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".
The ICD-10 Emperor Has No Clothes
This outstanding article has been posted with the permission of Besty Nicoletti, one of the premier consultants in the country. The article is well worth the read for articulating, in a refreshingly honest way, the truth about ICD-10!
The howling about the delay of ICD-10 was loud and fierce. It seems the quality of health care in the United States depends on our ability to use 68,000 diagnosis codes. The rest of the world has switched to ICD-10, and we alone insist on using an outdated coding system. Here’s a secret. The World Health Organization’s version of ICD-10 has about 16,000 codes, equivalent to ICD-9-CM. The rest of the world is not using ICD-10-Clinical Modification set, which has 68,000 codes. Only we, in the US, are considering that. The Canadian version of ICD-10 has about 16,000 codes, but the physicians do not use those codes for billing and reimbursement. They use a more limited code set of about 600 three-digit codes. Let me repeat this: The WHO version of ICD-10 that the rest of the world uses about 16,000 codes. Our version, developed jointly by the CDC and the American Hospital Association has 68,000 codes.
ICD-10-CM is going is going to add significant cost and complexity to physician practices without any benefit to the patient or physician. Perhaps facilities or payers need this level of detail, but we on the medical practice side do not. Selecting an ICD-10 code in an electronic health record will add 1-3 minutes to each patient encounter. Is that a reasonable use of physician time? If your mother or child is in the exam room, wouldn’t you prefer that the doctor spent that time with your family member, or you?
For years, I listened to the experts say that we needed greater granularity and detail in our diagnosis coding. The transition from ICD-9-CM to ICD-10-CM increases the number of diagnosis codes from about 14,000 to 68,000. That is significant additional granularity. But, when I studied ICD-10-CM in order to teach it to physicians and coders, I realized the ICD-10 emperor has no clothes.
My objections to ICD-10-CM are that it includes needless specificity, absurd adherence to taxonomy, unnecessary detail about injuries and insufficient additional information about chronic illnesses to justify its use.
In ICD-9, there are about a dozen codes for acute or chronic conjunctivitis. There are about 50 in ICD-10. Here are four: unspecified chronic conjunctivitis, right eye, unspecified chronic conjunctivitis, left eye, unspecified chronic conjunctivitis bilateral eyes, unspecified chronic conjunctivitis, unspecified eye.
Coding for gout explodes from about a dozen codes in ICD-9 to over 150 codes for gout in ICD-10-CM, differentiating chronic gout, lead induced chronic gout, drug induced chronic gout, chronic gout due to renal failure, other secondary chronic gout, acute idiopathic gout, acute lead induced gout, drug induced chronic gout, chronic gout due to renal impairment, and other secondary chronic gout. Each is reported by joint and acute gout by with or without tophus. Idiopathic gout right knee, idiopathic gout left knee, idiopathic gout unspecified knee. Or, chronic gout, unspecified. You don’t believe me do you? Get out your ICD-10-CM book and compare the codes using the search function on the WHO website for ICD-10.
Of the 68,000 codes over half are for injuries and accidents. Is it a laceration with or without a foreign body, which side, initial or subsequent encounter? Is the fracture at the upper or lower end of the ulna? What type of fracture is it? The mainstream media focused on the external cause codes “struck by a parrot.” But, these external cause codes are the least of our worries as we attempt to use ICD-10-CM in medical practices. And, I assure you, “struck by a parrot” is not in the WHO ICD-10 code set.
Now I’m sure that in response to this post you will show me the chronic care codes that have increased specificity and provide additional information for physicians health systems and payers. I know they exist. Great, let’s use a version that includes those codes without all of the other detail.
If Stark was the full employment act for lawyers, and HIPAA was the full employment act for consultants, then ICD-10 is the full employment act for coders. Much of the outrage against ICD-10 came from my fellow coders and consultants. I am sure that some of them have a deep-seated belief that ICD-10 is better. And, coding is the job coders have selected to do, and coding in ICD-10-CM is a fun, interesting activity for coders. Not so much for physicians.
In the 1986 movie, “Star Trek IV the Voyage Home” Dr. McCoy says, “the bureaucratic mind set is the only constant of the universe.” You remember the scene don’t you? Our heroes are in a shuttle … well, maybe you don’t remember the scene. Dr. McCoy wasn’t talking about ICD-10-CM, but we can imagine his reaction to it.
“Dammit Jim, I’m a doctor not a coder.”
But, in medical practices today, the physician typically selects the CPT code and the diagnosis codes that were the reason to provide the service and the diagnosis code that is the indication to order tests. ICD-10-CM will do little more than increase the bureaucratic side of physicians’ lives at the expense of their being doctors.
Betsy Nicoletti is president, Medical Practice Consulting and author of Auditing Physician Services. She blogs at Nicoletti Notes.
Misvalued Codes-The Heavy Hand in the SGR "Patch"-ICD-10 Delay Bill
On 4/3/14 Physicians First Inc. posted an article (see below) about diagnostic imaging service impacts in the ICD-10 delay and SGR “Patch” Bill, (H.R. 4302). However, another area in the bill, Section 220, presents a heavier hand the government will be taking in “ensuring accurate valuation of services under the Physician Fee Schedule” (aka making sure the right amount is paid for services in the Medicare Part B program). Click here to download and read Section 220 of the bill.
Having the government review the accuracy of relative values assigned to billing codes is not new. It has been happening since the inception of the Resource Based Relative Value System (RBRVS) in 1992. The process of looking at “misvalued” codes, based on their relative values assigned for work, practice expense, and malpractice, was expanded by CMS in 2008; and the Affordable Care Act required continuing and expanding the review in seven (7) different categories. Up to this point, the American Medical Association Relative Value Update Committee (AMA-RUC) has always worked with the Center for Medicare Medicaid Services (CMS) in the process of evaluating and finalizing the relative values of billing codes. Section 220 of H.R. 4302 changes all that and seemingly excludes the AMA from the process while adding new requirements for “Eligible Professionals” (EPs) to participate in the process.
Included in Section 220:
1. Provides authority for the government to “collect and use information on physicians’ services in the determination of relative values…from any eligible professional or any other source”.
2. Each area of section 220 provides broad authority to “the Secretary” of Health & Human Services.
3. Types of Information for collection include any or all of the following:
Time involved in providing the service.
Amounts & types of practice expense in providing services.
Prices (net discounts) for practice expense such as paid invoices.
Overhead & accounting information for physician practices.
Any other information deemed valuable to the process.
4. Collection Mechanisms include:
Surveys of physicians, manufacturers, vendors.
Surgical logs, billing systems, or other practice records.
Electronic health records.
Any other mechanism as determined appropriate.
5. At the discretion of the “The Secretary”of Health & Human Services, incentive payments may be made to EPs to participate in providing information solicited.
6. “The Secretary may establish or adjust practice expense relative values” based on the data collected.
7. Sixteen (16) categories of codes (increased from the original 7 in the ACA) will be subject to review culminating in other “codes as determined by the Secretary”, so nothing is off the table. (See Section 220 for the list of code categories).
8. Targets will be established for relative value adjustments for misvalued services for fee schedules 2017-2020 at 0.5% of the estimated amount of expenditures under the fee schedule.
9. Reductions for misvalued services if the target is not met will apply to fee schedules starting in 2017.
10. As of 2017, if the reduction to the relative value of a code is equal to or greater than 20%, the reduction will be phased in over a two year period.
11. A study conducted by the Comptroller of the United States will be due to Congress no later than 1 year from now addressing the processes used by The Relative Update Committee (RUC). (Herein lies the potential for excluding the AMA RUC if not already, in essence, legislated in the bill!)
So What Else Is In the SGR "Patch"-ICD-10 Delay Bill?
The high drama of passing the “Protecting Access to Medicare Act of 2014” occupied most of the past two weeks with the final good news in preventing a 20.1% decrease in Medicare payments and the delay of ICD-10 implementation.
But…what else was in the bill? This article will review a couple of items specific to diagnostic imaging services that received little attention, other than general statements, in the frenzy of all the emails and media postings. By clicking here, you can download a copy of H.R. 4302. The areas referenced below are detailed in section 218 of the bill.
Quality Incentives for CT Diagnostic Imaging (section 218)
On or after January 1, 2016, the technical component of “applicable” CT services would be reduced by 5%, escalating to 15% in 2017 and each year thereafter, if the CT equipment used in furnishing the service was not consistent with the “CT equipment standard”.
“Applicable CT services” are defined as services billed using HCPCS codes 70450-70498, 71250-71275, 72125-72133, 72191-72194, 73200-73206, 73700-73706, 74150-74178, 74261-74263, & 75571-75574 (and any succeeding codes).
The “CT equipment standard” is defined as furnishing a service “using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association (NEMA) Standard XR-29-2013, entitled “Standard Attributes on CT Equipment Related to Dose Optimization and Management.” Through the rulemaking process, the “Secretary of HHS” could apply other standard.
Information to attest to being compliant with "the standard" may be required through the use of a modifier included in a claim when billing for the CT service.
Appropriate Use Criteria for Certain Imaging Services
“Appropriate use criteria” will be established for the ordering & furnishing of advanced diagnostic imaging (ADI) services. ADI services include MRI, CT, Nuclear Medicine, and PET.
The criteria for appropriate use of the ADI services will be developed by specialty societies and other provider led entities; and will be used by ordering and furnishing professionals to make an appropriate decision based on the clinical condition of the patient. If feasible, the criteria would be evidence based.
A report to Congress specifying the criteria is due by “the Secretary” of HHS no later than 11/15/2015. “Mechanisms” would be developed & announced no later than 4/1/2016 detailing the requirements for appropriate use, documentation of same, and the “mechanism” by which an ordering/furnishing provider discloses their compliance with “appropriate use”.
Beginning 1/1/2017, payment for the ADI service would only be made if the claim includes information regarding “appropriate use” criteria being met or not met. Information required in the claim is not defined in the bill.
Starting in 2017, data for individual professionals will be tracked for at least two years. . “Outlier” ordering professionals not adhering to “appropriate use criteria” will be identified. Starting in 2020, “outliers” would be required to obtain prior authorization for ADI services.
Check Your Status for 2014 ERx Payment Adjustment - Is your Physician Listed Correctly Based on Meaningful Use Attestation Hardship Exemptions? File Informal Appeal Now if You Disagree
Please check to insure your physicians will not be subject to the 2014 E-Prescribe 2% payment adjustment especially if you successfully attested to meaningful use in the EHR incentive program 1/1/12-12/31/12 OR 1/1/13-6/30/13.
In the final Medicare program rules for 2013, CMS created an automatic hardship exemption for the 2014 ERx payment adjustment if physicians had successfully attested to meaningful use during certain time periods which are noted above. CMS indicated they would query the CMS EHR Registration & Attestation system to determine the provider hardship exemption based on this new rule.
Recently, Physicians First has been working with two physicians from two different group practices who successfully attested 11/12/12 and 11/30/12 yet their NPIs are listed as being subject to the 2014 payment adjustment.
How do you check your physician’s status? There are two ways:
1. Download your 2012 ERx feedback report using your PQRS Portal login.
2. Call QualityNet – 1-866-288-8912. Provide QualityNet with the provider name and individual NPI; and ask them to check the physician status for the 2014 ERx payment adjustment.
QualityNet indicates, to the best of their knowledge, that the NPI list provided to them by CMS, dated 10/5/13, is the list reflecting physicians who will be exempt from the payment adjustment due to the CMS query regarding meaningful use. Unfortunately, the two physicians referenced above are in the list as being subject to the penalty.
QualityNet is indicating there is nothing further they can do other than to encourage physicians to file an Informal Appeal with CMS. If you find your physicians are subject to the payment adjustment, I would encourage you to do the same.
How do you file the Informal Appeal?
The process is simple requiring submission of an email to a specific CMS email address.
You may file an appeal during the period 11/1/13-2/28/14. I encourage you to file appeals NOW. The sooner you file the appeal, the greater the possibility an approval would be timely in order to update the provider NPI status and avoid claims payment issues starting 1/1/14.
Click here to read the CMS document, Electronic Prescribing (eRx) Incentive Program: Informal Review made Simple.
The email address is: eRxInformalReview@cms.hhs.gov.
Below is a sample of an email with the required information as recently submitted to CMS.
Physician name, address, and numbers have been changed.
Informal review request for: Andrew H Smith MD
Individual NPI: 1234567891
Organization Legal business name: ABC Medical & Surgical Group LLC
Last 6 digits of organization TIN: 567890
EP Mailing Address: 2231 Randall Rd, Ste 234, Orlando, FL 32822-3787
EP Phone Number: 407-234-1822
EP Email: email@example.com
Requestor: Donna Kaine
Requestor relationship to EP: Support Staff
Justification for review of 2014 eRx Payment Adjustment:
Dr Smith participated in and successfully attested to meaningful use in the Medicare EHR incentive program during the 2012 EHR reporting period. Confirmation of the successful attestation is dated by the EHR Registration & Attestation system as 11/30/2012. As documented by CMS in the final 2013 program rules and other CMS documents posted regarding hardship exemptions for the 2014 eRX payment adjustment, we believe Dr. Smith should qualify for an automatic hardship exemption as he achieved and attested to meaningful use during the 12 month eRX reporting period 1/1/2012-12/31/2012.
CMS Announces Front End Testing for ICD-10 - Testing Time Frame Will Occur for Only One Week
Earlier in the year CMS announced no testing for ICD-10 would occur between trading partners and CMS systems prior to the compliance mandate for ICD-10 on October 1, 2014. A recent CMS transmittal (CR 8465) indicates a change in the CMS position.
CR 8465 indicates front end testing between Medicare Administrative Contractors (MACs) and trading partners will now occur; BUT only during a one week period, March 3, 2014 through March 7, 2014. Registration at the MAC level will be required in order to participate in the testing phase. MACs will be posting information on their websites and through listserv emails regarding the registration process no greater than 4 weeks prior to the March testing week. Click here to read the MLN Matters document regarding CR 8465.
If you are using a clearinghouse for claims submission, your individual/group practice DOES NOT need to register for the testing period; BUT MAKE SURE your clearinghouse will be registering and ask them for followup regarding the testing results. If you are submitting claims to MACs directly from your system, contact your vendor now to start making inquiries as to their system updates for ICD-10 for your practice and to confirm their intent to be part of the front end testing period. Continue your follow up in the new year to insure these actions by the clearinghouse and vendor are taking place!
CMS Now Allows "Extended HPI" Criteria from "97" E/M Documentation Guidelines to be used with "95" Guidelines
CMS recently posted a FAQ regarding the 1995 & 1997 Documentation Guidelines for Evaluation & Management Services.
Documenting an "extended HPI (history of present illness)" using the "97" guidelines stipulates the provider may document either 4+ HPI elements (from the total of 8 HPI elements) OR; instead, may document the status of at least 3 chronic or inactive conditions.
Using the "95" guidelines, an "extended HPI" will allow only for documenting 4+ of the 8 possible HPI elements. Using "95" you have previously not had the option of documenting the status of 3 chronic or inactive conditions since it is a rule specific to the "97" guidelines.
Beginning with services performed on or after 9/10/13, CMS now states you may use the status of at least 3 chronic or inactive conditions option for an "extended HPI" when documenting your E/M services using the "95" guidelines.
Other than this small co-mingling of the "95" and "97" guidelines, you still must use one or the other guidelines sets for documentation purposes. You still may not use a combination of the two!!
Click here to read the CMS FAQ, and add it to your compliance file.
In 2013, if you do not "successfully report" a PQRS individual measure(s) or a measures group for your eligible providers, then "yes" your providers will face the 1.5% payment adjustment as of 1/1/2015. To "successfully report" (and avoid the 2015 penalty) there is no specific number of individual measures (beyond at least one!) or specific measures groups. There are no specific requirements for reporting the measure at a specific per cent threshold or for reporting the measures group a specific number of times.
CMS finalized this option for 2013 to help as many providers as possible to avoid the 2015 penalty by just "report something!!" NOTE: This option will only avoid the penalty for 2015. The option cannot be used to earn the PQRS bonus.
Your ability to report PQRS, using the above criteria, is for dates of service 1/1/2013 thru 12/31/2013. There is no deadline that states this reporting cannot be done after 10/15/13!!
So where did the confusion come from? Probably from a misunderstanding of the CMS term for another 2013 option providers may "elect" in order to avoid the 2015 penalty. The deadline to "elect" this option, via a secure CMS web portal, is 10/15/2103. The option is called "Administrative Claims".
When we think about "claims" we think about the claims we send, electronically or paper, to be paid for services rendered. The natural thought when you see the term "administrative claims" with a deadline of 10/15/2013 is to think "Game over". If I don't submit claims with PQRS data codes by 10/15/2013, I'm doomed for receiving a 2015 penalty." – NOT SO!
Electing Administrative Claims IS NOT a path to receiving a PQRS bonus. It is ONLY a method for trying to avoid the 2015 penalty.
By "electing" this option (no later than 10/15/2013), CMS will analyze the provider claims data for the 2013 reporting period (1/1/13-12/31/13) looking for indication of performance of specific actions for specific quality measures. CMS is not looking for your reporting of Quality Data Codes (QDC) under PQRS. Electing administrative claims assumes you probably were not reporting QDC codes at all or to a sufficient degree. After the end of 2013, CMS will analyze the provider's claims data based on the provider individual NPI for areas such as patient demographic information, diagnosis code(s), CPT codes reported, services ordered/referred. Based on their analysis, you may be exempt from the 2015 PQRS penalty.
There are 26 Measures CMS will use for administrative claims analysis. Click here to review the list and see how they relate to your practice.To "elect" the "administrative claims" option, you must have a CMS IACS account with a valid User Login. If you do not already have an IACS account, it will take at least two weeks to complete all aspects of registration. The deadline for logging into the actual portal to make the election of "administrative claims" is 10/15/2013.
If you have not started reporting PQRS, it is time to do so!! There are still 2013 options available for avoiding the 2015 payment adjustment. These options do not end as of 10/15/13!
2012 PQRS & E-Prescribe (ERx) Feedback Reports for Individual EPs Are Now Available
CMS recently announced feedback reports for 2012 PQRS and ERx are now available for individual eligible professionals (EPs) who participated in these programs. Specific dates for releasing incentive payments for both programs have not been provided although CMS did indicate PQRS incentive payments will start "August 2013" and ERx incentive payments will begin "Fall 2013". These incentive payments are posted electronically to your bank account based on your EFT enrollment as required in the Medicare program.
Please be sure to access these reports. Practices say to me all the time “I’m ok, I received an incentive payment”; but receiving the incentive DOES NOT mean that ALL EPs in your group are “ok” from the perspective of being PQRS reporters. The feedback report will provide that information; and the information is vital now that we are moving to the PQRS penalty phases.
To obtain your feedback reports there are 2 options (Option #1 is NOT recommended):
1. Individual reports based on the EP's NPI may be requested through the Communication Support Page (CSP). Click here to access the CSP. Pick "NPI Level Report". At the next screen, after completing identifying information, pick program year 2012 from the drop down menu. The report field will then expand; and you may pick the report you would like - PQRS or ERx.
The downside to using this option for obtaining reports is the burden of entering information for each EP. In addition, it may take 2-4 weeks to process the request. The report will be forwarded via email to the address listed during the completion of your request.
2. Obtain one feedback report which contains information for all EPs affiliated with your group practice from the QualityNet PQRS Portal. This is the preferable option to use; but you must have a login for the "PQRS Portal" at the QualityNet website. Click here to access the portal login area at QualityNet. If you do not have a login, you will see an area in the middle of the page where you may start the registration process. There is also a link to download "Quick Reference Guides" to aid in guiding you through the process of applying for your login. The login is called an "IACS" login which stands for "Individuals Authorized Access to CMS Systems".
1. The process starts by establishing a "Security Official". If you are the person(s) who ultimately wants access to the reports as an "End User", DO NOT make yourself the Security Official (SO). Security Officials MAY NOT be End Users. The Security Official simply controls the approval process of other users.
2. When entering the information for the Security Official you will be asked if you want the SO to have a two factor authentication. Answer "Yes". The reason is listed below regarding the new role which you MUST have for meaningful use for 2014 reporting called an "EHR Data Submitter". Two factor authentication means, for example, the SO will be sent an email AND a text message to their smartphone. The Security Official MUST respond to BOTH in order to keep the registration process moving forward.
3. Following completion of the SO piece, you will be required to send documentation received from the IRS to QualityNet documenting the legal business name and tax identification number for your entity. Once this is completed the SO will eventually receive approval and End Users may then be assigned.
4. The entire process may take 2-3 weeks; BUT IT IS TIME FOR EVERYONE TO HAVE A LOGIN. YOU CAN NO LONGER PUT THIS OFF!! Not only is it vital to PQRS now and in the future, it will be required in order for you to submit meaningful use clinical quality measures electronically (eCQM) in the Medicare EHR Incentive program.
5. To submit eCQMs for meaningful use you MUST add a new role to your PQRS Portal Login. The new role is called "EHR Data Submitter". The Security Official MUST have two factor authentication in order to approve the person(s) for this new role.
6. Once you receive your PQRS Portal Login you MUST login to the account AT LEAST every 60 days or YOUR ACCOUNT WILL DEACTIVATE!!
7. If at anytime during the registration process you have difficulty, contact QualityNet - 866-288-8912. QualityNet has a reputation for being very helpful.
New 1500 Claim Form Approved-Significant Changes to Section 21 Due to Transition to ICD-10-Tentative Implementation Schedule Posted
On June 10, 2013 the Office of Management and Budget (OMB) approved the revised CMS 1500 claim form, version 02/2012.
Significant changes in Section 21 of the form have occurred due to ICD-10 implementation.
To view the final form click here.
In section 21 you will note there are now 12 lines for entry of diagnosis codes (rather than the current limitation of 4 diagnosis codes). These lines are no longer numbered 1-4. The lines are designated by alpha characters A-L.
Instead of using a diagnosis pointer of 1, 2, 3, or 4 (as is currently the case) for each line item of service, the entry would now be an alpha character A-L.
In addition, note the area in section 21 for the “ICD Indicator”. During transition from use of ICD-9 to ICD-10, an entry of “9” is required for claims containing ICD-9 codes or a “0” for claims with ICD-10 codes.
A “claim log” outlining all changes to the 1500 claim may be accessed by clicking here; and the new 1500 claim manual can be accessed by clicking here.
CMS has established a tentative schedule for implementation of the 1500 claim form:
1/6/2014 Medicare will begin receiving & processing the new form.
1/6/2014 thru 3/31/2014 will be a dual use period. Medicare will receive & process the old as well as the new 1500 claim form.
4/1/2014 Medicare will receive & process only the new form.
Just one more major change in an already chaotic environment!
The Office of Inspector General (OIG) released a report dated May 2013, Improvements Needed to Ensure Provider Enumeration and Medicare Enrollment Data are Accurate, Complete, and Consistent. To read the full report, click here.
The report details the significant inaccuracy of information in NPI (NPPES) files when compared to information found in the national Medicare enrollment system, PECOS. As the report states, "Provider data were inconsistent between NPPES and PECOS for 97 per cent of records." The OIG feels this is a significant fraud issue not just for Medicare; but for other health plans nationally since NPI files are used by all payers.
The results of this report could ultimately prove disastrous for providers if they do not update NPI files to insure the information in the NPI file is the same as that found in PECOS and vice versa. CMS reviewed the draft OIG report in March, 2013 and stated they concur with the recommendations made in the report by the OIG. For example, CMS stated, "CMS is currently working on a process to rapidly deactivate NPIs for practice locations that are determined to be invalid. In conjunction with other data obtained, CMS will take action to deactivate records with invalid practice locations or other circumstances justifying deactivation."
PLEASE immediately review and consistently update NPI files for your individual providers as well as your organizations. Since the implementation of NPI several years ago, the provider community has tended to overlook the importance of updating this information; and it could now ultimately prove costly. In addition, there will probably be greater scrutiny in the Medicare enrollment process resulting in enrollment delays when NPI information is found to be inconsistent with enrollment documents.
NOTE: If you are changing your correspondence address in a Medicare group enrollment file, it is imperative you also change the correspondence address for the individual providers reassigned to the group. Changing the address in the group file does NOT automatically change the address in the individual provider enrollment!
For years practices participating in claims submission for PQRS & E-Prescribe have been told by CMS to insure your Medicare remittance confirms a rejection of the PQRS & E-Prescribe codes with the remark code N365. If N365 did not appear in your Medicare remittance, then your codes did not move into the Medicare claims National Claims History file and would not be counted for your eligible professionals reporting.
Last week a client of Physicians First indicated the N365 was no long appearing even though the PQRS codes did appear in the remittance. The client contacted the Medicare contractor and was advised the contractor had "internally" decided to stop posting the N365 as of 4/1/13; but to "trust" the PQRS codes were being processed correctly! In addition, the client was advised the only way for the N365 to appear was if they started charging at least $0.01 for their quality reporting codes. As I am sure you are recognizing in reading this information thus far, this advice is contrary to all you have been taught in quality reporting.
Follow up with QualityNet, the arm of CMS for quality reporting questions, was completed as of Friday 6/7/13. QualityNet indicated the following:
1. "Certain" Medicare contractors elected to eliminate the N365 from Medicare remittances as of 4/1/13. QualityNet did not know the specific contractors involved. (Being Florida based, however, we do know that one contractor is First Coast Service Options)
2. Quoting exactly from the QualityNet email response:
"For those eligible professionals participating in the 2013 PQRS and/or eRx Incentive Program via claims, CMS is aware that remittance advice/EOBs may not be displaying the N365 remark code for program quality-data codes. Valid quality-data codes submitted on Medicare Part B PFS claims with $0 line items have been [and will be] processed into the National Claims History file (NCH) even though the remittance advice/EOB did not indicate the N365 remark code. The remittance advice/EOB should still show the quality-data code line item."
PLEASE make sure your quality data codes still appear in your Medicare remittance. As long as the codes appear in the remittance you, therefore, should have confidence the codes have, in fact, been processed into the claims history file and validly counted for your eligible professionals. It SHOULD NOT be necessary for you to start charging for the quality codes unless you have already been required to do so if your vendor or clearinghouse was stripping the codes from your claims.
Physicians First has communicated again with QualityNet to ask for CMS to publish an article concerning this issue in their weekly Fee for Service Provider eNews. It is too early to have received a response from QualityNet. It would be helpful to provide awareness to as many providers as possible about this major change especially since it apparently started occurring in April, 2013. Please forward this information to other friends and colleagues who may benefit from the information.
Prior to the American Taxpayer Relief Act of 2012 (ATRA), Medicare beneficiaries were responsible for payment to providers for therapy services once they exceeded the annual therapy cap. ATRA changed that provision. As of January 1, 2013, once a beneficiary exceeds the cap, the provider may not collect payment from the beneficiary unless a valid advanced beneficiary notice of noncoverage (ABN) has been signed by the Medicare beneficiary.
In a fairly stunning notification, CMS recently announced that Medicare claims systems were not updated in time in 2013 for the Medicare remittance to accurately reflect this change. Even though a Medicare remittance may reflect the beneficiary has exceeded a therapy cap, the remittance will, in error, still reflect the beneficiary liability (group code PR which means patient responsibility) rather than the provider liability (group code CO which means contractual obligation).
Correction of this error for Medicare Part B remittances will not occur until January 1, 2014. Medicare contractors nationally will NOT adjust claims already processed.
What does this mean to the provider? For every therapy claim processed you will need to check your Medicare remittances. If the therapy service exceeded the therapy cap, you will need to check to see if you collected any money from the beneficiary, If you did collect the money and you did not have a validly signed ABN, you are required to refund the money to the Medicare beneficiary.
Quite a burden to be placed on providers.
CMS posted this information in a prior weekly CMS Medicare Fee For Service eNews. Click Here to read the same article that was recently posted by the Florida Medicare contractor First Coast Service Options.
Medicare Enrollment Revocation for Providers Occurring for Reasons You May Not Suspect - Be Proactive!
Revocation of Medicare enrollments are occurring for physicians and other providers not only in jurisdictions where they previously practiced; but, as a result of those enrollments in prior Medicare jurisdictions, revocations are now occurring for their Medicare enrollments where they currently practice. Revocation is a serious problem resulting not only in termination of revenue; but re-enrollment in the Medicare program in these cases is barred for ONE YEAR.
How is this happening??
Here is an example; and you will agree, it happens all the time thus being an issue that EVERY practice will need to pay attention to and be proactive in preventing!
Dr. Jones was doing his fellowship in Minnesota; and as required, had a valid medical license in Minnesota. During his fellowship, his employer enrolled him in Medicare Part B in the Minnesota jurisdiction in order to bill Medicare for valid services.
When Dr. Jones completed his fellowship, he then left Minnesota and came to Florida to work for a Florida entity. When he left Minnesota, he never intended to maintain an active medical license in Minnesota; and when the time came to renew the license, he did not renew it.
In addition, when he left the Minnesota employer, the employer did not terminate his reassignment; and Dr. Jones Medicare enrollment in Minnesota remained an active enrollment. Dr. Jones could have initiated a voluntary termination of his Minnesota Medicare enrollment; but he was not aware of Medicare enrollment rules.
State medical licensing boards share information with Medicare contractors. Following the expiration of Dr. Jones medical license in Minnesota, the Minnesota Medicare contractor received information from the board indicating Dr. Jones’ medical license had expired. The Medicare contractor revoked Dr. Jones Medicare enrollment. Dr. Jones never received any communication notifying him of the revocation.
If a provider has an enrollment revoked, they then have an obligation to report this “adverse legal” action to their current Medicare contractor. Dr. Jones was now working in Florida and enrolled in Florida Medicare. Not being aware of the revocation, he made no disclosure to Florida Medicare regarding the Minnesota revocation.
Medicare contractors are able to share information through the PECOS enrollment system. Florida Medicare then became aware of Dr. Jones revocation due to an expired medical license in Minnesota.
Recently Dr. Jones received a letter from Florida Medicare indicating his Florida enrollment would be revoked since he did not disclose the Minnesota revocation! A Corrective Action Plan (CAP) to prevent the revocation in Florida has been filed with Florida Medicare and is currently in process. Should you have a provider who faces this type of situation, it is imperative to immediately file a corrective action plan with the Medicare contractor to prevent the revocation from finalizing. Follow up regularly to insure the CAP application is in process and continue the appeals process if it becomes necessary.
So what should you do to be proactive?
1. Check the PECOS enrollment records for your providers to insure there are no revocations listed in PECOS for other Medicare jurisdictions where the provider has worked.
2. If you note revocation(s), immediately disclose it to the provider’s current Medicare contractor by completing either a paper enrollment (CMS 855I) or a PECOS enrollment.
3. Submit a paper CMS 855I enrollment document to the contractor who revoked the Medicare enrollment asking for a change of status for the enrollment from “Revocation” to “Voluntary Termination”.
In completing this enrollment, you will need to know the actual Medicare PTAN originally assigned to the provider in the previous Medicare jurisdiction. This may be difficult to determine and require the involvement of the provider and yourself to contact any and all prior employers.
If the enrollment record is not changed from revocation to voluntary termination, this action will ALWAYS need to be disclosed by the provider as an adverse legal action with EVERY Medicare enrollment or revalidation completed by the provider in the future.
4. Whenever you are looking to hire new providers who have been working in other Medicare contractor jurisdictions, obtain from them their existing individual Medicare PTAN(s); and require they provide a working User ID and Password for their NPI file so you can access, (with their involvement), the provider’s PECOS record to be sure there are no current revocations. In addition, be proactive in insuring that any current Medicare enrollments in other Medicare jurisdictions noted in PECOS are voluntarily terminated. The provider’s prior employer may be taking care of the voluntary termination; but you need to confirm this is the case. If you are unable to confirm action being taken by the prior employer, you need to insure the enrollment record is terminated. If you do not, the future could be bad in terms of a sudden letter being received, like Dr. Jones, indicating the provider’s Medicare enrollment will be revoked with a one year bar from re-enrollment. Not a pretty picture from a revenue standpoint!
CMS Implements Claim Hold for Assistant at Surgery and ASC Claims
CMS issued an email yesterday annoucing technical issues with certain portions of the April 2013 quarterly releases for fee schedules. Where multiple types of entities are affected by the issues, the provider community will be impacted specific to Assistant-at-Surgery services and Ambulatory Surgical Center claims.
CMS anticipates having corrections for the technical issues completed by April 14, 2013.
In the meantime, claims for these types of service with dates of service on or after 4/1/13 will be held until 4/14/13. CMS states these claims should be released in the processing system on 4/15/13.
Below is the language from an email sent by CMS this afternnon with the details for the Medicare Part B 2% payment decrease due to sequestration. The effective date for the decrease is for dates of service or dates of discharge on or after April 1, 2013. It does not appear that new fee schedules will be released nor will your claims be held for issues related to releasing new fee schedules. The decrease will be applied to all claims in your Medicare remittance thus forcing a separate line item of posting and adding to your administrative burden.
In a separate statement yesterday, Health & Human Services also indicated the 2% decrease would apply to Medicare EHR bonus incentive payments. The decrease would NOT, however, apply to the Medicaid EHR incentive program since Medicaid is exlcuded from sequestration.
"To All Health Care Professionals, Providers, and Suppliers
Mandatory Payment Reductions in the Medicare Fee-for-Service (FFS) Program – “Sequestration”
The Budget Control Act of 2011 requires, among other things, mandatory across-the-board reductions in Federal spending, also known as sequestration. The American Taxpayer Relief Act of 2012 postponed sequestration for 2 months. As required by law, President Obama issued a sequestration order on March 1, 2013. The Administration continues to urge Congress to take prompt action to address the current budget uncertainty and the economic hardships imposed by sequestration.
This listserv message is directed at the Medicare FFS program (i.e., Part A and Part B). In general, Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment. Claims for durable medical equipment (DME), prosthetics, orthotics, and supplies, including claims under the DME Competitive Bidding Program, will be reduced by 2 percent based upon whether the date-of-service, or the start date for rental equipment or multi-day supplies, is on or after April 1, 2013.
The claims payment adjustment shall be applied to all claims after determining coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments.
Though beneficiary payments for deductibles and coinsurance are not subject to the 2 percent payment reduction, Medicare’s payment to beneficiaries for unassigned claims is subject to the 2 percent reduction. The Centers for Medicare & Medicaid Services encourages Medicare physicians, practitioners, and suppliers who bill claims on an unassigned basis to discuss with beneficiaries the impact of sequestration on Medicare’s reimbursement.
Questions about reimbursement should be directed to your Medicare claims administration contractor. As indicated above, we are hopeful that Congress will take action to eliminate the mandatory payment reductions."
CMS Releases FAQs Regarding Transitional Care Management (TCM) Codes - 99495 & 99496
On 3-7-13 CMS issued a document with frequently asked questions for the new TCM codes.
Click here for the full two page document.One of the questions frequently asked by providers is:
"If the patient is readmitted in the 30 day period, can TCM still be reported?"
Here is the CMS answer:
"Yes, TCM services can still be reported as long as the services described by the code are furnished by the practitioner during the 30 day period, including the time following the second discharge. Alternatively, the practitioner can bill for TCM services following the second discharge for a full 30-day period as long as no other provider bills for the service for the first discharge. (bold and underline is my emphasis) CPT guidance for TCM services states that only one individual may report TCM services and only once per patient within 30 days of discharge. Another TCM may not be reported by the same individual or group for any subsequent discharge(s) within 30 days."
One could say the answer adds another layer of confusion! In my opinion, if the patient is readmitted during the initial billing practitioner 30 day TCM period, continue to document the service related to the first admission; and add specifics relevant to the second discharge. To bill instead for TCM for the second discharge may get complicated if the practitioner is unable to determine if another provider has already billed or will be billing for TCM for the first discharge.
NOTE: If you bill for TCM and it is denied (e.g the service was already paid to another practitioner), always go back and bill for the face to face E/M visit that was bundled with the TCM code.
CMS Identifies Issue with Crossover Claims for Functional Therapy Codes & Severity Modifiers
In their weekly "E-News" on 3-7-13 CMS issued a notification regarding problems with crossover to supplement payers for Medicare Part B Therapy Claims related to the new functional limitation "G" codes and severity modifiers.
The errors occurred as a result of the new "G" codes for funtional limitations and the two digit severity modifiers "inadvertently" not being loaded to the 2013 Healthcare Common Procedure Coding system (HCPCS) and the Coordination of Benefits system.
All required updates were completed as of 2-25-13 so the issue should now be resolved. Unfortunately, however, any claims that were not automatically crossed over to the supplement will need to be manually filed by your office.
To read the email portion of the CMS E-news related to this issue click here.
The Communication Support Page (CSP) is now available for providers to file for a hardship exemption to avoid the 2014 E-Prescribe penalty adjustment. If you beleive you may be subject to the 2014 penalty, you must file your hardship exemption no later than 6/30/2013.
To access the CSP click here. Once at the page, click on "Create Hardship Exemption".
In the area where you must "Select the Hardship Exemption that Best Applies", note there is an error in the selection for "
MedLearn Article SE1305 was just posted reviewing the final details for full implementation of the ordering/referring claim edits effective 5/1/2013. As of this date, if the ordering/referring provider does not have a valid Medicare enrollment record in the PECOS system and/or is not eligibale to order/refer services or supplies, claims will be denied for Part B, DME, and Part A Home Health Agency (HHA). Warnings regarding the implementation of the edits have been occurring in claims processing since October 5, 2009. Please keep in mind, these edits will not only affect services YOUR providers order/refer; BUT will also affects services you provide to beneficiaries who were referred TO your practice.
To read the full Medlearn article, click here.
How do you tell if a provider has a PECOS enrollment record? There are 3 ways to check.
1. Call your Medicare contractor. Provide the contractor with the provider NPI, Medicare PTAN, and last five digits of the provider social security number. The contractor will be able to verify if the provider has a valid PECOS enrollment record.
2. Check the CMS "Ordering/Referring" report. If the provider's NPI is listed in this report, then the provider has a valid PECOS record. Click here for the CMS website where the report is posted. Scroll down to the bottom to download the report which is updated periodically.
3. Have the provider login to the PECOS enrollment system to verify their enrollment record is in PECOS. Click here to access the PECOS Login website.
There is not much time left before 5/1/2013! If your provider does not have a valid PECOS record, you MUST start the enrollment process now in order to insure timely processing. If you discover providers who refer to your practice do not have a PECOS record, contact them NOW to insure they start the enrollment process.
Time to Start Planning for Sequestration
"Sequestration” is a term applied to automatic spending cuts to enforce federal budget policy. The Budget Control Act of 2011 was signed into law by President Obama on 8/2/2011.The law brought conclusion to the 2011 United States debt-ceiling crisis. However, the law provided incentive for Congress to act no later than 12/31/12 to address required deficit reduction. If Congress failed to act, across the board spending cuts (sequestration) in many areas of the federal budget would be triggered. These cuts apply to federal spending in the years 2013 to 2021.
Where Congress did postpone sequestration until 3/1/13, we are a little more than a week away from the deadline; and thus far there is no current positive legislative outlook that the cuts will be prevented from occurring. The cuts will have dramatic effects across many domestic programs as well as military programs.
The affect to Medicare providers will be a 2% decrease to your Medicare allowed amounts. The decrease would occur annually for the years 2013-2021.
If sequestration is not averted by 3/1/13, your Medicare allowed amount decrease would probably occur approximately 30 days later. Exact details, however, are not known at this time since the Department of Health & Human Services has yet to release details of exactly how and when the decreases would be implemented.
On 12/18/12, CMS announced the availability of a new "dashboard" feature allowing eligible professionals to access and review interim feedback information for their claims based 2012 PQRS reporting. The information will be available on a quarterly basis for 2012 for both individual measures and measures groups.
In order to access the information, you must have a login for the PQRS portal at the QualityNet website. Click here to access the QualityNet site. If you have not yet applied for a login, it is long past time to do so. This login is vital to accessing ERx & PQRS Feedback reports for other program years; and now the importance is expanding with the availability of these interim feedback reports. Applying for the login may also be done at the QualityNet site.
CMS has developed a User Guide for the 2012 Interim Feedback Dashboard. The guide is available at the QualityNet site; but click here to access the guide a bit quicker!
CMS started issuing bonuses for the 2011 PQRS reporting period as of 10/9/12. All bonuses due to eligible providers (EPs) will be issued as of 11/11/12.
For the first time this year, due to congressional legislation, EPs have the ability to file for an informal review if they feel the bonus amount was incorrect or was denied.
Prior to requesting the informal review, you should review the EPs PQRS Feedback Report to determine if there is a valid reason to file for the review. CMS stated today Feedback Reports for PQRS should be available by "the end of October".
To access feedback reports go to the QualityNet website. Click here for the link. You must have a PQRS Portal login in order to access the feeback reports.
If you decide to file for an informal review, you do so by using the Communication Support Page (CSP). The CSP is accessed through a direct link at the QualityNet website.
CMS will accept requests for the informal review from 11/1/2012 through 2/28/2013. CMS will make a determination within 60 days. You will receive the determination via email. Unfortunately, all CMS decisions are final. No further appeal rights are offered.
CMS Announces Re-Opening of Communication Support Page, 11/1/12, to Apply for 2013 ERx Penalty Exemption
Last week CMS announced the re-opening, 11/1/12, of the Communication Support Page (CSP) to allow providers an additional opportunity to apply for an exemption to the 2013 E-Prescribe (ERx) penalty. Exemption requests may be filed 11/1/12 through 1/31/13. CMS will review requests on a case by case basis. All decisions will be final.
PLEASE NOTE: If your providers have received an ERx bonus for the 2011 ERx reporting period, there is NO NEED to apply for an exemption. Achieving the 2011 bonus automatically excludes providers from any penalty in 2013.
To refresh your memory of the current ERx rules, click here to read a MedLearn article regarding the ERx rules, exceptions, and exemptions.
The Communication Support Page may be accessed by clicking here for the web link.
If you need to apply for an exemption, do so quickly after the CSP page opens on 11/1/12. If your exemption is not approved prior to 1/1/13 and the provider is in a penalty situation, claims will be processed to include the penalty reduction of 1.5%. Subsequent approval after 1/1/13 means all those claims will need to be re-processed; and that will take time not to mention the administrative burden to your accounts receivable.
On August 24, 2012 the Department of Health & Human Services (HHS) posted for display a final rule related to certain HIPAA administrative simplification rules. This final rule will be published in the federal register on 9/5/12.
Noteworthy in the rule is the long awaited finalization of the delay in mandatory compliance for ICD-10 diagnosis coding from 10/1/2013 until 10/1/2014.
The rule also adopts final rules for the assignment of Health Plan IDs (HPID) and use in electronic transactions. All covered entities will be required to use the HPID as of 2016.
To read the HHS press release regarding the final rules, click here.
The National Uniform Claim Committee (NUCC) has issued proposed changes to the 1500 claim form. One major area of change involves section 21 for the entry of diagnosis codes moving from ICD-9 to ICD-10.
Approval for the changes must be made by CMS as well as the Office of Management & Budget. NO DATE has yet been set for final approval or transition to the new form so do not take any action to implement this new 1500 claim form at this time.
To view the DRAFT proposal for the new form click here.
In section 21 you will note there would now be 12 lines for entry of diagnosis codes (rather than the current 1500 claim limitation of 4 diagnosis codes). These lines are no longer numbered 1-4. The lines are now designated by alpha characters A-L.
To view the page from the proposed 1500 claim completion manual specific to Section 21 click here
Two items of note are found in this page:
During transition from use of ICD-9 codes to ICD-10, the user would need to enter the "ICD Indicator"-"9" for ICD-9 or "0" for ICD-10.
Instead of using a diagnosis pointer of 1, 2, 3, or 4 (as is currently the case) for each line item of service, the user would now use the alpha letters "A-L".
For more information about the 1500 claim revision, go to the NUCC website, (click here) and scroll down to the section, "The NUCC Approves a Revised 1500 Health Insurance Claim Form".
CMS recently issued a transmittal adding two new physician specialty codes for Medicare & DME enrollments. Even though the EFFECTIVE date for the specialty codes is April 1, 2012, the actual IMPLEMENTATION date for the new specialty codes in the Medicare/DME systems is not until October 1, 2012. If these specialty codes are applicable to the physician, do not update your enrollments until 10/1/2012.
There is a new specialty code for Sleep Medicine. The new two digit code is C0.
There is also a new specialty code for Sports Medicine which will now be specific to DME claims. For Medicare Part B purposes, the Sports Medicine spcialty code was implemented 4/4/2011. The two digit code for Sports Medicine is 23.
To access the MLN Matters article regarding these changes click here.
In an email dated May 10, 2012, CMS announced the following:
"Providers and suppliers can now submit their enrollment applications 30 days sooner. CMS 855-enrollment applications and Internet-based PECOS applications may now be submitted 60 days prior to the effective date.
NOTE: This does not apply to providers and suppliers submitting a Form CMS 855-A application, Ambulatory Surgical Centers (ASCs), or Portable X-ray Suppliers (PXRSs)."
This change should be especially helpful for adding new providers to group practices. By allowing for earlier enrollment submission, the time frame in which claims for new provider services must be held waiting for an enrollment to finalize should decrease thus improving your cash flow!
On 4/9/12 the Department of Health & Human Services (HHS) issued a proposed rule which includes postponing the implementation date for
ICD-10 from 10/1/13 to 10/1/14. Since this is a proposed rule, there will first be a 30 day comment period followed by HHS reviewing comments received. One would hope the postponement date for ICD-10 implementation will become part of the final rule; but that outcome cannot be certain until the final rule is actually published (hopefully by sometime July, 2012). The proposed rule also establishes plans for assigning unique health plan identifiers for health plans and other entities such as third party administrators as required under HIPAA.
To see a copy of the press release from HHS, click here.
To read the actual proposed rule, click here.
CMS announced on 3/15/12 that enforcement action for non-compliance with HIPAA 5010 transaction standards would be postponed for another 90 days, thru 6/30/12. Enforcement for compliance with HIPAA 5010 is NOT just for health care providers. ALL covered entities are subject to compliance and enforcement with the HIPAA 5010 transaction standards including payers, clearinghouses, vendors, etc.
Between now and 6/30/12, if you are having issues with specific transactions with specific covered entities, make sure you document the issue(s), who you spoke to, dates, times, information provided by the entity, proposed solutions to your problems, failure to comply with promised solutions, etc. When and if you choose to file a complaint, you will need documentation to support your issue(s).
After 6/30/12, if you choose to file a complaint, here is how to do it:
1. You may file a complaint using a paper form. Click here to download the form. The address for where to send the form is included.
2. You may file the complaint electronically using the Administration Simplification Enforcement Tool, otherwise known as ASET. Click Here to Access the Site
During a national audio conference on 2/21/12 CMS verbally indicated the code 99024, post op visit, should not be used during the 6 month claims filing payment adjustment period for E-Prescribe (ERx). See article below dated 2/29/12.
An email was sent to QualityNet to clarify this statement by CMS. Where 99024 is not a payable code during the global surgical payment period, it is a billable code. QualityNet agreed and escalated the email inquiry to a higher tier at CMS. Below is the response received from CMS on 3/5/12:
If the 99024 is billed within the global surgical package, and so is not billed with any reimbursible charge, then no, it cannot be used alone with the g8553 for eRx, as the entire claim would show $0.00 in charges, and would be rejected by the carrier. For the first six months of 2012, when reporting the G8553 to avoid the 2013 payment adjustment, CMS will analyze any claim that includes the G8553 and any billable/payable service. For just that first six month period, you are not limited to the following encounters specified in the eRx Measure denominator: 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90862, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0108, G0109.
Notice CMS is using the words “reimbursable charge” and “billable/payable” charge.. Despite disagreeing with this outcome, you would be wise NOT to use the 99024 code during the 6 month claims filing period, 1/1/12 thru 6/30/12, in order to meet the required 10 ERx events to avoid ERx penalty adjustments for 2013.
CMS recently issued change request 7631 to revise rules for place of service (POS) codes. The new rules will be implemented 4/2/12. Changes being made are a result of problems identified by the Office of Inspector General (OIG) in a sampling of provider claims. The errors made by providers resulted in higher Medicare payments being made than are allowed under Medicare regulations. Many claims, for example, were incorrectly paid at the higher "non-facility" rate becasue the claim contained the POS code for office rather than the correct POS code for outpatient or ASC which pays at the lower "facility rate".
The old POS rules instructed providers to use a POS code to describe where the provider was when he/she rendered the service. Now, the rules, effective 4/1/12, stipulate the POS code used by the provider should be the setting in which the beneficiary received the face to face service.
This rule will have a direct impact on those physicians/practitioners providing the PC/interpretation of a diagnostic test from a distant site. The POS code to use in this situation will be the POS for the setting where the beneficiary received the techincal component (TC).
To read the complete MedLearn article posted regarding all revisions to the rules Click Here.
The good news in this recent legislation is averting the 27.4% decrease to Medicare Physician Fee Schedule Payments that would have occurred as of today. Medicare reimbursement for the majority of services will remain the same through 12/31/12. However, the bad news is:
1. The law DOES NOT extend the special 2011 rates for bone mass measurements.
2. The law DOES NOT allow for the 5% physician fee schedule add-on payment for mental health services.
Becasue of these two items, CMS needs to recalculate and test Medicare allowed amounts for these services. Medicare contractors have been instructed they may hold these claims with March dates of service for up to 10 business days. CMS expects the claims to be released for processing no later than 3/15/12.
3. Unless Congress intervenes prior to 1/1/2013, the dollar conversion factor is now expected to decrease by 32%!!
During a national audio call on 2/21/12, CMS verbally indicated providers should NOT bill 99024, post op visit, with the G8553 during the 6 month penalty adjustment period for E-Prescribe, 1/1/12 thru 6/30/12.
In the final rules for the Medicare program for 2012, the rules indicate providers may file a claim with any BILLABLE code as the E-Prescribe denominator during the 6 month period in order to avoid the E-Prescribe penalty in 2013. 99024 is a valid BILLABLE CPT code. The code may not be PAYABLE; but it is BILLABLE. In the final rules CMS made NO distinctions as to codes that should not be billed.
An email was forwarded by Physicians First, Inc. to QualityNet to pursue the issue. It is an issue that others nationally are concerned about too. QualityNet responded verbally to the inquiry indicating their understanding that a code such as 99024 could be used. QualityNet indicated they would forward the question to a higher tier at CMS for final response.
Until such time as a formal response is received, it would probably be best for providers NOT to use the 99024 as a reportable E-Prescribe event for the 6 month payment adjustment reporting period.
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.
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.
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.
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.
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.
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 or 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: firstname.lastname@example.org
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.
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.
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.
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.
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
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
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.
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
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.
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
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!!
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.
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
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!
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.
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
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
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.
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.
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
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
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."
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.
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.
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."
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 188.8.131.52 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
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."
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
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
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