMS confirmed that the NPI entry in the 855I is a "typo" and will be corrected in the future!
May 4, 2006
Article: CMS Implements Revised CMS 855 Enrollment Forms With No Grace Period
On 5/1/06 CMS posted completely revised 855 forms for provider enrollment. The shocking revelation is two fold. First, there is no transition period. The forms are effective NOW without any real provider outreach and education. Second, with the new forms, if you are newly enrolling OR making any change to enrollment, you MUST provide your NPI number(s) and documentation of assignment of the NPI from the Enumerator, AND you MUST complete a CMS Form 588 in order to enroll for Electronic Funds Transfer (EFT).
Not that these items are not expected or unreasonable; but it is unreasonable to expect compliance immediately; and yet that is the case.
If you submit the old CMS 855 forms, your enrollment documents will be rejected. If you want to access the new forms you may find them by Clicking here, click on "show only items...", enter 855 and click refresh, and then download forms
If you need assistance in completing the forms, please contact Physicians First.
April 24, 2006
Article: CMS Publishes Final Rules for Medicare Enrollment and Revalidation
On Friday, 4/21/06, CMS published final rules in the federal register for enrollment and revalidation in the Medicare program. The effective date of the rules is 6/20/06. All CMS 855 enrollment forms are also in the final review process by the Office of Management and Budget (OMB); and we are expecting the issuance of the final forms anytime now.
Highlights of the new rules:
1. You will have to revalidate your enrollment information with the carrier every 5 years.
2. If, in the past, you had enrolled using a CMS 855 form(s), copies of the form(s) will be sent to you to recertify the information, make any changes, sign, and forward back to the carrier.
3. If you had not completed CMS 855 form(s) in the past, you will be required to complete the appropriate forms.
4. Revalidation must be received by the carrier in 60 days or risk having your billing number deactivated.
5. Retroactive issuance of enrollment numbers is still possible.
6. Billing numbers will deactivate if there have been no claims submitted for a 12 month period.
7.Definition of felonies that must be reported in enrollment applications has been expanded.
8. Billing numbers cannot be sold or allowed to be used by any other entity.
9. Any changes to enrollment information must be submitted to the carrier within 90 days except for a change of ownership which must be completed within 30 days.
The revalidation process will not be started until such time as the final revised CMS forms are released.
April 22, 2006
Article: PRIT Issues Consult Clarification
CMS issued clarifications to consult billing in December, 2005. One area that concerned providers was what appeared to be a stipulation that the consulting physician had to verify that the consult request was documented in the requesting provider's patient record. The Medical Group Management Association (MGMA) asked the Physician Regulatory Issues Team (PRIT) to clarify this aspect of the new rules. PRIT is a CMS group designed to reduce the regulatory burden on physicians who participate in the Medicare Program. PRIT issued the following statement on their website 3/30/06:
"Medicare does not expect the consulting physician to verify that the requesting physician has documented the consultation request in his/her patient's medical record."
April 12, 2006
Article: Physician Voluntary Reporting Program (PVRP)
CMS announced a pilot program to occur for the period 4/1/06 thru 6/30/06 allowing physicians to report performance measures in claims processing. Unfortunately, many would say that the ability to know, let alone prepare for this pilot was not timely!! On 4/4/06 CMS held a national audioconference regarding this topic. Encouraging physicians to register the intent to participate was stated frequently even if you would not be able to implement reporting of the performance measures during this period (you could elect a different quarter in 2006 to start). One came away with the impression that the volume of participation registration by physicians could be a factor in the debate that will inevitably occur at the end of 2006 regarding payment updates for 2007 and the potential for Pay for Performance! It is true that participation in this project will allow practices to provide feedback and have direct contact with CMS as performance measures continue to develop. I would encourage people to participate and to start the educational process related to the codes, the reporting mechanisms, and operational issues related to implementation. Performance reporting is here and ultimately will probably be mandatory. For great information related to the program, the website to register, the revised set of codes to use (16 sets of measures now rather than the original 36), as well as certain specialty forms that CMS has developed for use in capturing the data Click Here. Contact Physicians First, Inc. if a direct educational session would be helpful.
February 24, 2006
Article: Important New Policy and Coding for Therapy Caps Exception Process
As you are probably aware, a cap on Outpatient Physical Therapy/Speech Language and Occupational services became effective 1/1/06. The caps are $1,740 for PT/Speech Language combined and $1,740 for OT. Recently, however, CMS issued a policy that will allow for certain beneficiaries with specific diagnosis codes to qualify for an automatic exception. For those not qualifying for the automatic exception, guidelines are also in place for documentation to apply for the exception. There is a new modifer to use when billing for exception services once the cap has been exceeded. KX modifier would be used in addition to the GN, GO, or GP. Below is the direct link to the MedLearn article that will also provide direct links to the carrier manuals for the actual diagnosis codes and procedural policies.
Click Here for Article
February 23, 2006
Article: Medicare Carriers Will Now Return Incomplete Enrollment Applications
The previous potential nightmare days of returning incomplete Medicare enrollment applications are now back. Prior to 2/5/06, if your application(s) were incomplete at the time of pre-screening by the carrier, such as you omitted an occupational license, IRS Tax ID# letter, or a signature, the carrier would contact you and you were able to forward the outstanding information to them. The application was not returned to you.
AS OF 2/5/06, CMS has notified carriers that your incomplete applications, in entirety, MUST be forwarded back to you if they fail the pre-screening.
This will cause significant delays in your enrollments. In the past when we were dealing with this, it was not uncommon for the applications to be lost in return and/or significant delays in the returned applications being received by you.
Take note and take extra care in completion of your applications. If you need help, this is one of the services offered by Physicians First, Inc. in helping providers complete applications correctly.
You can also check carrier websites enrollment areas for helpful hints and tips regarding the completion of the CMS 855I, 855B, and 855R.
February 17, 2006
Article: Prepare for NO Medicare Payments 9/22/06-9/30/06
Just when you thought the struggles for 2006 were over, we now have an unnoticed part of the Congressional legislation that recently fixed the pay rates for Medicare 2006 that will result in your receiving NO Medicare payments for the period 9/22/06 thru 9/30/06.
Medicare carriers have been instructed to hold all payments during that period and to pay you on October 2, 2006 instead. Why you may ask? Well, the federal government fiscal year ends 9/30/06, so payment for the period 9/22-9/30 would be pushed into the fiscal year 2007.
This is more of the "dialing for dollars" that Congress has implemented in order to pay for the expense of freezing your pay rates at the 2005 dollar conversion factor level and maintaining their budget. This provision will allow them to move about $1.3 billion dollars into fiscal year 2007.
So mark your calendars and prepare now for what could be a cash flow issue especially for smaller high volume Medicare practices. This also could affect the analysis of your business when you compare September 2005 to September 2006 and wonder why your revenue is less.
The pay hold will not be based on date of service. It will be based on the typical date of payment. For example, if you submit an electronic claim on 9/14/06, you normally would expect payment 9/28/06 after the typical floor time of 14 days. With this provision, the payment would not be made until 10/2/06. Do not plan on receiving interest on your money for the delay. It won't be happening!
Since Congress did not fix the original problem with the dollar conversion factor, the sustainable growth rate (SGR), I am also concerned that 2007 is going to bring another round of potential payment reductions and there is no guarantee that Congress will act to correct the problem.
February 16, 2006
Article: CMS Revises and Clarifies Consult Rules Effective for 2006
CMS issued a change request for consult rules that became effective as of January 2006. Go to the "Documents" section of this website, and you will be able to download, for free, a summary of the changes. Explanations regarding the deletion of the Confirmatory Consult Codes (99271-99275) as well as Follow-Up Consult Codes (99261-99263) are included in the summary.
Click Here to Access the CMS document
February 4, 2006
Article: New and FREE Download for Medicare Part D Formularies!!
Epocrates website now has the ability for providers (or anyone for that matter)to donwload the Medicare Part D Plan formularies to your PDA and desktop computer. This is providing great assistance for physicians who may be getting questions from patients about their drug coverage under the new prescription drug benefit. To perform the free download go to www2.epocrates.com and click on the right side where it says "Resource Center" and "Medicare Part D" below. The www2 to access the website is not a typo, it is actually part of the web address. CMS has recommended this site to be used by providers.
February 2, 2006
Article: CMS Posts Revised Enrollment Forms for Comment Period
Comments regarding the new Medicare enrollment forms will be accepted until 2/27/06. All CMS forms are being revised and will be implemented later in 2006. Some of the highlights:
As a newly enrolling sole proprietor who is incorporated, you would only have to complete the CMS 855I instead of the current requirements for 855I, 855B, and 855R.
Newly enrolling applicants MUST obtain their NPI PRIOR to Medicare enrollment.
New enrollments would be MANDATED to use EFT for Medicare payments.
Eliminating entry of practice locations from the 855R which was always a duplication of effort.
Ability for EITHER the provider leaving the group OR the group itself to terminate reassignment as well as either the physician assistant (PA) or the group to terminate PA arrangements.
If you would like to view and download the proposed formsClick Here
December 22, 2005
Article: CMS Dramatically Changes Their Website as of 12/15/05
CMS has re-designed their website. As a result, many of the common links found at the Physicians First website are no longer valid. We are in the process of updating these links and apologize for any inconvenience caused as a result of this change. If you would like to go to the CMS website and take a "flash" tour of the changes Click Here.
December 1, 2005
Article: New Power Operated Vehicle Regulations With Face to Face Payment Became Effective 10/25/05
Go to the "Documents" section of this website and download the document, at no charge, about this Medicare regulation. Face to face encounters are now required in order to prescribe power operated vehicle devices; BUT you can get paid for the face to face encounter by following the rules.
November 8, 2005
Article: CMS Posts Prescription Drug Plan Finder Tool to Website
The CMS main website for helpful information and tools related to the Medicare Prescription Drug Benenfit has posted a new tool to help beneficiaries find a drug plan in their state that will cover the drugs they are currently taking. The beneficiary will click on their state, enter the medications they are currently taking, and then find available plans in the final search.
Click here to get to the site, then click on Formulary Finder
November 4, 2005
Article: CMS Posts Final Rules for Medicare Physician Fee Schedule for 2006
CMS has posted the 2006 final rules for public inspection. The actual federal register publication will not take place until 11/21/05. Included in the rules are also updates for Medicare's Competitive Acquisition Program. The bad news is...a 4.4% reduction to the conversion factor driving Medicare payments down. Now it is a wait and see as to whether Congress can or will alter the reduction.
Physicians First, Inc. will be doing seminars in December and January to cover all the changes in policy and coding for 2006 (See the Upcoming Seminars Section of the Website).
Click Here to View the CMS Posting
November 1, 2005
Article: CMS Announces That The 2006 Physician Medicare Fee Schedule WILL NOT Be Delivered To Physicians In CD-ROM Format
CMS has decided not to place the 2006 fees on the CD-ROM this year in order to have greater flexibility for making any last minute changes to the 2006 payment rates. According to CMS, placing the fees on carrier websites instead will assure that providers will have the most current and correct fees available. We are waiting now for the final rules for 2006 to be published; but still looming is the potential for a 4.3% decrease in Medicare rates for 2006 unless Congress acts to make a last minute change. Since that action, if it occurs, may take place at the eleventh hour, CMS is being cautious about producing fees in a format that could become incorrect at any moment.
October 27, 2005
Article: CMS Now Has An Easy Online Way for Medicare Beneficiaries to Find Out What Prescription Drug Plans are Available by State
By clicking on the direct link below, you will be brought to a map of the United States. Click on the state you are interested in. Then click on the file type you would like to open. You will then see a spreadsheet listing all drug plans approved to date in the state, premiums, deductibles, coverage, and convenience information.
Click Here for Link
October 12, 2005
Article: Medicare Eliminates Bilateral Coding Modifiers for 36215, 36216, & 36217...BUT Do Not Despair
The October 2005 Update to the Medicare Fee Schedule Database eliminated the use of the LT, RT, or 50 modifiers with these codes. The change is retroactive to January 1, 2005. However, the Society of Interventional Radiology posted an article to their website indicating that practices instead should now code these services, if they occur bilaterally, either in a quantity of two (2) OR use two line items with the second line using the 59 modifier.
Click Here to Read the SIR article
September 27, 2005
Article: CMS Announces New Modifier for Disaster Claims
CMS wants to insure that the Medicare program will be flexible in order to accommodate the health care needs of those medicare beneficiaries displaced due to Hurricane Katrina. As a result, carriers are required to implement in their claims processing systems a new modifier (CR) for physicians to use when billing for services related to these people. Implementation date is targeted for 10/3/05 but is mandated that carriers implement no later than 10/31/05. You should click below to read the full article (it is only 3 pages). You will see a "condition code" also listed (DR); BUT this is not related to physician services. The DR modifier will be used only by Fiscal Intermediaries which do not affect the typical physician services.
Click Here for the Article
September 22, 2005
Article: How can a provider research to determine if a certain diagnosis meets medical necessity for a specific procedure code?
You can always go to your local Medicare carrier website and check their Medical Policy (LMRP/LCD) area for a policy related to the procedure code.
You may also:
Go to the CMS website linked below.
In separate fields shown, input the Procedure code and Diagnosis code in question.
Select appropriate bullet/search criteria.
Click on Create Report at bottom of screen.
Results will be categorized under Supports Medical Necessity, Does NOT Support Medical Necessity, or Non-Covered.
Click on correspnding hyperlink to display LMRP/LCD ID list.
Click Here to Access Site
July 25, 2005
Article: If your Medicare beneficiary signed a valid ABN, and if you submitted the claim with the "GA" modifier, and if Medicare then denies the services as medically unnecessary, what can you charge the patient?
You may charge the patient your normal charge. You are not bound by the limiting charge (for Non-Par providers) or the Medicare Fee Schedule amount. The proof is in the actual language from the Medicare Carrier Manual quoted below:
"50.7.7.4 - Collection From Liable Beneficiary (Rev. 1, 10-01-03) When an ABN was properly executed and given timely to a beneficiary (who, if RR applies, agreed to pay in the event of denial by Medicare) and, in fact, Medicare denies payment on the related claim (whether assigned or unassigned), the physician or supplier may bill and collect from the beneficiary for that service. Medicare does not limit the amount which the physician or supplier, participating or nonparticipating, may collect from the beneficiary in such a situation. Medicare charge limits do not apply to either assigned or unassigned claims when collection from the beneficiary is permitted on the basis of an ABN. A beneficiary's agreement to be personally and fully responsible for payment means that the beneficiary agrees to pay out-of-pocket or through any other insurance that the beneficiary may have, e.g., through employer group health plan coverage, Medicaid or other Federal or non-Federal payment source."
July 18, 2005
Article: For a Medicare patient, does a Physician have to be physically present when a flu shot, EKG, laboratory test (such as a blood draw) or x-ray is performed in an office setting to be billed as "incident to" services?
If you answered "Yes", then you would be wrong. Read the documented answer "No" referenced in page 3 of a CMS document dated 11/4/04 at the Medlearn Matters website.
Click Here to View Site-Click on Article SE0441 dated 11/4/04
As you can see on page 3..."These services have their own statutory benefit categories and are subject to the rules applicable to their specific category. They are not "incident to" services and the "incident to" rules do not apply."
The key here is that they are not "incident to" services.
May 3, 2005
Article: CMS Issues Revised Coding Guidelines for Drug Administration Codes
Due to questions received from the medical community, CMS went to the CPT Editorial Panel and received clarifications from CPT that will be published in CPT 2006 when the current "G" codes for drug administration will be replaced by new CPT codes. CPT's advice clarifies certain issues that were raising the ire of the medical community. One clarification: "Intravenous or intra-arterial push is defined as: an injection in which the healthcare professional who administers the substance/drug is continuously present to administer the injection and observe the patient; or an infusion of 15 minutes or less." Prior to this clarification, practices were being told that an infusion of less than 30 minutes had to be coded using the "push" code, such as G0353 which pays less than the infusion codes, such as G0347. This also clarifies the requirements for attendance for the professional involved in the drug administration. To read and print the full CMS memoClick Here then scroll down to the "Comm" date of 4/15/05 and click on File # R1480TN
April 1, 2005
Article: Medical Interpretor Mandate
Questions are frequently received by Physicians First regarding the rules for interpretors and the expense to physicians. HHS revised and published a very informative document quite some time ago that you should find useful in answering questions. Click here to view and print the document
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