Labor Day Holiday
CPB will be closed on Monday, September 7th to celebrate the holiday.
RED FLAG RULES DELAYED AGAIN
The FTC announced on July 29th that the Red Flag Rules will be delayed again with a new date of November 1, 2009. Per the FTC announcement, their staff will “redouble its efforts to educate them (small businesses) about compliance with the "Red Flags" Rule and ease compliance by providing additional resources and guidance to clarify whether businesses are covered by the Rule and what they must do to comply."
COLLECTING DEDUCTIBLES, COPAYS & COINSURANCES
A report that was released on June 23 by the Dept. of Health and Human Services found the annual cost of co-pays and deductibles for those with employer health care plans increased 21% from $1,260 in 2001 to $1,522 in 2006. Management consulting firm McKinsey & Co. in 2007 issued a report that said doctors collect only about half of the balance due from patients which translates to $14 billion to $30 billion in bad debt annually.
Providers traditionally receive most of their income from insurers, but in the past few years there has a real shift for patients to higher deductibles and copays. This makes collecting patient balances at the time of care more important as even insured patients are increasingly on the hook for an ever-larger share of costs. Clearly, successful practices need to find ways to collect more at the time of service.
Not collecting on the days of service is not good because the odds of providers getting full payment go down the moment the patient leaves the office. For big ticket items – either high cost services or high frequency services – collections issues can be avoided by verification of benefits prior to the visit and requiring payment before services are provided.
The key is to train patients to pay this money and staff to ask for it prior to seeing the patient. Some practices even remind patients of the amount of payment owed during the appointment reminder phone call. A good strategy is to educate patients that these are legitimate charges which are not only not covered by their insurance, but health plans and state and federal insurance laws require that copays, deductible, and co-insurance be collected as a disincentive to over-utilizing healthcare services.
HITECH & Electronic Health Records (EHR) Payments
Medicare will pay up to $44,000 per physician for the “meaningful use” of Electronic Health Records. Medicaid will pay up to $65,000 per eligible provider. The ARRA references the Medicare definition of physician found in Section 1861(r) of the Social Security Act. This includes MD, DO, Dentist, podiatrist, optometry and chiropractor.
NPs & CNMs are eligible for Medicaid incentives but not Medicare incentives. PAs are only eligible to the extent they work in Rural Health Clinics “led” by the PA. In order to receive the Medicaid incentive payment, the 30% of patient visits must be with Medicaid patients. Thus, even though the Medicaid incentives are higher, most physicians will not be able to meet the 30% threshold. Pediatricians can receive a lower Medicaid incentive payment by achieving a 20% Medicaid Threshold.
The incentive program specifically excludes “hospital based” physicians such as emergency medicine, pathology and anesthesiology. The secretary is authorized to define other physician specialists as hospital-based. The rationale behind this exclusion is that these physicians will use a system bought by the hospital and not incur any direct or indirect costs associated with the purchase or use of the EHR.
These incentives are available for each "provider" in a group practice. For example two physicians and three PAs, would be eligible for up to $65k EACH under the Medicaid plan. As written, the incentive payment is available for each “eligible professional”. Therefore the amount of the incentive is calculated on a per provider basis rather than per organization.
One final note, providers who qualify for both can collect from either Medicare or Medicaid, but not both.
MORE EHR
Several physician clients have expressed an interest in starting to look at EHR programs. We have the names of 4 promising programs, one of which has some interesting features. If you are interested in becoming part of the demos, let me know.
Observation Codes
Recently hospitals have begun to push the use of admitting patients to Observation Status, particularly for Medicare patients. This has resulted in confusion with how the billing is to be done in accordance with CMS policy. According to Highmark ““When a physician decides to place a patient in “hospital observation” status, that patient has not formally been admitted to the hospital. The physician who placed the patient in "hospital observation," is the only one who may care for the patient during his/her stay in observation, and the only one that may bill hospital observation codes.
In order to bill the initial observation care codes, 99218-99220, the following must be created and maintained:
· A medical observation record for the patient which contains dated and timed physician’s admitting orders regarding the care the patient is to receive while in observation;
· Nursing notes; and
· Progress notes prepared by the physician while the patient was in observation status.
If applicable, this record is in addition to any record prepared as a result of an emergency department or outpatient clinic encounter.
When payment is made for an initial observation care code, it is for all the care rendered by the physician on the date patient was placed in observation. All other physicians who see the patient in observation must bill the outpatient/office visit codes (99201-99205, 99211-99215), or outpatient consultation codes (99241-99245), for the services they provide to that patient.
For example, if an internist admits a patient to observation and asks an allergist for a consultation on patient's condition, only the internist may bill the initial observation care code. The allergist must bill using the outpatient consultation code that best represents the services provided. The allergist cannot bill inpatient consultation because the patient was not admitted as a hospital patient.”
For additional information, see the CMS Intranet Only Manual PUB 100-4, Chapter 12, Section 30.6.8 - Payment for Hospital Observation Codes (Codes 99217-9220).
Use of 99211 when doing INR’s
Highmark Medicare Services Position on the Necessity of E/M Services Submitted as a Component Service of Anti-Coagulation Management.
July 27, 2009
Highmark Medicare Services continues to experience both questions and confusion regarding the billing of 99211, (office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician), in addition to the laboratory blood draws for warfarin management.
An evaluation and management (E/M) service (99211) would be allowable if it is determined that the patient's medication needs adjustment, the INR is not therapeutic, or if the patient has symptoms that need to be addressed.
The billing of an E/M service in addition to obtaining the clinical specimen (phlebotomy or fingerstick) is not medically reasonable and necessary if the following conditions are met:
If the INR is within the therapeutic range, and
1. the documentation does not support a need for adjustment of warfarin dosage, or
2. the documentation does not support that the patient is symptomatic, or
3. the documentation does not support the presence of a new medical co-morbidity or dietary change.
Rather, information may be relayed to the beneficiary telephonically, and there is no need for a face-to-face E/M service.
In this clinical setting, the medical necessity of a unique clinical service may be predicated upon the clinical circumstances of a previous visit, i.e., a significantly sub or supra-therapeutic INR necessitates quick follow-up. Use of a flow sheet and established protocol helps to provide both good patient care and documentation of medical necessity in these cases. Documentation of the services provided by the physician or nurse, discussion of symptoms, side effects, patient observations, etc. are considered supportive of the 99211 service.
The American Heart Association/American College of Cardiology Foundation Guide to Warfarin Therapy suggests that the INR be checked daily until the therapeutic range has been reached and sustained for two consecutive days, then 2 or 3 times weekly for 1 to 2 weeks, and then less often based on stability of results. Once the INR becomes stable, the frequency of testing can be reduced to intervals as long as 4 weeks. Highmark Medicare Services expects to see the educational component of anticoagulation management reflected in the use of 99211 in the early post-initiation visits, and less frequently as the stable target of anti-coagulation is reached. Two cited European studies make a strong case for Patient Self-Testing and Management, in which case, the patient education would be documented within the appropriate level of an established E/M service, where time/counseling service guidelines would apply.
Physician Signature Requirements for Diagnostic Testing
July 31, 2009
Medicare has identified a recent increase in the number of CERT errors attributed to the lack of physician orders for diagnostic tests. A diagnostic test includes all diagnostic x-ray tests, all diagnostic laboratory tests, and other diagnostic tests furnished to a beneficiary.
An “order” is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y). An order may be delivered via the following forms of communication:
· A written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility;
· A telephone call by the treating physician/practitioner or his/her office to the testing facility; and
· An electronic mail by the treating physician/practitioner or his/her office to the testing facility.
If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary’s medical records.
NOTE: While a physician order is not required to be signed on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services; the physician must clearly document, in the medical record, his or her intent that the test be performed.
Failure to do so may result in denial of the service which may subsequently lead to the patient being responsible for payment. Furthermore, the absence of a signature on an order may lead to a medical record audit of the ordering physician to verify that the physician's intent is indeed documented as directed in the regulation. Therefore, HMS recommends that physicians provide their signature on all orders for diagnostic and laboratory services.Make sure that your office, billing, and/or laboratory staffs are aware of this updated guidance regarding the signature requirement for diagnostic tests and are complying with this regulation. Also, note that in keeping with standard auditing principles, items such as signatures, attestations, and other addendums which are added to the medical record after the date of the Additional Documentation Request (ADR) letter will generally not be considered as acceptable documentation. Furthermore, providers who exhibit a pattern of adding documentation after ADR requests could be subject to corrective action.
If you receive a request for medical records from the CERT contractor or Highmark Medicare Services, it is critical that the signed physician order for all diagnostic tests be included. Without the order, the services could be determined to be medically unnecessary and the claim will be denied.
You can find additional information on the CMS Internet Only Manual:
PUB 100-2, Chapter 15, Section 80.6.1.
Physician Signature Requirements for Diagnostic Testing
July 31, 2009
Medicare has identified a recent increase in the number of CERT errors attributed to the lack of physician orders for diagnostic tests. A diagnostic test includes all diagnostic x-ray tests, all diagnostic laboratory tests, and other diagnostic tests furnished to a beneficiary.
An “order” is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y). An order may be delivered via the following forms of communication:
· A written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility;
· A telephone call by the treating physician/practitioner or his/her office to the testing facility; and
· An electronic mail by the treating physician/practitioner or his/her office to the testing facility.
If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary’s medical records.
NOTE: While a physician order is not required to be signed on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services; the physician must clearly document, in the medical record, his or her intent that the test be performed.
Failure to do so may result in denial of the service which may subsequently lead to the patient being responsible for payment. Furthermore, the absence of a signature on an order may lead to a medical record audit of the ordering physician to verify that the physician's intent is indeed documented as directed in the regulation. Therefore, HMS recommends that physicians provide their signature on all orders for diagnostic and laboratory services. Make sure that your office, billing, and/or laboratory staffs are aware of this updated guidance regarding the signature requirement for diagnostic tests and are complying with this regulation. Also, note that in keeping with standard auditing principles, items such as signatures, attestations, and other addendums which are added to the medical record after the date of the Additional Documentation Request (ADR) letter will generally not be considered as acceptable documentation. Furthermore, providers who exhibit a pattern of adding documentation after ADR requests could be subject to corrective action.
If you receive a request for medical records from the CERT contractor or Highmark Medicare Services, it is critical that the signed physician order for all diagnostic tests be included. Without the order, the services could be determined to be medically unnecessary and the claim will be denied. You can find additional information on the CMS Internet Only Manual:
PUB 100-2, Chapter 15, Section 80.6.1.
