CPB STAFF OUTING
On Friday, August 17th CPB will be closed for the day to enable our staff to enjoy our annual office Employee Appreciation outing.
NPI #’s
CMS is supposed to make the full NPI # list available online for download as a file on August 1st. We have printed the entire list of referring physicians in the CPB database and will begin loading NPI #’s as soon as they are available.
Zostavax – Not Covered By Medicare
The Zostavax ® vaccine for prevention of shingles (herpes zoster) is excluded from Part B Medicare coverage [CMS Internet Only Manual publication 100-2, Chapter 15, Section 50.4.4.2]. In the absence of an immunocompromised state, beneficiaries are not at direct risk for developing herpes zoster; and in an immunocompromised state, the vaccine is contraindicated and should not be administered. The vaccine (but not the administration) may be covered under the Part D (prescription drug) Medicare benefit. In such cases it is a non-covered service and can be collected from the patient on the date of service. Posted by CMS on 07/25/2007.
CMS CERT Audits
Providers Nationwide recently received requests for charts as part of the Comprehensive Error Rate Testing (CERT) by Medicare. The auditor is independent of all carriers. We are not aware of any CPB clients that received such a request. However, if you received one, be sure to review the records prior to sending them to Medicare. When you do, look at them from the perspective of auditor – is it clear what you wrote? Is it legible and does what was written makes sense? The auditor isn't familiar with the patient or your style of documentation.
Some things the auditor will look for:
-Does the documentation support the services & level of services billed?
-Is the medical necessity for each service clear & concise?
-For those encounters where the key elements in the documentation supported the E/M you billed, was the level of service billed consistent with the nature of the presenting problem in the documentation of that encounter? Or is this a case where there's lots of documentation, but the problem severity isn't articulated in a way that supports the problem?
-Did you bill any procedures? Would someone who knows nothing about you, how you practice, or anything about the patient, be able to say that the documentation of the procedure clearly mapped to the CPT code(s) (and associated modifiers, if applicable) that you billed?
-Was there any part of the encounter that was routine or would otherwise be excluded from Medicare coverage? If so, was it billed to Medicare in a manner to obtain the expected denial?
-If the service you provided is one where the carrier has an NCD or LCD, does the documentation support the diagnosis code(s) you submitted that established medical necessity for claims payment?
-If there was a frequency limitation for the service billed, does the encounter reflect that there was sufficient time since the previous encounter for Medicare to consider this DOS a covered service?
Suggestions:
-If there appears to be some gaps in what the auditor needs to know, send a cover letter explaining it for each patient.
-Send the requested information as soon as it is ready and do not miss the deadline. Missing the deadline will raise attention to your audit in unnecessary ways.
-Send it to the address given in the letter – it does not go to the Medicare Carrier for your state.
Be sure to send ALL the requested information. Make sure each page has the patient’s name on it so they cannot get mixed with another patient’s documentation. Each patient’s data should be clipped together neatly. You want that packet of documents to clearly, logically and concisely present the practice's supporting documentation for the encounters under review.
Friday, August 3, 2007
July 2007
NPI #’s
The data dissemination notice (for NPI #’s) was put on display on May 23rd at 4:00 for CMS officials to review. CMS is supposed to make it available for download as a file in 30 days with NPIs office addresses, practitioner name, and license number (no SSN).
Approximately 98% of the estimated 2.3 million covered health care providers now have NPIs.
The NPPES Data Dissemination Notice (CMS-6060-N) was published on May 30, 2007. NPPES health care provider data that are required to be disclosed under the Freedom of Information Act (FOIA) will be made publicly available.
CMS believes that health care providers need additional time, beyond what was afforded in the Data Dissemination Notice, in which to view their FOIA-disclosable NPPES data and make any updates or deletions (where permitted) that they feel are necessary. Therefore, CMS has decided to delay the dissemination of FOIA-disclosable NPPES health care provider data until August 1, 2007, 60 days after the publication date of the Notice.
CMS will provide additional information in the near future with respect to the date by which changes would have to be submitted in order to be reflected in the initial downloadable file. CMS understands that the health care industry is in urgent need of the FOIA-disclosable NPPES health care provider data; however, CMS believes it is in the best interests of the industry, and the health care providers in particular, that the NPPES data we will be disclosing be as accurate as possible.
Paper Attachments for Medicare Claims.
Effective July 1, 2007 Empire Medicare (NGS) Part B has indicated it will no longer accept paper attachments for electronic claims prior to submission of the claims. Claims that require supporting documentation should be submitted electronically. When the claim is received for processing, if documentation is required for adjudication of that claim, Medicare will send an automatic request to the provider of service requesting additional documentation. The provider has 45 days to submit the information to Medicare. We expect that these letters will come direct to each client which you will then need to forward to CPB as soon as possible so that we do not miss the 45 day deadline.
In the past, Medicare allows us to fax documentation to them seven days in advance which they would then match to the electronic claim.
The data dissemination notice (for NPI #’s) was put on display on May 23rd at 4:00 for CMS officials to review. CMS is supposed to make it available for download as a file in 30 days with NPIs office addresses, practitioner name, and license number (no SSN).
Approximately 98% of the estimated 2.3 million covered health care providers now have NPIs.
The NPPES Data Dissemination Notice (CMS-6060-N) was published on May 30, 2007. NPPES health care provider data that are required to be disclosed under the Freedom of Information Act (FOIA) will be made publicly available.
CMS believes that health care providers need additional time, beyond what was afforded in the Data Dissemination Notice, in which to view their FOIA-disclosable NPPES data and make any updates or deletions (where permitted) that they feel are necessary. Therefore, CMS has decided to delay the dissemination of FOIA-disclosable NPPES health care provider data until August 1, 2007, 60 days after the publication date of the Notice.
CMS will provide additional information in the near future with respect to the date by which changes would have to be submitted in order to be reflected in the initial downloadable file. CMS understands that the health care industry is in urgent need of the FOIA-disclosable NPPES health care provider data; however, CMS believes it is in the best interests of the industry, and the health care providers in particular, that the NPPES data we will be disclosing be as accurate as possible.
Paper Attachments for Medicare Claims.
Effective July 1, 2007 Empire Medicare (NGS) Part B has indicated it will no longer accept paper attachments for electronic claims prior to submission of the claims. Claims that require supporting documentation should be submitted electronically. When the claim is received for processing, if documentation is required for adjudication of that claim, Medicare will send an automatic request to the provider of service requesting additional documentation. The provider has 45 days to submit the information to Medicare. We expect that these letters will come direct to each client which you will then need to forward to CPB as soon as possible so that we do not miss the 45 day deadline.
In the past, Medicare allows us to fax documentation to them seven days in advance which they would then match to the electronic claim.
June 2007
NPI #’s – A CASH FLOW ISSUE IN JUNE ?
The Centers for Medicare & Medicaid Services (CMS) announced that it is implementing a contingency plan for covered entities (other than small health plans) who will not meet the May 23, 2007, deadline for compliance with the National Provider Identifier (NPI) regulations under HIPAA. CMS will not enforce the deadline as long as the entity is making progress toward compliance and that cash flow for providers is not adversely affected. This decreases the likelihood of cash flow issues but does not guarantee there will be no problems. Insurers can still implement the requirement to rely only on the NPI # starting May 23rd. Health care providers who are covered entities under HIPAA are required by regulation to update their NPPES data within 30 days of any change.
Part of the contingency plan is that the UPINs can still be used until May 23, 2008 when necessary for payment. This is not a surprise since CMS still has not released the NPI # list needed to replace the UPINs. The data dissemination notice (for NPI #’s) was put on display on May 23rd at 4:00 for CMS officials to review. CMS is supposed to make it available for download as a file in 30 days with NPIs office addresses, practitioner name, and license number (no SSN).
CPB still strongly encourages you to be very frugal with your cash until we see how this progresses thru the end of June.
PQRI
CMS continues to roll out the Physician Quality Reporting Initiative (PQRI). Their latest point is that while there is only a 1.5% bonus starting July 1st, they estimate that within the next few years as much as 30% of your reimbursement could be quality-based. The fee schedule will not be increased – rather there will be 70% as a base fee and 30% for reporting quality measures.
Clinical vignettes are supposed to be available in June. CPB is able to submit the required codes if you elect to participate. You will need to select which codes you will use, modify your charge forms, understand when to use modifiers, and let us know so we can load the codes you select. We can assist if you are interested.
CERT Reviews
In May, many of our physician clients received a “Comparative Distribution Report” from the CMS CERT (Comprehensive Error Rate Testing) Program indicating an "alarming increase in errors on the claims reviewed in the... New Jersey region." Specifically they looked at the Subsequent Hospital Visit codes (99231-99233).
If you have specific questions, please call Rich. Even if your distribution is similar to the overall groups, it will be important to ensure that your documentation meets the requirements for each E&M level of service. CERT audits that find upcoding can result in large monetary refunds to CMS in some cases and even removal from the Medicare program for more serious offenses. We strongly advise not taking this lightly.
Billing Medicare for Digital Rectal Exam (DRE) & an E&M Code
Billing the G0102 (digital rectal exam) for a Medicare patient and an office visit on the same day results in only the E&M code being paid. The G0102 is bundled by Medicare into the E&M code. A modifier is not allowed.
Revised Horizon Fee Schedule
As you may know, last month Horizon sent a letter indicating that effective July 1, 2007 they were going to update their HMO and PPO fee schedules based on the 2007 CMS fee schedule and begin to reimburse procedures based on a site of service differential.
On the face of it, it may be positive but being “based-on the 2007 CMS Fee Schedule” can be interpreted many different ways. The CMS FS has some codes that went up – and others that decreased – including E&M codes. Horizon is not likely to be very generous since their high-level employees need to be appropriately paid (often $ millions per year) in order to avoid being "homeless." Okay, I know, that was sarcastic.
The second paragraph refers to the "site of service differential." This simply means that they will use the same logic as Medicare -Horizon will pay more for procedures performed in the office (since you have the cost of overhead, supplies, employees, etc. there) and less for procedures performed in a hospital or other facility setting.
For those who perform no procedures, that part will have no effect on your income. For those who perform procedures in both the office and the hospital (or other facilities), this is likely to decrease your income since they will now pay less for procedures performed in the hospital (or other facilities). However, Horizon has not indicated how they will apply this fee schedule based on their current fee schedule. They could leave the fees for hospitals alone, and increase the office payments (that would be a surprise!). Or more likely, we think, leave the office procedure payments as they are and decrease those paid in the hospital.
The Centers for Medicare & Medicaid Services (CMS) announced that it is implementing a contingency plan for covered entities (other than small health plans) who will not meet the May 23, 2007, deadline for compliance with the National Provider Identifier (NPI) regulations under HIPAA. CMS will not enforce the deadline as long as the entity is making progress toward compliance and that cash flow for providers is not adversely affected. This decreases the likelihood of cash flow issues but does not guarantee there will be no problems. Insurers can still implement the requirement to rely only on the NPI # starting May 23rd. Health care providers who are covered entities under HIPAA are required by regulation to update their NPPES data within 30 days of any change.
Part of the contingency plan is that the UPINs can still be used until May 23, 2008 when necessary for payment. This is not a surprise since CMS still has not released the NPI # list needed to replace the UPINs. The data dissemination notice (for NPI #’s) was put on display on May 23rd at 4:00 for CMS officials to review. CMS is supposed to make it available for download as a file in 30 days with NPIs office addresses, practitioner name, and license number (no SSN).
CPB still strongly encourages you to be very frugal with your cash until we see how this progresses thru the end of June.
PQRI
CMS continues to roll out the Physician Quality Reporting Initiative (PQRI). Their latest point is that while there is only a 1.5% bonus starting July 1st, they estimate that within the next few years as much as 30% of your reimbursement could be quality-based. The fee schedule will not be increased – rather there will be 70% as a base fee and 30% for reporting quality measures.
Clinical vignettes are supposed to be available in June. CPB is able to submit the required codes if you elect to participate. You will need to select which codes you will use, modify your charge forms, understand when to use modifiers, and let us know so we can load the codes you select. We can assist if you are interested.
CERT Reviews
In May, many of our physician clients received a “Comparative Distribution Report” from the CMS CERT (Comprehensive Error Rate Testing) Program indicating an "alarming increase in errors on the claims reviewed in the... New Jersey region." Specifically they looked at the Subsequent Hospital Visit codes (99231-99233).
If you have specific questions, please call Rich. Even if your distribution is similar to the overall groups, it will be important to ensure that your documentation meets the requirements for each E&M level of service. CERT audits that find upcoding can result in large monetary refunds to CMS in some cases and even removal from the Medicare program for more serious offenses. We strongly advise not taking this lightly.
Billing Medicare for Digital Rectal Exam (DRE) & an E&M Code
Billing the G0102 (digital rectal exam) for a Medicare patient and an office visit on the same day results in only the E&M code being paid. The G0102 is bundled by Medicare into the E&M code. A modifier is not allowed.
Revised Horizon Fee Schedule
As you may know, last month Horizon sent a letter indicating that effective July 1, 2007 they were going to update their HMO and PPO fee schedules based on the 2007 CMS fee schedule and begin to reimburse procedures based on a site of service differential.
On the face of it, it may be positive but being “based-on the 2007 CMS Fee Schedule” can be interpreted many different ways. The CMS FS has some codes that went up – and others that decreased – including E&M codes. Horizon is not likely to be very generous since their high-level employees need to be appropriately paid (often $ millions per year) in order to avoid being "homeless." Okay, I know, that was sarcastic.
The second paragraph refers to the "site of service differential." This simply means that they will use the same logic as Medicare -Horizon will pay more for procedures performed in the office (since you have the cost of overhead, supplies, employees, etc. there) and less for procedures performed in a hospital or other facility setting.
For those who perform no procedures, that part will have no effect on your income. For those who perform procedures in both the office and the hospital (or other facilities), this is likely to decrease your income since they will now pay less for procedures performed in the hospital (or other facilities). However, Horizon has not indicated how they will apply this fee schedule based on their current fee schedule. They could leave the fees for hospitals alone, and increase the office payments (that would be a surprise!). Or more likely, we think, leave the office procedure payments as they are and decrease those paid in the hospital.
May 2007
Medicare’s Physician Quality Reporting Initiative (PQRI) Program
Detailed program instructions, educational materials, and supportive tools are posted as they become available on the CMS PQRI Web site at: http://cms.hhs.gov/PQRI . Here are a few key aspects of the program that begins July 1, 2007 and ends December 31, 2007.
Eligible Professionals
1. Medicare physician, as defined in Social Security Act (SSA) section 1861(r):
• Doctor of Medicine
• Doctor of Osteopathy
• Doctor of Podiatric Medicine
• Doctor of Optometry
• Doctor of Oral Surgery
• Doctor of Dental Medicine
• Chiropractor
2. Other practitioners described in SSA section 1842 (b)(18)(C):
• Physician Assistant
• Nurse Practitioner
• Clinical Nurse Specialist
• Certified Registered Nurse Anesthetist
• Certified Nurse Midwife
• Clinical Social Worker
• Clinical Psychologist
• Registered Dietician
• Nutrition Professional
3. Therapists:
• Physical Therapist
• Occupational Therapist
• Qualified Speech Language Pathologist
All Medicare enrolled professionals in these categories are eligible to participate in the 2007 PQRI, regardless of whether the professional has signed a Medicare participation agreement to accept assignment on all claims.
Payment for Reporting
Participating eligible professionals who successfully report as prescribed by TRHCA Section 101 may earn a 1.5% percent bonus, subject to the cap. The potential 1.5 percent bonus will be based on allowed charges for covered professional services:
Furnished during the reporting period of July 1 through December 31, 2007,
Received into the CMS National Claims History (NCH) file by February 29, 2008, and
Paid under the Medicare Physician Fee Schedule.
The bonus will apply to allowed charges for all covered professional services, not just those charges associated with reported quality measures. The term “allowed charges” refers to total charges, including the beneficiary deductible and co-payment, not just the 80 percent paid by Medicare or the portion covered by Medicare where Medicare is the secondary payer. So if you were paid $50,000 by Medicare during the 6 month period you could earn up to $750 extra.
Feel free to call Rich with any questions.
If you plan to participate in this incentive program please notify CPB ASAP so we can begin to load the Quality codes into your data set. We will also need to discuss how you will report these codes on your charge forms.
Detailed program instructions, educational materials, and supportive tools are posted as they become available on the CMS PQRI Web site at: http://cms.hhs.gov/PQRI . Here are a few key aspects of the program that begins July 1, 2007 and ends December 31, 2007.
Eligible Professionals
1. Medicare physician, as defined in Social Security Act (SSA) section 1861(r):
• Doctor of Medicine
• Doctor of Osteopathy
• Doctor of Podiatric Medicine
• Doctor of Optometry
• Doctor of Oral Surgery
• Doctor of Dental Medicine
• Chiropractor
2. Other practitioners described in SSA section 1842 (b)(18)(C):
• Physician Assistant
• Nurse Practitioner
• Clinical Nurse Specialist
• Certified Registered Nurse Anesthetist
• Certified Nurse Midwife
• Clinical Social Worker
• Clinical Psychologist
• Registered Dietician
• Nutrition Professional
3. Therapists:
• Physical Therapist
• Occupational Therapist
• Qualified Speech Language Pathologist
All Medicare enrolled professionals in these categories are eligible to participate in the 2007 PQRI, regardless of whether the professional has signed a Medicare participation agreement to accept assignment on all claims.
Payment for Reporting
Participating eligible professionals who successfully report as prescribed by TRHCA Section 101 may earn a 1.5% percent bonus, subject to the cap. The potential 1.5 percent bonus will be based on allowed charges for covered professional services:
Furnished during the reporting period of July 1 through December 31, 2007,
Received into the CMS National Claims History (NCH) file by February 29, 2008, and
Paid under the Medicare Physician Fee Schedule.
The bonus will apply to allowed charges for all covered professional services, not just those charges associated with reported quality measures. The term “allowed charges” refers to total charges, including the beneficiary deductible and co-payment, not just the 80 percent paid by Medicare or the portion covered by Medicare where Medicare is the secondary payer. So if you were paid $50,000 by Medicare during the 6 month period you could earn up to $750 extra.
Feel free to call Rich with any questions.
If you plan to participate in this incentive program please notify CPB ASAP so we can begin to load the Quality codes into your data set. We will also need to discuss how you will report these codes on your charge forms.
April 2007
NPI #’s – A CASH FLOW ISSUE IN JUNE ?
Just as we are getting past the cash flow slow-down due to the annual deductibles another looms on May 23rd. As you probably know by now, NPI #’s are required for payment on and after May 23rd.
CPB strongly encourages you to be very frugal with your cash until we see how this conversion progresses thru the end of June.
We have also filed the #s with various insurers as we are aware of their needs. The following insurers have received your NPI #’s:
Aetna
AmeriGroup
AmeriHealth
AtlantiCare
GHI
HealthNet
Health Partners
Horizon Blue Shield
Operating Engineers 835
Unicare
United Healthcare (3/20/07 call received that all clients had been set up).
NJ Medicaid said it is getting them from the electronic files when we send claims - which we suspect other insurers are doing also.
We have not seen a request from any other insurers. If you have requests from others please send them to CPB ASAP so we can handle.
In January CPB began sending NPI #’s for all providers without any problem. In early March CPB began sending NPI #’s for:
1. Referring physicians
2. Office locations
3. Facilities (hospitals, nursing homes, etc.) locations.
So far no problems have been found on these either.
We are still being told that the dissemination notice allowing for public availability of the NPI #’s will be released "soon" by HHS. This is critically important as they will be required on May 23rd for referring physicians (in place of UPINs). Thousands of these need to be loaded into billing systems nationwide so the electronic file is critical. We will do it manually, if necessary, but HHS says they will make this file available “shortly.”
We are hearing that there will be a contingency plan put in place prior to May 23rd. All entities required to use or accept the NPI will continue to be expected to be ready to use the NPI; however, CMS recognizes that the system will not be ready to go by the 23rd. If the contingency plan exists it has not been released yet. Stay tuned.
Billing for Medications
Effective April 1, 2007 we will be required to send the NDC (National Drug Code) 11 digit # to get paid for medications. NJ Medicaid is the only insurer we are aware that wants it now but suspect others will follow. If you receive anything on this from insurers please be sure to forward it to us ASAP. The NDC # is specific to:
o Each medication
o Dosage, and
o Manufacturer / labeler.
Which means we will need that information on each charge slip in order to select the correct NDC #. We do have that chart, of course, and will select with the above information.
Just as we are getting past the cash flow slow-down due to the annual deductibles another looms on May 23rd. As you probably know by now, NPI #’s are required for payment on and after May 23rd.
CPB strongly encourages you to be very frugal with your cash until we see how this conversion progresses thru the end of June.
We have also filed the #s with various insurers as we are aware of their needs. The following insurers have received your NPI #’s:
Aetna
AmeriGroup
AmeriHealth
AtlantiCare
GHI
HealthNet
Health Partners
Horizon Blue Shield
Operating Engineers 835
Unicare
United Healthcare (3/20/07 call received that all clients had been set up).
NJ Medicaid said it is getting them from the electronic files when we send claims - which we suspect other insurers are doing also.
We have not seen a request from any other insurers. If you have requests from others please send them to CPB ASAP so we can handle.
In January CPB began sending NPI #’s for all providers without any problem. In early March CPB began sending NPI #’s for:
1. Referring physicians
2. Office locations
3. Facilities (hospitals, nursing homes, etc.) locations.
So far no problems have been found on these either.
We are still being told that the dissemination notice allowing for public availability of the NPI #’s will be released "soon" by HHS. This is critically important as they will be required on May 23rd for referring physicians (in place of UPINs). Thousands of these need to be loaded into billing systems nationwide so the electronic file is critical. We will do it manually, if necessary, but HHS says they will make this file available “shortly.”
We are hearing that there will be a contingency plan put in place prior to May 23rd. All entities required to use or accept the NPI will continue to be expected to be ready to use the NPI; however, CMS recognizes that the system will not be ready to go by the 23rd. If the contingency plan exists it has not been released yet. Stay tuned.
Billing for Medications
Effective April 1, 2007 we will be required to send the NDC (National Drug Code) 11 digit # to get paid for medications. NJ Medicaid is the only insurer we are aware that wants it now but suspect others will follow. If you receive anything on this from insurers please be sure to forward it to us ASAP. The NDC # is specific to:
o Each medication
o Dosage, and
o Manufacturer / labeler.
Which means we will need that information on each charge slip in order to select the correct NDC #. We do have that chart, of course, and will select with the above information.
March 2007
NPI #’s – A FUTURE CASH FLOW ISSUE ?
Just as we are about to get past the cash flow slow-down due to the annual deductibles another looms on May 23rd. As you probably know by now, NPI #’s are required for payment on and after May 23rd. Providers with NPI #’s that have not been properly linked by insurers will likely be part of the financial crisis for providers across the nation. Current information is that nearly 50% of providers have not obtained their NPI # and many who have still need their # linked at every insurance company to get paid.
Even if providers all had their NPI # (which they do not) the government still requires the individual NPI #’s to be used in place of UPINs. But the list of provider NPI #’s has not been made available for adding to referring physician files. It has been promised for over a year!
And we are being told that many software vendors and insurers are not ready to receive and process NPI #’s. Finally, the new HCFA 1500 form that replaces the current form and is required on April 1st, may compound the problem.
We have also filed the #s with various insurers as we are aware of their needs. In many cases they required a copy of the actual letter giving the NPI # sent by NPPES. For those clients that provided that form to CPB you were included with those insurers that required it.
CPB & its software vendor are ready and have successfully tested as far as insurers have allowed. All CPB clients have their NPI #s and those #’s have been sent on claim submissions since early January. Even tho CPB is ready those insurers who are not may not pay timely. If you have not signed up for electronic fund transfer (EFT) may want to seriously consider doing so as it will facilitate payments better than paper checks.
CPB strongly encourages you to be very frugal with your cash until we see how this conversion progresses thru June.
Date of Birth Needs to Be On All Charge Forms
The patient’s date of birth (DOB) is an important item of information on Charge forms especially for patients with the same or similar names in your practice. DOBs are also used by our staff for HIPAA Privacy purposes to confirm the identity of all patients prior to entering charges.
United Healthcare – Oops!
Due to a question about our United Healthcare article last month we contacted Wendy Licorich (sp?), South Jersey's Local Network Account Representative with United Healthcare. United Healthcare allows one Initial Inpatient Consultation per consultant (provider), per patient confinement. Any additional visits by that provider/consultant must be billed as subsequent hospital care – (codes 99231-99233). She did apologize for the unclear wording as it did prompt many calls.
NJ Medicaid Inpatient Consults
We recently clarified with NJ Medicaid how they will handle inpatient consultations. They stated that a provider is allowed to perform 1 inpatient consult per 335 “rolling” days (not 365) per patient regardless of whether the patient receives inpatient consults from other providers during that time frame. In other words, if a provider performs an inpatient consultation & the patient also has another inpatient consultation performed by another provider, it is no longer a first in - first paid situation. Both providers are eligible for payment as long as they have not performed another inpatient consult for the same patient during the previous 335 days.
One inpatient consultation per patient, per individual provider, during the past 335 days.
Just as we are about to get past the cash flow slow-down due to the annual deductibles another looms on May 23rd. As you probably know by now, NPI #’s are required for payment on and after May 23rd. Providers with NPI #’s that have not been properly linked by insurers will likely be part of the financial crisis for providers across the nation. Current information is that nearly 50% of providers have not obtained their NPI # and many who have still need their # linked at every insurance company to get paid.
Even if providers all had their NPI # (which they do not) the government still requires the individual NPI #’s to be used in place of UPINs. But the list of provider NPI #’s has not been made available for adding to referring physician files. It has been promised for over a year!
And we are being told that many software vendors and insurers are not ready to receive and process NPI #’s. Finally, the new HCFA 1500 form that replaces the current form and is required on April 1st, may compound the problem.
We have also filed the #s with various insurers as we are aware of their needs. In many cases they required a copy of the actual letter giving the NPI # sent by NPPES. For those clients that provided that form to CPB you were included with those insurers that required it.
CPB & its software vendor are ready and have successfully tested as far as insurers have allowed. All CPB clients have their NPI #s and those #’s have been sent on claim submissions since early January. Even tho CPB is ready those insurers who are not may not pay timely. If you have not signed up for electronic fund transfer (EFT) may want to seriously consider doing so as it will facilitate payments better than paper checks.
CPB strongly encourages you to be very frugal with your cash until we see how this conversion progresses thru June.
Date of Birth Needs to Be On All Charge Forms
The patient’s date of birth (DOB) is an important item of information on Charge forms especially for patients with the same or similar names in your practice. DOBs are also used by our staff for HIPAA Privacy purposes to confirm the identity of all patients prior to entering charges.
United Healthcare – Oops!
Due to a question about our United Healthcare article last month we contacted Wendy Licorich (sp?), South Jersey's Local Network Account Representative with United Healthcare. United Healthcare allows one Initial Inpatient Consultation per consultant (provider), per patient confinement. Any additional visits by that provider/consultant must be billed as subsequent hospital care – (codes 99231-99233). She did apologize for the unclear wording as it did prompt many calls.
NJ Medicaid Inpatient Consults
We recently clarified with NJ Medicaid how they will handle inpatient consultations. They stated that a provider is allowed to perform 1 inpatient consult per 335 “rolling” days (not 365) per patient regardless of whether the patient receives inpatient consults from other providers during that time frame. In other words, if a provider performs an inpatient consultation & the patient also has another inpatient consultation performed by another provider, it is no longer a first in - first paid situation. Both providers are eligible for payment as long as they have not performed another inpatient consult for the same patient during the previous 335 days.
One inpatient consultation per patient, per individual provider, during the past 335 days.
February 2007
HMO, PPO & OTHER MANAGED CARE AGREEMENTS
We occasionally hear providers express concern that they are not being paid well enough by a particular insurance company (OK – usually “companies”!). Practicing medicine is one profession, doing the business of medicine is another.
One of the most economically challenging business arrangements is the solo practice who negotiates on their own. Often clients are amazed at what they have agreed to do in participation contracts and what they are actually paid for – assuming they are able to find the agreements!
You should periodically review all of your health plan arrangements. If you cannot find your copy of the agreement, contact them for a copy and get the renewal date. If there is no renewal date, contact the insurance representative in writing to start the renegotiation process. Plans should be reviewed at least every 3 years. When it's time to renegotiate ask in advance for a copy of the current fee schedule (needed to compare with other plans) and you may want to get professional help to ensure you are treated fairly. CPB is very familiar with the plans in your area and has the expertise to provide this consulting service.
Things to consider:
-Renegotiate unfair contract arrangements,
-Work around the low payments by designing better office efficiency,
-Drop plans that pay poorly when you can replace them with higher paying plans and have a full patient schedule each day.
2007 Medicare PHYSICAL THERAPY CAP
Beginning on January 1, 2007, the annual limit on the Medicare Allowed Amount for outpatient physical therapy and speech-language pathology combined is $1780; the limit for occupational therapy is $1780.
HIPAA PRIVACY & SECURITY
Just a reminder, if you have questions about HIPAA Privacy or Security issues feel free to call or have your staff give us a call. If you need annual training for your staff to meet Compliance requirements, we have slide programs to meet that need.
Zostavax ® vaccine
From Empire Medicare:
“The Zostavax ® vaccine for prevention of shingles (herpes zoster) is excluded from Medicare coverage. Medicare manual instructions [ Medicare Benefits Manual (Pub 100-02), Chapter 15, Section 50.4.4.2 – Immunizations ] (see below) prohibit coverage unless the beneficiary is at risk directly related to exposure to a pathogen. In the absence of an immunocompromised state, beneficiaries are not at direct risk for developing herpes zoster. In an immunocompromised state, the vaccine is contraindicated and should not be administered. In 2007, the administration of this vaccination can be billed to the local carrier with the HCPCS code G0377 which is the equivalent of CPT 90471. Please note in Item 19 of the CMS-1500 claim or the electronic media claims (EMC) equivalent that you have administered Zostavax.”
Medicare DIAGNOSES
Medicare announced that effective for claims processed July 1, 2007 and later the Part B standard systems and the carrier claims processing systems will capture and process up to eight diagnosis codes on all of your claims (both paper and electronic). Accordingly, starting with July 1st processing we encourage all providers to begin sending as many diagnoses as appropriate (up to 8) that demonstrate the medical conditions the patient is being seen for that day. The increased number will help to show the wider picture of a patient’s medical complexity to justify various levels of E&M codes.
United Healthcare (UHC)
UHC announced 2 new policies affecting providers:
Only 1 initial inpatient consult (hospital & nursing home) will be paid per admission for the same patient. Thus, whenever possible be sure to get yours to CPB quickly. Feel free to fax the hospital card and indicate on the card that the insurance is “UHC” and CPB will process it immediately.
“Seven new reimbursement policies will become effective in second quarter of 2007. These policies will define when specific services are reimbursable based on ICD-9 diagnosis codes(s) reported. The policies were developed by first identifying areas of convergence across the Centers for Medicare and Medicaid Services (CMS) Local Carrier Determinations (LCDs) on each topic. A coding matrix of CPT and ICD-9 diagnosis codes based upon the LCD policies was then submitted to various specialty societies for comment. A list of applicable ICD-9 diagnosis codes for each of these policies.” CPB has a copy of these new policies.
We occasionally hear providers express concern that they are not being paid well enough by a particular insurance company (OK – usually “companies”!). Practicing medicine is one profession, doing the business of medicine is another.
One of the most economically challenging business arrangements is the solo practice who negotiates on their own. Often clients are amazed at what they have agreed to do in participation contracts and what they are actually paid for – assuming they are able to find the agreements!
You should periodically review all of your health plan arrangements. If you cannot find your copy of the agreement, contact them for a copy and get the renewal date. If there is no renewal date, contact the insurance representative in writing to start the renegotiation process. Plans should be reviewed at least every 3 years. When it's time to renegotiate ask in advance for a copy of the current fee schedule (needed to compare with other plans) and you may want to get professional help to ensure you are treated fairly. CPB is very familiar with the plans in your area and has the expertise to provide this consulting service.
Things to consider:
-Renegotiate unfair contract arrangements,
-Work around the low payments by designing better office efficiency,
-Drop plans that pay poorly when you can replace them with higher paying plans and have a full patient schedule each day.
2007 Medicare PHYSICAL THERAPY CAP
Beginning on January 1, 2007, the annual limit on the Medicare Allowed Amount for outpatient physical therapy and speech-language pathology combined is $1780; the limit for occupational therapy is $1780.
HIPAA PRIVACY & SECURITY
Just a reminder, if you have questions about HIPAA Privacy or Security issues feel free to call or have your staff give us a call. If you need annual training for your staff to meet Compliance requirements, we have slide programs to meet that need.
Zostavax ® vaccine
From Empire Medicare:
“The Zostavax ® vaccine for prevention of shingles (herpes zoster) is excluded from Medicare coverage. Medicare manual instructions [ Medicare Benefits Manual (Pub 100-02), Chapter 15, Section 50.4.4.2 – Immunizations ] (see below) prohibit coverage unless the beneficiary is at risk directly related to exposure to a pathogen. In the absence of an immunocompromised state, beneficiaries are not at direct risk for developing herpes zoster. In an immunocompromised state, the vaccine is contraindicated and should not be administered. In 2007, the administration of this vaccination can be billed to the local carrier with the HCPCS code G0377 which is the equivalent of CPT 90471. Please note in Item 19 of the CMS-1500 claim or the electronic media claims (EMC) equivalent that you have administered Zostavax.”
Medicare DIAGNOSES
Medicare announced that effective for claims processed July 1, 2007 and later the Part B standard systems and the carrier claims processing systems will capture and process up to eight diagnosis codes on all of your claims (both paper and electronic). Accordingly, starting with July 1st processing we encourage all providers to begin sending as many diagnoses as appropriate (up to 8) that demonstrate the medical conditions the patient is being seen for that day. The increased number will help to show the wider picture of a patient’s medical complexity to justify various levels of E&M codes.
United Healthcare (UHC)
UHC announced 2 new policies affecting providers:
Only 1 initial inpatient consult (hospital & nursing home) will be paid per admission for the same patient. Thus, whenever possible be sure to get yours to CPB quickly. Feel free to fax the hospital card and indicate on the card that the insurance is “UHC” and CPB will process it immediately.
“Seven new reimbursement policies will become effective in second quarter of 2007. These policies will define when specific services are reimbursable based on ICD-9 diagnosis codes(s) reported. The policies were developed by first identifying areas of convergence across the Centers for Medicare and Medicaid Services (CMS) Local Carrier Determinations (LCDs) on each topic. A coding matrix of CPT and ICD-9 diagnosis codes based upon the LCD policies was then submitted to various specialty societies for comment. A list of applicable ICD-9 diagnosis codes for each of these policies.” CPB has a copy of these new policies.
January 2007
A FEW REMINDERS
· The new Medicaid ID cards have a CCN # listed. This is not the Medicaid ID# needed to bill with. To ensure the patient is covered Medicaid requires you to follow their procedure to contact them and obtain their Medicaid #.
· Make sure when a patient is filling out the Patient Information form that they indicate whether the charges are related to an auto accident or Worker's Comp injury. If so the date of the accident/injury is required by insurers. Not receiving this information can significantly delay payment.
· When updated insurance info is sent, we need to know if this replaces what we have on file or is in addition to what we have on file. If in addition to, then is the new insurance primary or secondary? Also, if the insured is not the patient, insurers require the subscriber's name and DOB.
· Since the New Year is approaching, this may be a good time to ask patients for a current copy of their insurance cards. This, as you know, is vital information.
· The new year is also a good time to review your HMO, PPO and other managed care agreements for the fees you are being paid. If the fees have lagged behind other insurers, it may be a good time to renegotiate them. More details on this next month.
2007 Medicare Fee ScheduleS
Congress has passed a law to keep the Medicare physician fee schedule Conversion Factor the same as 2006 and President Bush has signed it. Ambulance payments are slated for 4.3% increase.
The following is a summary of the compromise agreed to between House and Senate negotiators. To view the entire document, go to:
http://waysandmeans.house.gov/media/pdf/taxdocs/hr6408healthsummary.pdf
Highlights
• Prevents physician payment cuts in 2007 by freezing payment rates for physician services.
• Provides a 1.5 percent bonus-incentive payment to physicians who report on quality measures in 2007.
• Establishes a fund to promote physician payment stability and physician quality initiatives in 2008.
•Provides a one-year extension of the exceptions process established in the Deficit Reduction Act to allow patients to apply for additional physical, occupational, and speech language therapy services if their treatment is expected to exceed the annual cap on therapy services.
2007 PART B DEDUCTIBLE
The Centers for Medicare & Medicaid Services (CMS) announced the Part B annual deductible for 2007 is $131.00 (up from $124 for 2006). Empire Medicare Services, does allow you to call them to find out the patient's deductible status. If you are interested, you can check all Medicare patients that either don't have a secondary insurance, or a secondary insurance that does not pay their deductible. Then you can collect the deductible on the day of service.
If a patient questions you, inform him/her that as of that day, they've met $xx.xx of their deductible. If the patient pays you on the day of service, be sure to let CPB know the amount paid on the Charge form so we can post it on the claim that we submit electronically. If, by chance, another provider’s claim gets there before ours, inform the patient that they will receive a check directly from Medicare for the amount overpaid since their payment to you will have been reported. You can explain that it saves having to send a bill to the patient, and, in the event, that you get paid twice (Medicare also pays you), you will send a refund check to the patient.
NPI NUMBERS
As of October, CMS had issued slightly fewer than 1.3 million NPIs, or about 50% of the total 2.3 million CMS expects to issue. With the May 23, 2007 deadline looming, many in the healthcare community worry that there will not be enough time to test all of the transactions requiring NPI #’s.
CPB has received NPI #’s for all of our clients which puts you in good shape and is working with various insurers to send them with claims. Empire Medicare is still testing their software.
Insurers and other providers are now beginning to ask for both individual & Group NPI #’s. Please be sure to either respond to insurer requests (& copy CPB) or send all requests to CPB & we will do it (no cost). If you respond it is important that CPB receive a copy so we can add it to your file for reference if payment problems develop later.
If other providers call and ask for your NPI # to replace your UPIN (this is correct), they only need your individual NPI # not your group #. The Group # is only needed for billing your claims.
HOSPICE & HOME HEALTH PATIENTS – PT/OT & DME PATIENTS
Medicare Hospice and Home Health patients have restrictions on payments to providers because Medicare pays them under Part A to provide a significant amount of care to those patients. You MUST be sure to ask the patient if they are under the care of one of those programs BEFORE treating them. If so, be sure to get the date care started/ended. Medicare will not make any payment to you if they are or will take the money back later if paid in error – so you will be providing the care for FREE !
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