Medicare Provider Revalidation
“All providers and suppliers who enrolled in the Medicare program prior to Friday, March 25, 2011, will be required to submit their enrollment information so they can be revalidated under new risk screening criteria required by the Affordable Care Act (section 6401a). Providers/suppliers who enrolled on or after Friday, March 25, 2011 have already been subject to this screening, and need not revalidate at this time.Do NOT submit your revalidation until you are notified to do so by your MAC. You will receive a notice to revalidate between now and March 2015.” CMS extended the time frame early in November from 2013 to March 2015 and physicians will be among the last required to revalidate.Be advised that you/we only have 60 days from the date of the letter to submit the revalidation application – and non-physicians will be charged $505. Failure to submit within 60 days results in stopping your Medicare payments. Payment can be made online and is required before the application can be done on PECOS.
PATIENT STATEMENTS
Due to phenomenal growth, CMB has now reached the point that we began to send patient statements twice a month in order to spread patient calls out and further improve cash flow.
2012 Medicare FEE SCHEDULE
SGR Update: Congress has made no progress on legislation to avoid the SGR related 27.4% reduction in the Conversion Factor for Medicare physician fee schedule payments that is slated to take effect on January 1, 2012. You should be prepared for the possibility that Congress will fail to enact even a temporary SGR fix and a significant cut in physician fee schedule payments could occur on January 1.
CMS announced on November 2nd:
“In addition to the SGR related fee schedule adjustment, CMS is also announcing other changes for 2012 as well. Some of the other major changes being adopted in the final rule include:
* CMS is expanding its multiple procedure payment reduction policy to the professional interpretation of advance imaging services to recognize the overlapping activities that go into valuing these services. This policy better recognizes efficiencies that are expected when multiple imaging services are furnished to the same patient, by the same physician or group practice, in the same session on the same day.
* CMS is adopting criteria for a health risk assessment (HRA) to be used in conjunction with Annual Wellness Visits (AWVs), for which coverage began Jan. 1, 2011 under the Affordable Care Act. The HRA is intended to support a systematic approach to patient wellness and to provide the basis for a personalized prevention plan. CMS is increasing AWV payment modestly to reflect the additional office staff time required to administer an HRA to the Medicare population.
* CMS is expanding the list of services that can be furnished through telehealth to include smoking cessation services. CMS is also changing the criteria for adding services to the telehealth list to focus on the clinical benefit of making the service available through telehealth. This change will affect services proposed for the telehealth list beginning in CY 2013.
* CMS is updating or modifying aspects of a number of physician incentive programs including the Physician Quality Reporting System, the ePrescribing Incentive Program and the Electronic Health Records Incentive Program.
The announcement finalizes quality and cost measures that will be used in establishing a new value-based modifier that would adjust physician payments based on whether they are providing higher quality and more efficient care as required by the Patient Protection and Affordable Care Act. The PPACA requires CMS to begin making payment adjustments to certain physicians and physician groups on Jan. 1, 2015, and to apply the modifier to all physicians by Jan. 1, 2017.
* CMS announces that they will implement the third year of a 4-year transition to new practice expense relative value units, based on data from the Physician Practice Information Survey that was adopted in the MPFS CY 2010 final rule.”
ELECTRONIC CLAIMS AND PAYMENTS – 5010 FORMAT
On January 1, 2012 the medical billing industry must begin submitting claims and applying payments using the 5010 version. CPB and our vendor are testing and do not anticipate any problem meeting this deadline.
Friday, December 2, 2011
November 2011
Medicare Provider Revalidation
“All providers and suppliers who enrolled in the Medicare program prior to Friday, March 25, 2011, will be required to submit their enrollment information so they can be revalidated under new risk screening criteria required by the Affordable Care Act (section 6401a). Providers/suppliers who enrolled on or after Friday, March 25, 2011 have already been subject to this screening, and need not revalidate at this time.Do NOT submit your revalidation until you are notified to do so by your MAC. You will receive a notice to revalidate between now and March 2013.”Be advised that you/we only have 60 days from the date of the letter to submit the revalidation application – and non-physicians will be charged $505. Failure to submit within 60 days results in stopping your Medicare payments. Payment can be made online and is required before the application can be done on PECOS.
PROLIA
If you plan to bill Prolia, please let Rich know in advance so we can set up certain bill fields to contain the required data for payment. We will also update your charge form. Until January 1st when a new Prolia specific code will be available, you will bill the unclassified code (we will provide that info to you) plus the regular injection code (not a vaccine code). Since this is specifically used to treat osteoporosis, be sure to “checkmark” one of those diagnosis codes (e.g., 733.0X).
MEDICARE FLU SHOT FEES
Medicare released the Flu vaccine fees for Sept. 1, 2011 – August 31, 2012 on October 5th (great timing!):
Q2035 (Afluria): $11.543
Q2036 (Flulaval): $8.784
Q2037 (Fluvirin): $13.652
Q2038 (Fluzone): $13.306
ABN’s – THEY ARE CHANGING, AGAIN!
A new Medicare Advanced Beneficiary Notice (ABN) format has been released by CMS with an effective date 1/1/12 (just changed to 1/1/12 by CMS on 10/20). If you use an ABN, let Rich know ASAP and we will create an updated version. The 2008 version is not effective after 12/31/11.
BILLING INJECTION CODES 90471 & 90472
If you give 2 or more vaccine injections, you need to use both 90471 & 90472 (1 unit each). If you give 3 vaccine injections, then you would check both 90471 & 90472 and indicate 2 units on the charge form for 90472.
If the injection is for Tetanus for a Medicare patient, Medicare will pay as long as it is not a routine immunization - but we need to know if it is not a routine vaccination so we can bill correctly. We suggest that you indicate “injury” (or whatever is appropriate) on the charge form. We will do the rest. If it is routine and for a Medicare patient, in order to get paid (since it is not covered the patient is responsible) you will need the patient to sign a properly completed ABN.
If you are injecting allergens, use 95115 for 1, or 95117 for 2 or more. In this case, you do not use both codes.
ELECTRONIC CLAIMS AND PAYMENTS – 5010 FORMAT
On January 1, 2012 the medical billing industry must begin submitting claims and applying payments using the 5010 version. CPB and our vendor are testing and do not anticipate any problem meeting this deadline.
“All providers and suppliers who enrolled in the Medicare program prior to Friday, March 25, 2011, will be required to submit their enrollment information so they can be revalidated under new risk screening criteria required by the Affordable Care Act (section 6401a). Providers/suppliers who enrolled on or after Friday, March 25, 2011 have already been subject to this screening, and need not revalidate at this time.Do NOT submit your revalidation until you are notified to do so by your MAC. You will receive a notice to revalidate between now and March 2013.”Be advised that you/we only have 60 days from the date of the letter to submit the revalidation application – and non-physicians will be charged $505. Failure to submit within 60 days results in stopping your Medicare payments. Payment can be made online and is required before the application can be done on PECOS.
PROLIA
If you plan to bill Prolia, please let Rich know in advance so we can set up certain bill fields to contain the required data for payment. We will also update your charge form. Until January 1st when a new Prolia specific code will be available, you will bill the unclassified code (we will provide that info to you) plus the regular injection code (not a vaccine code). Since this is specifically used to treat osteoporosis, be sure to “checkmark” one of those diagnosis codes (e.g., 733.0X).
MEDICARE FLU SHOT FEES
Medicare released the Flu vaccine fees for Sept. 1, 2011 – August 31, 2012 on October 5th (great timing!):
Q2035 (Afluria): $11.543
Q2036 (Flulaval): $8.784
Q2037 (Fluvirin): $13.652
Q2038 (Fluzone): $13.306
ABN’s – THEY ARE CHANGING, AGAIN!
A new Medicare Advanced Beneficiary Notice (ABN) format has been released by CMS with an effective date 1/1/12 (just changed to 1/1/12 by CMS on 10/20). If you use an ABN, let Rich know ASAP and we will create an updated version. The 2008 version is not effective after 12/31/11.
BILLING INJECTION CODES 90471 & 90472
If you give 2 or more vaccine injections, you need to use both 90471 & 90472 (1 unit each). If you give 3 vaccine injections, then you would check both 90471 & 90472 and indicate 2 units on the charge form for 90472.
If the injection is for Tetanus for a Medicare patient, Medicare will pay as long as it is not a routine immunization - but we need to know if it is not a routine vaccination so we can bill correctly. We suggest that you indicate “injury” (or whatever is appropriate) on the charge form. We will do the rest. If it is routine and for a Medicare patient, in order to get paid (since it is not covered the patient is responsible) you will need the patient to sign a properly completed ABN.
If you are injecting allergens, use 95115 for 1, or 95117 for 2 or more. In this case, you do not use both codes.
ELECTRONIC CLAIMS AND PAYMENTS – 5010 FORMAT
On January 1, 2012 the medical billing industry must begin submitting claims and applying payments using the 5010 version. CPB and our vendor are testing and do not anticipate any problem meeting this deadline.
October 2011
ELECTRONIC CLAIMS AND PAYMENTS – 5010 FORMAT
On January 1, 2012 the medical billing industry must begin submitting claims and applying payments using the 5010 version. CPB and our vendor are testing and do not anticipate any problem meeting this deadline.
Medicare EHR Payments
From CMS:
“To qualify as certified EHR technology for the EHR Incentive Programs, an EHR needs to be tested by one of the Office of the National Coordinator for Health Information Technology-Authorized Testing and Certification Bodies (otherwise known as the ONC-ATCBs). If an EHR technology has been certified by an ONC-ATCB, it indicates to EPs and eligible hospitals that it has the capacities necessary to support their efforts to meet meaningful use goals and objectives.
Note that you do not need to already have certified EHR technology in place when you register for the EHR Incentive Programs. However, you will need to have meaningfully used your certified EHR technology to receive your first year Medicare incentive payment.”
MEDICARE FLU SHOT FEES
We have not received an update for Fall 2011. Fees currently are:
Q2035 Afluria vacc $12.398 (Effective May 23, 2011)
Q2036 Flulaval vacc $8.784
Q2037 Fluvirin vacc $13.253
Q2038 Fluzone vacc $12.593
ABN’s – THEY ARE CHANGING, AGAIN!
A new Medicare Advanced Beneficiary Notice (ABN) format has been released by CMS with an effective date 11/1/11. If you use an ABN, let Rich know and we will create an updated version.
On January 1, 2012 the medical billing industry must begin submitting claims and applying payments using the 5010 version. CPB and our vendor are testing and do not anticipate any problem meeting this deadline.
Medicare EHR Payments
From CMS:
“To qualify as certified EHR technology for the EHR Incentive Programs, an EHR needs to be tested by one of the Office of the National Coordinator for Health Information Technology-Authorized Testing and Certification Bodies (otherwise known as the ONC-ATCBs). If an EHR technology has been certified by an ONC-ATCB, it indicates to EPs and eligible hospitals that it has the capacities necessary to support their efforts to meet meaningful use goals and objectives.
Note that you do not need to already have certified EHR technology in place when you register for the EHR Incentive Programs. However, you will need to have meaningfully used your certified EHR technology to receive your first year Medicare incentive payment.”
MEDICARE FLU SHOT FEES
We have not received an update for Fall 2011. Fees currently are:
Q2035 Afluria vacc $12.398 (Effective May 23, 2011)
Q2036 Flulaval vacc $8.784
Q2037 Fluvirin vacc $13.253
Q2038 Fluzone vacc $12.593
ABN’s – THEY ARE CHANGING, AGAIN!
A new Medicare Advanced Beneficiary Notice (ABN) format has been released by CMS with an effective date 11/1/11. If you use an ABN, let Rich know and we will create an updated version.
Thursday, September 1, 2011
September 2011
WorkWell
WorkWell is a Pennsylvania Workman’s Comp Carrier which is expanding into NJ. Their rates look reasonable. They are looking for the following specialties:
Family Practice
Internal Medicine
If you are interested, let me know and I’ll forward additional information to you.
Medicare NEW Patients definition
Effective August 15, 2011, WPS Medicare Part B will turn on an edit that will deny a new patient visit within 3 years of any professional face-to-face service, e.g. other evaluation and management (E/M) or surgery service. WPS Medicare conducted a 30-day data analysis and identified more than 300,000 potential claim payment errors in all WPS claims processing jurisdictions. The identified claims were for a new patient visit billed within 3 years of a surgery procedure performed by the same person or a member of the same group with the same specialty.The Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM), Publication 100-04, Chapter 12, Section 30.6.7 states, "Interpret the phrase "new patient" to mean a patient who has not received any professional services, i.e. E /M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years."The above IOM statement is not new. Please conduct data analysis to determine if you have received payment for a new patient visit following a surgery by the same person or a member of the same group with the same specialty. If so, please refund Medicare. You can use the voluntary refund form from our website:http://www.wpsmedicare.com/j5macpartb/forms/_files/nonmsp_voluntaryform.pdfYou can find more information on E/M services on our website at http://www.wpsmedicare.com/j5macpartb/resources/provider_types/evalandmngmnt.shtml
HORIZON FEE SCHEDULE INCREASE
In a letter dated July 27, 2011 (received by CPB on 8/10/11) Horizon states:
“Effective October 1, 2011, Horizon Blue Cross Blue Shield of New Jersey will base our
managed care and PPO fee schedules primarily on Resource-Based Relative Value Scale
(RBRVS) methodology and the 2011 Centers for Medicare &Medicaid Services (CMS)
fee schedule. Our current fee schedules are based primarily on RBRVS methodology and the
2007 CMS fee schedule.
The impact of basing our fee schedules primarily on RBRVs methodology and the 2011 CMS fee schedule will vary by specialty and services rendered. Reimbursements for specific
services may increase, decrease or remain the same. On average, however, this change will
represent an approximate:
• 6 percent total increase in reimbursement.
• 10 percent increase in reimbursement for Evaluation and Management (E&M) Services.
• II percent increase in maximum per visit reimbursement for physical therapy services.
To obtain a sample of the new fee schedule applicable to your specialty; please e-mail a request to Fee_Requests@HorizonBlue.com or contact your Network Specialist.”
While this sounds good, keep in mind that some specialties have not had an increase for quite a few years. So the above may not even be keeping up with inflation. But it is better than nothing.
Medicare Provider Revalidation
Just announced by Medicare:
“All providers and suppliers who enrolled in the Medicare program prior to Friday, March 25, 2011, will be required to submit their enrollment information so they can be revalidated under new risk screening criteria required by the Affordable Care Act (section 6401a). Providers/suppliers who enrolled on or after Friday, March 25, 2011 have already been subject to this screening, and need not revalidate at this time.Do NOT submit your revalidation until you are notified to do so by your MAC. You will receive a notice to revalidate between now and March 2013.This will allow MACs to process revalidations in a timely fashion and allow providers to take advantage of innovative technologies and streamlined enrollment processes now under development. Updates will be shared with the provider community as these efforts progress.”
ABN’s – THEY ARE CHANGING, AGAIN!
A new ABN format has been released by CMS with an effective date 11/1/11. If you use an ABN, let Rich know and we will create an updated version.
WorkWell is a Pennsylvania Workman’s Comp Carrier which is expanding into NJ. Their rates look reasonable. They are looking for the following specialties:
Family Practice
Internal Medicine
If you are interested, let me know and I’ll forward additional information to you.
Medicare NEW Patients definition
Effective August 15, 2011, WPS Medicare Part B will turn on an edit that will deny a new patient visit within 3 years of any professional face-to-face service, e.g. other evaluation and management (E/M) or surgery service. WPS Medicare conducted a 30-day data analysis and identified more than 300,000 potential claim payment errors in all WPS claims processing jurisdictions. The identified claims were for a new patient visit billed within 3 years of a surgery procedure performed by the same person or a member of the same group with the same specialty.The Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM), Publication 100-04, Chapter 12, Section 30.6.7 states, "Interpret the phrase "new patient" to mean a patient who has not received any professional services, i.e. E /M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years."The above IOM statement is not new. Please conduct data analysis to determine if you have received payment for a new patient visit following a surgery by the same person or a member of the same group with the same specialty. If so, please refund Medicare. You can use the voluntary refund form from our website:http://www.wpsmedicare.com/j5macpartb/forms/_files/nonmsp_voluntaryform.pdfYou can find more information on E/M services on our website at http://www.wpsmedicare.com/j5macpartb/resources/provider_types/evalandmngmnt.shtml
HORIZON FEE SCHEDULE INCREASE
In a letter dated July 27, 2011 (received by CPB on 8/10/11) Horizon states:
“Effective October 1, 2011, Horizon Blue Cross Blue Shield of New Jersey will base our
managed care and PPO fee schedules primarily on Resource-Based Relative Value Scale
(RBRVS) methodology and the 2011 Centers for Medicare &Medicaid Services (CMS)
fee schedule. Our current fee schedules are based primarily on RBRVS methodology and the
2007 CMS fee schedule.
The impact of basing our fee schedules primarily on RBRVs methodology and the 2011 CMS fee schedule will vary by specialty and services rendered. Reimbursements for specific
services may increase, decrease or remain the same. On average, however, this change will
represent an approximate:
• 6 percent total increase in reimbursement.
• 10 percent increase in reimbursement for Evaluation and Management (E&M) Services.
• II percent increase in maximum per visit reimbursement for physical therapy services.
To obtain a sample of the new fee schedule applicable to your specialty; please e-mail a request to Fee_Requests@HorizonBlue.com or contact your Network Specialist.”
While this sounds good, keep in mind that some specialties have not had an increase for quite a few years. So the above may not even be keeping up with inflation. But it is better than nothing.
Medicare Provider Revalidation
Just announced by Medicare:
“All providers and suppliers who enrolled in the Medicare program prior to Friday, March 25, 2011, will be required to submit their enrollment information so they can be revalidated under new risk screening criteria required by the Affordable Care Act (section 6401a). Providers/suppliers who enrolled on or after Friday, March 25, 2011 have already been subject to this screening, and need not revalidate at this time.Do NOT submit your revalidation until you are notified to do so by your MAC. You will receive a notice to revalidate between now and March 2013.This will allow MACs to process revalidations in a timely fashion and allow providers to take advantage of innovative technologies and streamlined enrollment processes now under development. Updates will be shared with the provider community as these efforts progress.”
ABN’s – THEY ARE CHANGING, AGAIN!
A new ABN format has been released by CMS with an effective date 11/1/11. If you use an ABN, let Rich know and we will create an updated version.
Wednesday, August 10, 2011
August 2011
Medicare Annual wellness visits and ekg’s
Medicare does not have a separate CPT code to bill an EKG on the same day as a Medicare Annual Wellness Visit (G0438 & G0439) like they do for an IPPE (G0402). Thus, to bill an EKG with either a G0438 or G0439 you will need one of the “normal” diagnosis indications.
GOOD OFFICE FINANCIAL POLICIES
By 2010, more than 54 percent of large employers offered their employees at least one high-deductible health plan, according to a Rand Corporation survey (http://www.rand.org/pubs/external_publications/EP20110086.html).
Patients are responsible for increasingly larger portions of their medical bills – in fact patients’ financial responsibility is the largest it’s been since medical insurance came onto the scene in the mid-20th Century. Copayments, coinsurance and deductibles have never been higher. We have seen deductibles now as high as $5,000 per year! If you are relying solely on your billing staff to respond to this trend, you won’t be successful. Your patients are your worst payers – and asking them for money long after the fact only results in higher postage costs and accounts receivable. Requiring your front office to perform date-of-service collections is essential for financial success.
Here are seven (7) steps to successfully dealing with today’s reimbursement environment.
Check eligibility 1-2 days before the patient’s appointment. This allows you to confirm the patient is covered, who the insured is, amount of co-pay, deductible, and/or coinsurance. Critical information if you want to be paid. It also spells the difference between charity care and bad debt!
Set expectations. Develop a financial policy to distribute to patients when they arrive & make it available on your website, if you have one. Hang tasteful but clear signage in the front office. Don’t beat around the bush by printing signs that say, “Our Practice Expects You to Pay Your Copayment.” Instead, be direct with signs that read, “Your Insurance Company Requires You to Pay Your Copayment.” Send the message professionally, but make it clear that you expect to receive payment at the time of service. If the patient owes a co-pay, ask for payment prior to seeing the provider, not after.
Know how to ask. There is an art to collections, and a large part is knowing how to ask for money. Instruct your staff to stop asking patients, “Would you like to pay?” Replace that request with “How would you like to pay today?” Be sure to ask for past open patient balances at the same time. As they ask for payment, staff must make eye contact with the patient (or guarantor) and use his/her name during the conversation. Print a statement for all patients at check out that reflects any payments they have made as well as any remaining balance due. Giving these statements to patients at check-out is essentially free (no postage), and it reinforces your expectations of getting paid. It also eliminates the excuse patients so often give to your business office: “I never received a statement.”
Accept all forms of payment. Allow patients to pay by cash, debit or credit card. Personal checks could be an option, but consider using a check verification service if you encounter bad checks. Look at the commission rates on credit card services to make sure you get the best deal possible from card merchants. Don’t hesitate to steer your patients to a particular form of payment. For example, you might get a better rate when patients use debit cards for amounts under $20, but a more favorable rate when patients use credit cards for amounts over $20. Of course, you should not hesitate to accept any form of payment, but it doesn’t hurt to request a particular type of payment depending on which is more advantageous to you. Most patients won’t care one way or another because it is you, not they, who gets charged the commission going to the card processing company.
Consider pre-authorized credit cards. Pre-authorized cards allow you to accept pre-payments via credit card without encountering the hassle and danger of storing the patient’s credit card information. These systems capture and store credit card information for you to use later when the claim has been adjudicated. These systems also allow you to set up payment plans securely and seamlessly.
Determine what to ask for. If you have a contract with an insurance company, review it to determine whether you can request the payment of the coinsurance and unmet deductible at the time of service. Despite the well-entrenched urban myth that circulates in the medical practice industry, most insurers do allow you to collect the patient’s copayment, coinsurance and unmet deductible at the time of service. Once you’ve identified any exceptions, ask the patient for these payments prior to seeing the provider. For coinsurance and unmet deductibles, you’ll need to know what services the patient is receiving (because allowances are based on CPT® codes). Thus, you’ll need to perform this collection activity as patients check out of your practice. Some insurers offer a web-based look-up tool to locate the correct rate. Develop a spreadsheet that lists your top CPT® codes and the corresponding allowances for each code by each of your major payers for your check-out staff to look up the codes on this spreadsheet.
Collect a deposit from the uninsured. For patients who do not carry insurance, request a minimum deposit. Set the “deposit” as your full charge, a reduced flat rate, or an average of the copayment that would be expected of your commercially insured patients. You may choose to collect different deposit amounts from new patients versus established patients (typically, deposits required of new patients are higher because there is no relationship or history with your practice), but be consistent within the categories. For patients who can’t afford to pay, offer a financial hardship policy that grants discounts based on the level of hardship. The key to making this work is to take a consistent approach to charging deposits – and have a written hardship policy that you follow consistently.
These days, more insured patients owe higher deductibles, copayments and coinsurance amounts. You can no longer afford to let these patients walk out the door of your practice without paying. Administrative costs and low collection rates make after-the-fact collections a losing proposition for most medical practices. Update your practice’s operations and financial policies and look for other ways to improve the revenue cycle in your practice so that you collect 100 percent of patient time-of-service payments due every day.
August 1, 2011
Workwell
WorkWell is a third-party workman’s comp physical therapy administrator who started in Pennsylvania in 1982 and is now entering the NJ market for some large employers. Each of you has signed their agreement.
CPB was able to negotiate more favorable terms than originally proposed:
$75 per diem (was $70) based on providing at least 4 modalities.
Payment to be made in 45 days (was 60).
If they change your fees, you can opt out immediately (previously no provision).
Billing:
When the patient is scheduled they will provide the patient’s Social Security # as their policy #. Please be sure to forward that to CPB.
Billing needs to be at weekly. More often is better, of course.
All claims require a copy of their “Physical Therapy Notes” form be attached to the claim. WorkWell requires the PT notes have times clearly documented along with the procedures done that day.
We have also negotiated a way to submit these electronically to get the payment clock running sooner.
CLIENT BULLETIN PRIMARY CARE SUPPLEMENT
August 1, 2011
Medicare Preventive Services
In the June 1, 2011 edition of the Highmark Medicare Services “Medicare Report,” page 5,
( https://www.highmarkmedicareservices.com/bulletins/partb/med-reports/pdf/mr0611.pdf )
Medicare specifies what is included in both an Initial and Subsequent AWV. Please note that providing “smoking cessation” counseling (G0436 & G0437) is included with at least the G0438 and will be denied when billed together.
What is Included in an Initial AWV with PPPS (G0438)?
The initial AWV providing PPPS provides for the following services to an eligible beneficiary by a health professional:
• Establishment of an individual’s medical/family history.
• Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual.
• Measurement of an individual’s height, weight, BMI (or waist circumference, if appropriate), BP, and other routine measurements as deemed appropriate, based on the beneficiary’s medical/family history.
• Detection of any cognitive impairment that the individual may have as defined in this section.
• Review of the individual’s potential (risk factors) for depression, including current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression, which the health professional may select from various available standardized screening tests designed for this purpose and recognized by national medical professional organizations.
• Review of the individual’s functional ability and level of safety based on direct observation, or the use of appropriate screening questions or a screening questionnaire, which the health professional may select from various available screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations.
• Establishment of a written screening schedule for the individual, such as a checklist for the next 5 to 10 years, as appropriate, based on recommendations of the United States Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices (ACIP), as well as the individual’s health status, screening history, and age-appropriate preventive services covered by Medicare.
• Establishment of a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway for the individual, including any mental health conditions or any such risk factors or conditions that have been identified through an IPPE, and a list of treatment options and their associated risks and benefits.
• Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management, or community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition.
• Any other element(s) determined appropriate by the Secretary of Health and Human Services through the National Coverage Determination (NCD) process.
What would be Included in a Subsequent AWV/PPPS (G0439)?
In subsequent AWVs, the following services would be provided to an eligible beneficiary by a health professional:
• An update of the individual’s medical/family history.
• An update of the list of current providers and suppliers that are regularly involved in providing medical care to the individual, as that list was developed for the first AWV providing PPPS.
• Measurement of an individual’s weight (or waist circumference), BP, and other routine measurements as deemed appropriate, based on the individual’s medical/family history.
• Detection of any cognitive impairment that the individual may have as defined in this section.
• An update to the written screening schedule for the individual, as that schedule is defined in this section, that was developed at the first AWV providing PPPS.
• An update to the list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are under way for the individual, as that list was developed at the first AWV providing PPPS.
• Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs.
• Any other element(s) determined by the Secretary through the NCD process.
Medicare does not have a separate CPT code to bill an EKG on the same day as a Medicare Annual Wellness Visit (G0438 & G0439) like they do for an IPPE (G0402). Thus, to bill an EKG with either a G0438 or G0439 you will need one of the “normal” diagnosis indications.
GOOD OFFICE FINANCIAL POLICIES
By 2010, more than 54 percent of large employers offered their employees at least one high-deductible health plan, according to a Rand Corporation survey (http://www.rand.org/pubs/external_publications/EP20110086.html).
Patients are responsible for increasingly larger portions of their medical bills – in fact patients’ financial responsibility is the largest it’s been since medical insurance came onto the scene in the mid-20th Century. Copayments, coinsurance and deductibles have never been higher. We have seen deductibles now as high as $5,000 per year! If you are relying solely on your billing staff to respond to this trend, you won’t be successful. Your patients are your worst payers – and asking them for money long after the fact only results in higher postage costs and accounts receivable. Requiring your front office to perform date-of-service collections is essential for financial success.
Here are seven (7) steps to successfully dealing with today’s reimbursement environment.
Check eligibility 1-2 days before the patient’s appointment. This allows you to confirm the patient is covered, who the insured is, amount of co-pay, deductible, and/or coinsurance. Critical information if you want to be paid. It also spells the difference between charity care and bad debt!
Set expectations. Develop a financial policy to distribute to patients when they arrive & make it available on your website, if you have one. Hang tasteful but clear signage in the front office. Don’t beat around the bush by printing signs that say, “Our Practice Expects You to Pay Your Copayment.” Instead, be direct with signs that read, “Your Insurance Company Requires You to Pay Your Copayment.” Send the message professionally, but make it clear that you expect to receive payment at the time of service. If the patient owes a co-pay, ask for payment prior to seeing the provider, not after.
Know how to ask. There is an art to collections, and a large part is knowing how to ask for money. Instruct your staff to stop asking patients, “Would you like to pay?” Replace that request with “How would you like to pay today?” Be sure to ask for past open patient balances at the same time. As they ask for payment, staff must make eye contact with the patient (or guarantor) and use his/her name during the conversation. Print a statement for all patients at check out that reflects any payments they have made as well as any remaining balance due. Giving these statements to patients at check-out is essentially free (no postage), and it reinforces your expectations of getting paid. It also eliminates the excuse patients so often give to your business office: “I never received a statement.”
Accept all forms of payment. Allow patients to pay by cash, debit or credit card. Personal checks could be an option, but consider using a check verification service if you encounter bad checks. Look at the commission rates on credit card services to make sure you get the best deal possible from card merchants. Don’t hesitate to steer your patients to a particular form of payment. For example, you might get a better rate when patients use debit cards for amounts under $20, but a more favorable rate when patients use credit cards for amounts over $20. Of course, you should not hesitate to accept any form of payment, but it doesn’t hurt to request a particular type of payment depending on which is more advantageous to you. Most patients won’t care one way or another because it is you, not they, who gets charged the commission going to the card processing company.
Consider pre-authorized credit cards. Pre-authorized cards allow you to accept pre-payments via credit card without encountering the hassle and danger of storing the patient’s credit card information. These systems capture and store credit card information for you to use later when the claim has been adjudicated. These systems also allow you to set up payment plans securely and seamlessly.
Determine what to ask for. If you have a contract with an insurance company, review it to determine whether you can request the payment of the coinsurance and unmet deductible at the time of service. Despite the well-entrenched urban myth that circulates in the medical practice industry, most insurers do allow you to collect the patient’s copayment, coinsurance and unmet deductible at the time of service. Once you’ve identified any exceptions, ask the patient for these payments prior to seeing the provider. For coinsurance and unmet deductibles, you’ll need to know what services the patient is receiving (because allowances are based on CPT® codes). Thus, you’ll need to perform this collection activity as patients check out of your practice. Some insurers offer a web-based look-up tool to locate the correct rate. Develop a spreadsheet that lists your top CPT® codes and the corresponding allowances for each code by each of your major payers for your check-out staff to look up the codes on this spreadsheet.
Collect a deposit from the uninsured. For patients who do not carry insurance, request a minimum deposit. Set the “deposit” as your full charge, a reduced flat rate, or an average of the copayment that would be expected of your commercially insured patients. You may choose to collect different deposit amounts from new patients versus established patients (typically, deposits required of new patients are higher because there is no relationship or history with your practice), but be consistent within the categories. For patients who can’t afford to pay, offer a financial hardship policy that grants discounts based on the level of hardship. The key to making this work is to take a consistent approach to charging deposits – and have a written hardship policy that you follow consistently.
These days, more insured patients owe higher deductibles, copayments and coinsurance amounts. You can no longer afford to let these patients walk out the door of your practice without paying. Administrative costs and low collection rates make after-the-fact collections a losing proposition for most medical practices. Update your practice’s operations and financial policies and look for other ways to improve the revenue cycle in your practice so that you collect 100 percent of patient time-of-service payments due every day.
August 1, 2011
Workwell
WorkWell is a third-party workman’s comp physical therapy administrator who started in Pennsylvania in 1982 and is now entering the NJ market for some large employers. Each of you has signed their agreement.
CPB was able to negotiate more favorable terms than originally proposed:
$75 per diem (was $70) based on providing at least 4 modalities.
Payment to be made in 45 days (was 60).
If they change your fees, you can opt out immediately (previously no provision).
Billing:
When the patient is scheduled they will provide the patient’s Social Security # as their policy #. Please be sure to forward that to CPB.
Billing needs to be at weekly. More often is better, of course.
All claims require a copy of their “Physical Therapy Notes” form be attached to the claim. WorkWell requires the PT notes have times clearly documented along with the procedures done that day.
We have also negotiated a way to submit these electronically to get the payment clock running sooner.
CLIENT BULLETIN PRIMARY CARE SUPPLEMENT
August 1, 2011
Medicare Preventive Services
In the June 1, 2011 edition of the Highmark Medicare Services “Medicare Report,” page 5,
( https://www.highmarkmedicareservices.com/bulletins/partb/med-reports/pdf/mr0611.pdf )
Medicare specifies what is included in both an Initial and Subsequent AWV. Please note that providing “smoking cessation” counseling (G0436 & G0437) is included with at least the G0438 and will be denied when billed together.
What is Included in an Initial AWV with PPPS (G0438)?
The initial AWV providing PPPS provides for the following services to an eligible beneficiary by a health professional:
• Establishment of an individual’s medical/family history.
• Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual.
• Measurement of an individual’s height, weight, BMI (or waist circumference, if appropriate), BP, and other routine measurements as deemed appropriate, based on the beneficiary’s medical/family history.
• Detection of any cognitive impairment that the individual may have as defined in this section.
• Review of the individual’s potential (risk factors) for depression, including current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression, which the health professional may select from various available standardized screening tests designed for this purpose and recognized by national medical professional organizations.
• Review of the individual’s functional ability and level of safety based on direct observation, or the use of appropriate screening questions or a screening questionnaire, which the health professional may select from various available screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations.
• Establishment of a written screening schedule for the individual, such as a checklist for the next 5 to 10 years, as appropriate, based on recommendations of the United States Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices (ACIP), as well as the individual’s health status, screening history, and age-appropriate preventive services covered by Medicare.
• Establishment of a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway for the individual, including any mental health conditions or any such risk factors or conditions that have been identified through an IPPE, and a list of treatment options and their associated risks and benefits.
• Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management, or community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition.
• Any other element(s) determined appropriate by the Secretary of Health and Human Services through the National Coverage Determination (NCD) process.
What would be Included in a Subsequent AWV/PPPS (G0439)?
In subsequent AWVs, the following services would be provided to an eligible beneficiary by a health professional:
• An update of the individual’s medical/family history.
• An update of the list of current providers and suppliers that are regularly involved in providing medical care to the individual, as that list was developed for the first AWV providing PPPS.
• Measurement of an individual’s weight (or waist circumference), BP, and other routine measurements as deemed appropriate, based on the individual’s medical/family history.
• Detection of any cognitive impairment that the individual may have as defined in this section.
• An update to the written screening schedule for the individual, as that schedule is defined in this section, that was developed at the first AWV providing PPPS.
• An update to the list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are under way for the individual, as that list was developed at the first AWV providing PPPS.
• Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs.
• Any other element(s) determined by the Secretary through the NCD process.
July 2011
Medicare routine services
Routine services such as a TB test are not covered by Medicare. In such cases, an Advanced Beneficiary Notice (ABN) is NOT required and payment can be collected on the date of service.
Medicare eRx & EHR Vendor Codes
Just a reminder, the eRx & EHR vendor codes for Medicare is required to be billed on the same claim as the E&M code it goes with. It cannot be billed later per Medicare rules. A few more points:
You cannot collect both the eRx program incentive and the EHR incentive.
You can be penalized under the eRx program and still receive the EHR incentive.
The only way to avoid the eRx penalty is to report the G8553 code a sufficient number of times within the time frame specified. Participating in the EHR program does NOT exempt you from this requirement.
Useful related websites:
Meaningful Use Attestation Calculator: http://www.cms.gov/apps/ehr
CMS Attestation Page: https://www.cms.gov/EHRIncentivePrograms/32_Attestation.asp#TopOfPage
Spring 2011 HHS OIG Semi-annual Report to Congress
This report was recently released and contained examples of hospitals, physicians, therapists, etc. who were found to have committed various types of healthcare fraud. Following are a few examples from the report:
· Pennsylvania—John Kristofic, a physician, was excluded for a minimum of 20 years based on his health care fraud conviction. Over a 5‐year period, Kristofic submitted false and fraudulent claims to Medicare, TRICARE, the Federal Employee Health Benefit (FEHB) program, and private insurers for treatment and services which were not rendered because Kristofic was not in the office or the patients were being treated by other physicians on the dates claimed. Kristofic was sentenced to 1 year and 1 day of incarceration and ordered to pay $1 million in restitution.”
· Florida—Orthopedic surgeon Steven J. Lancaster agreed to pay $101,000 to resolve his civil monetary penalty liability for allegedly soliciting kickbacks from a medical device manufacturer. The Government contends that Lancaster offered to leverage his product usage and ability to influence purchasing decisions through his position as Chief of Orthopedics at Baptist Medical Center Beaches Hospital in exchange for a personal services contract worth a guaranteed $40,000.
CMB’s Compliance Plan actively works to help prevent such issues for our clients when we become aware of any possible concerns.
Medicare EHR Incentive payments
In order to qualify for the full payment incentives of $44,000 over a 5-year period an EP's initial year of reporting must be 90 days in either 2011 or but no later than October 1, 2012.
The 90-day requirement is applicable in 2013 and beyond for the initial year of reporting; however the payment incentives are reduced after 2012. If an EP's initial reporting year is 2013 the EP may report on a 90-day period but s/he will only qualify for a maximum of $39,000 in payment incentives. If the initial reporting year is 2014, the payment incentives are reduced to $24,000. And in 2015 there are no more payment incentives and the payment penalties kick in at -1%.
Tricare
Beginning June 1, 2011 the Department of Defense (DoD) is removing Social Security Numbers from all ID cards and replacing them with a new DoD Identification number and a DoD Benefits number.
We have been informed by our clearinghouse that these newly assigned numbers, however, will not work for Claim submission or Eligibility so continue to use the insured’s Social Security Numbers as the Member ID. If you are presented with one of these new cards, request the Insured’s Social Security Number for Claim Submission and Eligibility.
Centers for Medicare & Medicaid Services (CMS) BAnking change
On 6/17/11 CMS announced it “has converted its banking contracts with JP Morgan and U.S. Bank to Federal Acquisition Regulation (FAR) contracts. These banks serve all the Medicare contractors. Accordingly, CMS has instructed the banks to close all bank accounts and letters of credit associated with the old configuration and contracts.
Normally, Medicare checks are valid for a 12-month period after the payment date on the check and then they are automatically stale-dated, at which point they become void. CMS needed to close some of the old bank accounts prior to the end of the 12-month period due to contractual requirements. Some checks drawn on these old bank accounts may be presented for payment within the next two to three months, but will be returned and annotated “account closed.” If providers encounter this situation, they may contact the Provider Contact Center and have the checks reissued under a new appropriate account number. If the provider receives a fee for the check being returned as unpaid please bring that to the attention of the Provider Contact Center and they will address that issue as well for the provider.”
CLIENT BULLETIN PRIMARY CARE SUPPLEMENT
July 1, 2011
Medicare Preventive Services
There is some confusion about billing the 3 Wellness visit codes. Neither code has a co-pay or deductible so is particularly helpful during the first 3 months of the year when all Medicare patients must meet their annual deductible.
Medicare has recently prepared 2 guides (a copy of each has been enclosed) to assist with:
· What is required for each code, and
· When they can be billed.
The Initial Preventive Physical Examination (IPPE)
“In addition to the new AWV, Medicare also provides coverage for the Initial Preventive Physical Examination (IPPE), commonly known as the "Welcome to Medicare" Visit (WMV). Medicare has provided coverage for this exam since 2005; it is provided as a one-time service to newly-enrolled beneficiaries. The IPPE is an introduction to Medicare and covered benefits, with a focus on health promotion and disease detection. The IPPE must be performed within the first 12 months after the beneficiary’s effective date of their Medicare Part B coverage. It contains a number of components that focus on prevention, including a complete medical/social/family history, a focused physical examination (i.e. body mass index, blood pressure, visual acuity), an assessment of functional ability, and counseling.”
The Annual Wellness Visit (AWV) – New for 2011
“Under the Affordable Care Act, Medicare beneficiaries may now receive coverage for an Annual Wellness Visit (AWV), which is a yearly office visit that focuses on preventive health. During the AWV, healthcare providers will review a patient’s history and risk factors for diseases, ensure that the patient’s medication list is up to date, and provide personalized health advice and counseling. The first AWV also allows the provider to establish a written personalized prevention plan. This new benefit will provide an ongoing focus on prevention that can be adapted as a beneficiary’s health needs change over time.”
Effective for dates of service on or after January 1, 2011, Medicare will pay for an AWV (G0438 or G0439) for a beneficiary who is no longer within 12 months after the effective date of his or her first Medicare Part B coverage and who has not received either an IPPE (G0402) or an AWV providing PPPS within the past 12 months.
Medicare pays for only one first AWV (G0438) per beneficiary per lifetime, and pays for one subsequent AWV (G0439) per year thereafter.
When you bill the IPPE (G0402) and perform an EKG, you can also bill a G0403 if you also do the interpretation and report. If you only do the tracing with someone else doing the interpretation and report, use G0404. If you are doing the interpretation and report for another provider, then you can bill G0405. Let Rich know if you need these codes added to your charge form.
Examples:
A patient comes to you during the first 12 months of their Medicare coverage (traditional Medicare, not Medicare Advantage) for a preventive visit. During the first 12 months you must use G0402 for the visit. If an EKG is also performed as noted above, you can bill G0403.
A patient comes to you beyond their 12 months of initial Medicare coverage for an Annual Wellness visit and who received an IPPE (G0402) visit during that time. As long as 12 months have passed since the IPPE, then you can bill the G0438.
A patient comes to you beyond their 12 months of initial Medicare coverage for an Annual Wellness visit and who did not receive an IPPE (G0402) visit during that time. The G0402 cannot be billed but as long as 12 months have passed since the IPPE, you can bill the G0438.
The subsequent Annual Wellness Visit code, G0439, can be billed 12 months after the G0438 was last billed. If you have a new patient be sure to ask whether he/she received previous IPPE or AWV services before attempting to bill
For all of the examples above, you can also treat a patient for non-preventive issues on the same date and bill the appropriate E&M code. “Medicare payment can be made for a significant, separately identifiable medically necessary E/M service (Current Procedural Terminology [CPT] codes 99201-99215) billed at the same visit as the AWV when billed with modifier -25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member.”
Be sure that your office notes clearly show both services as separate and distinct from the other and meet all the requirements for each code billed. On the charge form, be sure to indicate which diagnoses are linked to each code.
One last suggestion. We have had a number of patients who have called to ask about the Wellness charges. Medicare, as do most other insurers, has historically focused on illness and injury rather than prevention and wellness. It will help patients understand both the additional service you provided, as well as their billing, if you take a moment to explain the value of the wellness service to their health and longevity.
If you develop a severe case of insomnia and enjoy reading as “therapy,” here is the link to download the entire 298 pages of the Medicare Guide to Preventive Services:
http://www.cms.gov/MLNProducts/downloads/mps_guide_web-061305.pdf
Routine services such as a TB test are not covered by Medicare. In such cases, an Advanced Beneficiary Notice (ABN) is NOT required and payment can be collected on the date of service.
Medicare eRx & EHR Vendor Codes
Just a reminder, the eRx & EHR vendor codes for Medicare is required to be billed on the same claim as the E&M code it goes with. It cannot be billed later per Medicare rules. A few more points:
You cannot collect both the eRx program incentive and the EHR incentive.
You can be penalized under the eRx program and still receive the EHR incentive.
The only way to avoid the eRx penalty is to report the G8553 code a sufficient number of times within the time frame specified. Participating in the EHR program does NOT exempt you from this requirement.
Useful related websites:
Meaningful Use Attestation Calculator: http://www.cms.gov/apps/ehr
CMS Attestation Page: https://www.cms.gov/EHRIncentivePrograms/32_Attestation.asp#TopOfPage
Spring 2011 HHS OIG Semi-annual Report to Congress
This report was recently released and contained examples of hospitals, physicians, therapists, etc. who were found to have committed various types of healthcare fraud. Following are a few examples from the report:
· Pennsylvania—John Kristofic, a physician, was excluded for a minimum of 20 years based on his health care fraud conviction. Over a 5‐year period, Kristofic submitted false and fraudulent claims to Medicare, TRICARE, the Federal Employee Health Benefit (FEHB) program, and private insurers for treatment and services which were not rendered because Kristofic was not in the office or the patients were being treated by other physicians on the dates claimed. Kristofic was sentenced to 1 year and 1 day of incarceration and ordered to pay $1 million in restitution.”
· Florida—Orthopedic surgeon Steven J. Lancaster agreed to pay $101,000 to resolve his civil monetary penalty liability for allegedly soliciting kickbacks from a medical device manufacturer. The Government contends that Lancaster offered to leverage his product usage and ability to influence purchasing decisions through his position as Chief of Orthopedics at Baptist Medical Center Beaches Hospital in exchange for a personal services contract worth a guaranteed $40,000.
CMB’s Compliance Plan actively works to help prevent such issues for our clients when we become aware of any possible concerns.
Medicare EHR Incentive payments
In order to qualify for the full payment incentives of $44,000 over a 5-year period an EP's initial year of reporting must be 90 days in either 2011 or but no later than October 1, 2012.
The 90-day requirement is applicable in 2013 and beyond for the initial year of reporting; however the payment incentives are reduced after 2012. If an EP's initial reporting year is 2013 the EP may report on a 90-day period but s/he will only qualify for a maximum of $39,000 in payment incentives. If the initial reporting year is 2014, the payment incentives are reduced to $24,000. And in 2015 there are no more payment incentives and the payment penalties kick in at -1%.
Tricare
Beginning June 1, 2011 the Department of Defense (DoD) is removing Social Security Numbers from all ID cards and replacing them with a new DoD Identification number and a DoD Benefits number.
We have been informed by our clearinghouse that these newly assigned numbers, however, will not work for Claim submission or Eligibility so continue to use the insured’s Social Security Numbers as the Member ID. If you are presented with one of these new cards, request the Insured’s Social Security Number for Claim Submission and Eligibility.
Centers for Medicare & Medicaid Services (CMS) BAnking change
On 6/17/11 CMS announced it “has converted its banking contracts with JP Morgan and U.S. Bank to Federal Acquisition Regulation (FAR) contracts. These banks serve all the Medicare contractors. Accordingly, CMS has instructed the banks to close all bank accounts and letters of credit associated with the old configuration and contracts.
Normally, Medicare checks are valid for a 12-month period after the payment date on the check and then they are automatically stale-dated, at which point they become void. CMS needed to close some of the old bank accounts prior to the end of the 12-month period due to contractual requirements. Some checks drawn on these old bank accounts may be presented for payment within the next two to three months, but will be returned and annotated “account closed.” If providers encounter this situation, they may contact the Provider Contact Center and have the checks reissued under a new appropriate account number. If the provider receives a fee for the check being returned as unpaid please bring that to the attention of the Provider Contact Center and they will address that issue as well for the provider.”
CLIENT BULLETIN PRIMARY CARE SUPPLEMENT
July 1, 2011
Medicare Preventive Services
There is some confusion about billing the 3 Wellness visit codes. Neither code has a co-pay or deductible so is particularly helpful during the first 3 months of the year when all Medicare patients must meet their annual deductible.
Medicare has recently prepared 2 guides (a copy of each has been enclosed) to assist with:
· What is required for each code, and
· When they can be billed.
The Initial Preventive Physical Examination (IPPE)
“In addition to the new AWV, Medicare also provides coverage for the Initial Preventive Physical Examination (IPPE), commonly known as the "Welcome to Medicare" Visit (WMV). Medicare has provided coverage for this exam since 2005; it is provided as a one-time service to newly-enrolled beneficiaries. The IPPE is an introduction to Medicare and covered benefits, with a focus on health promotion and disease detection. The IPPE must be performed within the first 12 months after the beneficiary’s effective date of their Medicare Part B coverage. It contains a number of components that focus on prevention, including a complete medical/social/family history, a focused physical examination (i.e. body mass index, blood pressure, visual acuity), an assessment of functional ability, and counseling.”
The Annual Wellness Visit (AWV) – New for 2011
“Under the Affordable Care Act, Medicare beneficiaries may now receive coverage for an Annual Wellness Visit (AWV), which is a yearly office visit that focuses on preventive health. During the AWV, healthcare providers will review a patient’s history and risk factors for diseases, ensure that the patient’s medication list is up to date, and provide personalized health advice and counseling. The first AWV also allows the provider to establish a written personalized prevention plan. This new benefit will provide an ongoing focus on prevention that can be adapted as a beneficiary’s health needs change over time.”
Effective for dates of service on or after January 1, 2011, Medicare will pay for an AWV (G0438 or G0439) for a beneficiary who is no longer within 12 months after the effective date of his or her first Medicare Part B coverage and who has not received either an IPPE (G0402) or an AWV providing PPPS within the past 12 months.
Medicare pays for only one first AWV (G0438) per beneficiary per lifetime, and pays for one subsequent AWV (G0439) per year thereafter.
When you bill the IPPE (G0402) and perform an EKG, you can also bill a G0403 if you also do the interpretation and report. If you only do the tracing with someone else doing the interpretation and report, use G0404. If you are doing the interpretation and report for another provider, then you can bill G0405. Let Rich know if you need these codes added to your charge form.
Examples:
A patient comes to you during the first 12 months of their Medicare coverage (traditional Medicare, not Medicare Advantage) for a preventive visit. During the first 12 months you must use G0402 for the visit. If an EKG is also performed as noted above, you can bill G0403.
A patient comes to you beyond their 12 months of initial Medicare coverage for an Annual Wellness visit and who received an IPPE (G0402) visit during that time. As long as 12 months have passed since the IPPE, then you can bill the G0438.
A patient comes to you beyond their 12 months of initial Medicare coverage for an Annual Wellness visit and who did not receive an IPPE (G0402) visit during that time. The G0402 cannot be billed but as long as 12 months have passed since the IPPE, you can bill the G0438.
The subsequent Annual Wellness Visit code, G0439, can be billed 12 months after the G0438 was last billed. If you have a new patient be sure to ask whether he/she received previous IPPE or AWV services before attempting to bill
For all of the examples above, you can also treat a patient for non-preventive issues on the same date and bill the appropriate E&M code. “Medicare payment can be made for a significant, separately identifiable medically necessary E/M service (Current Procedural Terminology [CPT] codes 99201-99215) billed at the same visit as the AWV when billed with modifier -25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member.”
Be sure that your office notes clearly show both services as separate and distinct from the other and meet all the requirements for each code billed. On the charge form, be sure to indicate which diagnoses are linked to each code.
One last suggestion. We have had a number of patients who have called to ask about the Wellness charges. Medicare, as do most other insurers, has historically focused on illness and injury rather than prevention and wellness. It will help patients understand both the additional service you provided, as well as their billing, if you take a moment to explain the value of the wellness service to their health and longevity.
If you develop a severe case of insomnia and enjoy reading as “therapy,” here is the link to download the entire 298 pages of the Medicare Guide to Preventive Services:
http://www.cms.gov/MLNProducts/downloads/mps_guide_web-061305.pdf
Monday, June 20, 2011
June 2011
Medicare advantage
We have added a new Financial Class – Medicare Advantage – to your reports to help track this segment of patients. Financial Class is always based upon the primary insurance. If you have any questions, please call Rich.
CRedit card payments
As a follow-up to a question about credit cards, the credit card payment is deposited directly into your bank account by the credit card vendor. Other than recording the payment information, or potentially entering the credit card info, CPB is not involved in the transaction. If you are interested, I will be glad to forward the 2 vendors we interviewed who will be glad to give you an online demo.
EHR’s & weather disasters
A friend from our professional association lives near Joplin, MO which as you probably know experienced severe tornadoes the week of May 23rd. Here is what she related about 5 of her clients:
“Out of the five offices destroyed, two were using an EHR with offsite secure hosting. Those two practices were able to contact patients and do medication refills the day after the disaster (for those patients not affected by the devastation). Three were still using paper charts and have lost all records. They have their financial records with us but medical records are gone.”
We aren’t pushing EHR’s, but are supporting several clients who have begun using them and have been a resource to others who are still looking. As you search for an EHR vendor, remember that we have comparison data for a number of EMR programs in a spreadsheet. We are also happy to assist you with this process at no cost.
United Healthcare’s (UHC) Medicare advantage plan
We are hearing some complaints from our colleagues about low reimbursement rates for the Medicare Advantage Plan (Secure Horizons Plan) offered by United Healthcare. There has also been discussion about non-Medicare UHC low reimbursement and complaints that UHC will begrudgingly increase the fee schedule but then require the provider in writing to forego any further increases for 3 years!
Moral of the Story: Be careful what you sign – be sure to read the agreement for any plan you are considering participating with. Be sure to review the insurer’s Fee Schedule in advance of signing and be sure the contract provides for annual fee increases – or allows you to terminate the agreement without a long termination period.
We have added a new Financial Class – Medicare Advantage – to your reports to help track this segment of patients. Financial Class is always based upon the primary insurance. If you have any questions, please call Rich.
CRedit card payments
As a follow-up to a question about credit cards, the credit card payment is deposited directly into your bank account by the credit card vendor. Other than recording the payment information, or potentially entering the credit card info, CPB is not involved in the transaction. If you are interested, I will be glad to forward the 2 vendors we interviewed who will be glad to give you an online demo.
EHR’s & weather disasters
A friend from our professional association lives near Joplin, MO which as you probably know experienced severe tornadoes the week of May 23rd. Here is what she related about 5 of her clients:
“Out of the five offices destroyed, two were using an EHR with offsite secure hosting. Those two practices were able to contact patients and do medication refills the day after the disaster (for those patients not affected by the devastation). Three were still using paper charts and have lost all records. They have their financial records with us but medical records are gone.”
We aren’t pushing EHR’s, but are supporting several clients who have begun using them and have been a resource to others who are still looking. As you search for an EHR vendor, remember that we have comparison data for a number of EMR programs in a spreadsheet. We are also happy to assist you with this process at no cost.
United Healthcare’s (UHC) Medicare advantage plan
We are hearing some complaints from our colleagues about low reimbursement rates for the Medicare Advantage Plan (Secure Horizons Plan) offered by United Healthcare. There has also been discussion about non-Medicare UHC low reimbursement and complaints that UHC will begrudgingly increase the fee schedule but then require the provider in writing to forego any further increases for 3 years!
Moral of the Story: Be careful what you sign – be sure to read the agreement for any plan you are considering participating with. Be sure to review the insurer’s Fee Schedule in advance of signing and be sure the contract provides for annual fee increases – or allows you to terminate the agreement without a long termination period.
Monday, May 9, 2011
May 2011
Credit card payments
With more insurance policies than ever having high patient and family deductibles (we have seen them as high as $5,000 per year!), you may want to consider offering credit cards as one of your payment options.
We have researched this and it appears that an average cost per month for 75-80 patients to charge $2,500 (an average of about $32 each) is less than $100. Vendors now give offices more ways to collect payments, which gives patients more flexible payment options, including Front Office Payments (card swipe, internet, or both), automated Payment Plans, and Patient Payment Portal solutions. CMB patient statements have the ability to show whichever credit cards you accept so the patient can pay that way for statements also.
If interested we have 2 companies we have interviewed which you could consider.
Consults
Consults, by definition, require a referring physician which cannot be the provider performing the service. If the charge form is missing the name of a referring physician, CMB will always ask if there is one. If not, the only alternative which is compliant with billing rules is to bill a CPT code other than a consult (office visit, subsequent hospital visit, etc.).
Medicare Attestation Begins on April 18. (From CMS)
“Attestation for the Medicare Electronic Health Record (EHR) Incentive Program began on April 18, 2011. In order to receive your Medicare EHR incentive payment, you must attest through CMS' web-based Medicare and Medicaid EHR Incentive Programs Registration and Attestation System.
CMS will release additional information about the Medicare attestation process soon, including User Guides that provide step-by-step instructions for completing attestation, and educational webinars that describe the attestation process in depth.
Here is more information to help you prepare for Medicare attestation: You need to understand the required meaningful use criteria to successfully attest. Meaningful use requirements for eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) participating in the Medicare EHR Incentive Program are different:
EP Meaningful Use Criteria – Must report on 15 core measures, 5 of 10 menu measures, and 6 clinical quality measures, consisting of 3 required core measures and 3 additional measures.
Go to the Stage 1 EHR Meaningful Use Specification Sheets for EPs for information on core and menu measures for EPs.
Go to the Clinical Quality Measures page for information on the required clinical quality measures for EPs.
You should also make sure that you begin your 90-day reporting period in time to attest and receive a Medicare payment in 2011. The last day to begin your 90-day reporting period for 2011 incentive payments is October 1, 2011, for EPs.”
More ICD-10
While ICD-10 starts on October 1, 2013 (2.5 years away), it is only mandatory for HIPAA covered entities/plans. However, some insurers, specifically Medicaid, may not be able to comply with the deadlines. Workers Compensation, auto, attorneys and other types of non-health insurance indemnity plans are not subject to HIPAA and can continue to use ICD-9 - even though it will no longer be maintained or updated. The most current information we have indicates we will indeed see this, so it is critically important to expect coding and operational issues that will result. CMB will be ready, but there are major systems issues that could cause serious disruptions in payments regardless of what you bill with.
FILLING OUT AN ATTORNEY’S QUESTIONAIRE
Question: If you have a patient who was injured and has filed personal injury suit against a company and his attorney is requesting that you fill out a questionnaire regarding your patient to help with his suit, do you have to comply? Should you request payment for your service? If so, how do I determine a reasonable billing rate for my time and effort?
Answer: You are free to either respond or not respond to the attorney's questionnaire. A questionnaire is not the same as responding to a subpoena. It is reasonable for you to be paid for your time if you choose to respond, but you may want to contact the attorney and ask if he is willing to compensate you and to clarify the amount of your charges. If he/she is not willing to pay, then you can decide how to proceed. I would not just unilaterally fill out the questionnaire and then charge the attorney without having a written understanding first. Recognize also that if you "get involved" by responding to the attorney, you may be nominating yourself to become a witness in the litigation. This does not bother some people; others would dread such a possibility. Bottom line is to make a wise choice based on the possible future consequences.
More eRx – Avoiding the 2012 Payment Adjustment
In November, the Centers for Medicare & Medicaid Services announced that, beginning in calendar year 2012, eligible professionals who are not successful electronic prescribers based on claims submitted between January 1, 2011 – June 30, 2011, may be subject to a payment adjustment on their Medicare Part B Physician Fee Schedule (PFS) covered professional services. Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorizes CMS to apply this payment adjustment whether or not the eligible professional is planning to participate in the eRx Incentive Program.
From 2012 through 2014, the payment adjustment will increase each calendar year. In 2012, the payment adjustment for not being a successful electronic prescriber will result in an eligible professional or group practice receiving 99% of their Medicare Part B PFS amount that would otherwise apply to such services. In 2013, an eligible professional or group practice will receive 98.5% of their Medicare Part B PFS covered professional services for not being a successful electronic prescriber in 2011 or as defined in a future regulation. In 2014, the payment adjustment for not being a successful electronic prescriber is 2%, resulting in an eligible professional or group practice receiving 98% of their Medicare Part B PFS covered professional services.
The payment adjustment does not apply if <10% of an eligible professional’s (or group practice’s) allowed charges for the January 1, 2011 through June 30, 2011 reporting period are comprised of codes in the denominator of the 2011 eRx measure.
Please note that earning an eRx incentive for 2011 will NOT necessarily exempt an eligible professional or group practice from the payment adjustment in 2012.
How to Avoid the 2012 eRx Payment Adjustment
· Eligible professionals – An eligible professional can avoid the 2012 eRx Payment Adjustment if (s)he:
-- Is not a physician (MD, DO, or podiatrist), nurse practitioner, or physician assistant as of Jun 30, 2011 based on primary taxonomy code in NPPES;
-- Does not have prescribing privileges. Note: (S)he must report (G8644) at least one time on an eligible claim prior to June 30, 2011;
-- Does not have at least 100 cases containing an encounter code in the measure denominator;
-- Becomes a successful e-prescriber; and
-- Reports the eRx measure for at least 10 unique eRx events for patients in the denominator of the measure.
· Group Practices - For group practices that are participating in eRx GPRO I or GPRO II during 2011, the group practice MUST become a successful e-prescriber.
-- Depending on the group’s size, the group practice must report the eRx measure for 75-2,500 unique eRx events for patients in the denominator of the measure.
With more insurance policies than ever having high patient and family deductibles (we have seen them as high as $5,000 per year!), you may want to consider offering credit cards as one of your payment options.
We have researched this and it appears that an average cost per month for 75-80 patients to charge $2,500 (an average of about $32 each) is less than $100. Vendors now give offices more ways to collect payments, which gives patients more flexible payment options, including Front Office Payments (card swipe, internet, or both), automated Payment Plans, and Patient Payment Portal solutions. CMB patient statements have the ability to show whichever credit cards you accept so the patient can pay that way for statements also.
If interested we have 2 companies we have interviewed which you could consider.
Consults
Consults, by definition, require a referring physician which cannot be the provider performing the service. If the charge form is missing the name of a referring physician, CMB will always ask if there is one. If not, the only alternative which is compliant with billing rules is to bill a CPT code other than a consult (office visit, subsequent hospital visit, etc.).
Medicare Attestation Begins on April 18. (From CMS)
“Attestation for the Medicare Electronic Health Record (EHR) Incentive Program began on April 18, 2011. In order to receive your Medicare EHR incentive payment, you must attest through CMS' web-based Medicare and Medicaid EHR Incentive Programs Registration and Attestation System.
CMS will release additional information about the Medicare attestation process soon, including User Guides that provide step-by-step instructions for completing attestation, and educational webinars that describe the attestation process in depth.
Here is more information to help you prepare for Medicare attestation: You need to understand the required meaningful use criteria to successfully attest. Meaningful use requirements for eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) participating in the Medicare EHR Incentive Program are different:
EP Meaningful Use Criteria – Must report on 15 core measures, 5 of 10 menu measures, and 6 clinical quality measures, consisting of 3 required core measures and 3 additional measures.
Go to the Stage 1 EHR Meaningful Use Specification Sheets for EPs for information on core and menu measures for EPs.
Go to the Clinical Quality Measures page for information on the required clinical quality measures for EPs.
You should also make sure that you begin your 90-day reporting period in time to attest and receive a Medicare payment in 2011. The last day to begin your 90-day reporting period for 2011 incentive payments is October 1, 2011, for EPs.”
More ICD-10
While ICD-10 starts on October 1, 2013 (2.5 years away), it is only mandatory for HIPAA covered entities/plans. However, some insurers, specifically Medicaid, may not be able to comply with the deadlines. Workers Compensation, auto, attorneys and other types of non-health insurance indemnity plans are not subject to HIPAA and can continue to use ICD-9 - even though it will no longer be maintained or updated. The most current information we have indicates we will indeed see this, so it is critically important to expect coding and operational issues that will result. CMB will be ready, but there are major systems issues that could cause serious disruptions in payments regardless of what you bill with.
FILLING OUT AN ATTORNEY’S QUESTIONAIRE
Question: If you have a patient who was injured and has filed personal injury suit against a company and his attorney is requesting that you fill out a questionnaire regarding your patient to help with his suit, do you have to comply? Should you request payment for your service? If so, how do I determine a reasonable billing rate for my time and effort?
Answer: You are free to either respond or not respond to the attorney's questionnaire. A questionnaire is not the same as responding to a subpoena. It is reasonable for you to be paid for your time if you choose to respond, but you may want to contact the attorney and ask if he is willing to compensate you and to clarify the amount of your charges. If he/she is not willing to pay, then you can decide how to proceed. I would not just unilaterally fill out the questionnaire and then charge the attorney without having a written understanding first. Recognize also that if you "get involved" by responding to the attorney, you may be nominating yourself to become a witness in the litigation. This does not bother some people; others would dread such a possibility. Bottom line is to make a wise choice based on the possible future consequences.
More eRx – Avoiding the 2012 Payment Adjustment
In November, the Centers for Medicare & Medicaid Services announced that, beginning in calendar year 2012, eligible professionals who are not successful electronic prescribers based on claims submitted between January 1, 2011 – June 30, 2011, may be subject to a payment adjustment on their Medicare Part B Physician Fee Schedule (PFS) covered professional services. Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorizes CMS to apply this payment adjustment whether or not the eligible professional is planning to participate in the eRx Incentive Program.
From 2012 through 2014, the payment adjustment will increase each calendar year. In 2012, the payment adjustment for not being a successful electronic prescriber will result in an eligible professional or group practice receiving 99% of their Medicare Part B PFS amount that would otherwise apply to such services. In 2013, an eligible professional or group practice will receive 98.5% of their Medicare Part B PFS covered professional services for not being a successful electronic prescriber in 2011 or as defined in a future regulation. In 2014, the payment adjustment for not being a successful electronic prescriber is 2%, resulting in an eligible professional or group practice receiving 98% of their Medicare Part B PFS covered professional services.
The payment adjustment does not apply if <10% of an eligible professional’s (or group practice’s) allowed charges for the January 1, 2011 through June 30, 2011 reporting period are comprised of codes in the denominator of the 2011 eRx measure.
Please note that earning an eRx incentive for 2011 will NOT necessarily exempt an eligible professional or group practice from the payment adjustment in 2012.
How to Avoid the 2012 eRx Payment Adjustment
· Eligible professionals – An eligible professional can avoid the 2012 eRx Payment Adjustment if (s)he:
-- Is not a physician (MD, DO, or podiatrist), nurse practitioner, or physician assistant as of Jun 30, 2011 based on primary taxonomy code in NPPES;
-- Does not have prescribing privileges. Note: (S)he must report (G8644) at least one time on an eligible claim prior to June 30, 2011;
-- Does not have at least 100 cases containing an encounter code in the measure denominator;
-- Becomes a successful e-prescriber; and
-- Reports the eRx measure for at least 10 unique eRx events for patients in the denominator of the measure.
· Group Practices - For group practices that are participating in eRx GPRO I or GPRO II during 2011, the group practice MUST become a successful e-prescriber.
-- Depending on the group’s size, the group practice must report the eRx measure for 75-2,500 unique eRx events for patients in the denominator of the measure.
April 2011
Medicare EMR PAYMENTS
Recently we were asked what is required to qualify for the Medicare EMR funds for qualified providers:
Be using one of the 200+ ONC 2011 Certified EHR applications,
Use the product in a “meaningful way” for 90 days starting anytime after 01/01/2011, and
Go on-line to register with CMS.
CMS has asked that we remind eligible professionals that they must register in order to participate in the Medicare and Medicaid EHR incentive programs. At least 90 days of reporting is required to qualify. Registration opened on Jan. 3, 2011, at http://www.cms.gov/EHRIncentivePrograms/20_RegistrationandAttestation.asp.
MEDICARE eRx
In November, the Centers for Medicare and Medicaid Services (CMS) announced that, beginning in calendar year 2012, eligible professionals who are not successful electronic prescribers based on claims submitted between January 1, 2011 - June 30, 2011, may be subject to a payment adjustment on their Medicare Part B Physician Fee Schedule covered professional services. If you are a physician (with Medicare patients) who has not started to use eRx yet & wants to avoid a negative payment adjustment in 2012, you will want to get started ASAP. If you are using an eRx program but have not notified CPB, it is CRITICAL that you do so we can ensure that the correct eRx code is being sent with your charges to Medicare. That is how Medicare finds out you are actually using it on patients. The code must be billed at the time of the E&M visit – office, home, hospital, nursing home, etc..
Several of our clients are already using an electronic prescription program and will be able to benefit from the Medicare payment. Some are using a standalone product and others are looking at EMR programs that include this feature. Be sure it is certified with both CMS and Surescripts. The following website includes all products certified by Surescripts – both standalone & included with an EMR program: http://www.surescripts.com/connect-to-surescripts/prescriber-software/all.aspx?mode=viewAll&fullscreen=true&background=off
For a free product: http://www.nationalerx.com
CREDIT CARDS & eCHECKS FOR PATIENT PAYMENTS
As many of you know, high deductible insurance plans are becoming much more common. We are seeing deductibles as high as $5000 per year which is significantly changing insurance paradigm. Instead of receiving payment from an insurance company, we are seeing an increase in balances being applied to those deductibles and in the number of requests from patients for credit card payments.
In response to several requests by clients to set them up with the ability to accept credit card payments, CPB is investigating this option. The process works as follows:
Each client is set up so that the credit card payment goes directly to their bank account.
Patients send the required credit card information either on their statement or fax to us.
Our staff will enter the information on the secure website provided by the vendor with payment only to your bank account. Our staff will enter the payment information into the patient's account as usual.
If you if you are interested in participating in this, please contact Rich.
PROVIDER RELIANCE ON PRECERTIFICATION
NJAC 11:24A-3.4 2(e) which is applicable to all carriers using utilization management programs: "provides that a carrier shall not deny reimbursement retroactively for a covered service provided to a covered person by a provider who relied upon the written or oral authorization of that carrier (or its agents) prior to providing the service to the covered person, except in cases where there is material misrepresentation or fraud."
The New Jersey Department of Banking and Insurance further states "carriers may not circumvent these provisions through the use of quote disclaimers" purporting to reserve the right to retroactively revise utilization management determination."
This should solve the occasional denial but it is important that the billing diagnoses match whatever was used to obtain the precertification.
Medicare Annual wellness visits (AWV) – railroad medicare
Railroad Medicare is stating that they will not be ready to process either of the AWV codes until April 4, 2011. We will automatically resubmit any denied claims. Believe it or not, the RRMC rep told us that they “just received the memo yesterday” (3/7/11)! Funny how everyone else knew about this last Fall.
Ambulance Mileage
On February 23, 2011 UMWA Health and Retirement Fund announced that effective January 1, 2011 (yep, retroactive!) they will also follow the Medicare policy using Load Miles rounded to the nearest tenth of a mile.
NJ PIP PATIENTS
There are 3 medical specialties which are subject to the daily $99.00 NJ PIP Cap – Chiropractors, Therapists (PT & OT), and Osteopaths (for manipulation codes only). The FAQ’s on the NJ PIP website:
Q. “Is the $99.00 a per-provider cap or does it apply to all treatment on that day?
A. The $99.00 is the limit of the insurer’s liability for the CPT codes listed in the rule per day. Therefore, it applies regardless of the number of providers that the injured person visits.”
The only exception is found in N.J.A.C. 11:3-29.4 (m) Application of Medical Fee Schedules:
“… The daily maximum applies when such services are performed for the same patient on the same date. The daily maximum applies to all providers, including dentists. However, when the provider can demonstrate that the severity or extent of the injury is such that extraordinary time and effort is needed for effective treatment, insurer shall reimburse in excess of the daily maximum. Such injuries could include, but are not limited to, severe brain injury non-soft tissue injuries to more than one part of the body. Such injuries would not include diagnoses for which there are care paths in NJAC 11.3-4. … Unless already provided to the insurer as part of a decision point review or precertification requests, billing shall be accompanied by documentation of why the extraordinary time and effort for treatment was needed."
The above indicates that the documentation can be provided as part of the precertification process or documentation can be sent with initial claim. Please be sure to specify on the charge form if, during the preauthorization process (which is the best time to address this issue with the insurer), you were approved to exceed the daily cap, or attach a cover letter supporting "extraordinary time and effort for treatment was needed" as required above.
We believe that in group practices represented by more than one specialty, e.g., PT & OT, that this issue should be addressed during the preauthorization process and request this in writing. This ensures that you are aware prior to treating the patient, rather than after the claim has been denied, whether the insurer has agreed to waive the cap.
This approach is further supported by NJAC 11:24A-3.4 2(e) which is applicable to all carriers using utilization management programs: "provides that a carrier shall not deny reimbursement retroactively for a covered service provided to a covered person by a provider who relied upon the written or oral authorization of that carrier (or its agents) prior to providing the service to the covered person, except in cases where there is material misrepresentation or fraud."
The New Jersey Department of Banking and Insurance further states "carriers may not circumvent these provisions through the use of quote disclaimers" purporting to reserve the right to retroactively to revise utilization management determination."
If the insurer refuses to allow each provider to be paid for treating the patient on the same date of service, we recommend that patient's only be treated by one provider each day in order to avoid the second provider providing unreimbursed care.
In addition, if you see any patient being treated under NJ PIP, you should ask if the patient has an appointment to see any other providers that day. If so, scan or fax the charges to CPB as fast as possible AND call to notify us so we can bill before the other provider does.
Finally, when scheduling appointments for NJ PIP patients, ask if they already have an appointment scheduled with another provider on whatever day you would see them. If possible, schedule them a different day.
If you have any questions, please contact Rich.
Monday, March 21, 2011
FOR IMMEDIATE RELEASE
NEWS RELEASE
AssistMed Highlights Cost- and Time-Savings to Physicians and Billing Service Companies with Its Duet™ Digital Pen and Custom Forms Product
--Technology Eliminates Manual Processes; Improves Efficiency in Patient Care--
LOS ANGELES, CA – AssistMed, Inc. announced the results of an informal survey demonstrating improved time- and cost-savings to physicians and billing services through the utilization of the company’s Duet Digital Pen and Custom Form applications product, compared with traditional methods for capturing and delivering patient encounter data.
"We have seen improvements in processing efficiency of up to 50 percent by utilizing AssistMed’s technology, which eliminates the need to scan or fax the patient charges prior to entry. An added benefit is seamless data backup. Equally important, the elimination of manual data entry will enable our company to support new clients without requiring additional staff," said Rich Papperman, Chief Executive Officer of New Jersey-based Cape Medical Billing.
Papperman also stated, “Getting our clients paid faster is an important reason we agreed to try this technology. Of course, getting paid faster is an important issue for most providers! Depending on how a provider’s current charges are being managed, this technology can make a major difference in their speed of payment.”
Physicians are able to take advantage of AssistMed’s digital technology and custom forms, noted Papperman, to send information in real time directly to his organization’s Healthpac™ billing system. "The pen and forms fit very well into our existing office workflow. The technology is easy to use and saves time for the staff, since we have almost eliminated faxing and scanning for billing purposes," said Stuart Honick, DPM, a client of Cape Medical Billing.
“AssistMed’s billing service clients, such as Cape Medical Billing, will continue to realize even greater cost-effective benefits as more of their physicians adopt and utilize the digital pens and forms in their practice. Furthermore, an added benefit for physicians who use the pen to capture billing information is the ability to easily expand its use to capture and import patient information to their electronic health record systems,” said Raul Kivatinetz, President and Chief Operating Officer of AssistMed, Inc.
“This informal survey recognizes the opportunity of managing patient care more efficiently through innovative technology. We are pleased to receive such an enthusiastic response from our client, Cape Medical Billing, and its physician practices,” Kivatinetz added.
About AssistMed, Inc.
AssistMed Duet is a data capture, transformation, and distribution platform. It allows physicians and their staff to continue to use familiar tools such as pen and paper as well as dictation, to capture patient encounter data. The platform automatically transforms the information into structured, codified data for distribution and use in healthcare IT systems, including electronic health records systems.
Headquartered in Beverly Hills, California, AssistMed, Inc. is dedicated to the application of information technology to create elegant solutions that improve both the efficiency and effectiveness of medical practice. The company's products and services facilitate provider adoption while improving quality, streamlining workflow, and reducing costs. AssistMed’s integrated SaaS platforms, Duet™ and Trio™, include: CCHIT- and ONC-ATCB-Certified Electronic Health Record, Patient Portal, Practice Management System, and Digital Pen with Custom Forms, Dictation with Speech Recognition, Natural Language Processing and Transcription & Editing Services. AssistMed’s SaaS-based Patient Adherence Management solution compliments the suite. Additional information is available at www.assistmed.com.
About Cape Medical Billing, Inc.
Cape Medical Billing was founded in 1990 by Richard C. Papperman, MBA, CHBME and is an experienced and skilled medical billing service for physicians, therapists, ambulance companies, and mental health professionals. Located in Cape May Court House, New Jersey, Cape Medical Billing provides billing services for any size practice or business and serves clients nationwide. For further information on Cape Medical Billing visit www.capebilling.com or call 1-888-633-2457.
# # #
CONTACT:
For AssistMed:
Laurie Dressler
818.282.0162
laurie.dressler@assistmed.com
March 2011
New Medicare wellness visits
Medicare has redefined the G0402 (Initial Preventive Physical Exam). It is now valid for 12 months (it was 6 months) after the patient becomes eligible for Medicare (not the previous 6 months).
For new Medicare patients joining your practice, you will want to verify whether they received a previous well visit (G0402 now, or G0438/G0439 next year) with a previous provider before you provide that service. If so, you will need to know exactly when it was received since a full 11 months (12 months is safer) must pass before billing the subsequent AWV code. If there is any doubt, you could have the patient sign an ABN, tho technically none is required.
The AAFP has also developed some tools to assist with meeting the AWV documentation requirements and clarify some Frequently Asked Questions. These have been emailed to all of our PCP clients. If you did not receive a copy, call Rich and we will send to you.
Medicare learning network information
To assist our PCP’s who are taking advantage of the new Medicare Wellness codes, we have ordered several documents from CMS that provide details about the program and included them & a CD in this month’s mailing:
· “Medicare Preventive Services Quick Reference Information”
· “Smoking and Tobacco-Use Cessation Counseling Services”
· A CD entitled “Medicare Preventive Services Resources”
For other providers who qualify for the CMS EMR bonus, a brochure entitled
· “Medicare Electronic Health Record Incentive Program for Eligible Professionals”
is also enclosed available. CPB has the names of both free and inexpensive EMR programs if you want to see those products. We are also happy to provide information to help you with selection and installation to minimize cash-flow disruption. I have attended 3 EMR conferences - this is a SIGNIFICANT event for your practice that will require careful planning to implement correctly. As of 6 months ago, we were hearing that 74-76% of installations were either not being used after 1 year (in some cases were uninstalled) or only being partially used. You should strongly consider taking the time to review 3-4 programs before selecting one. There are a lot of things to consider – feel free to call if you want to discuss.
Medicare 2011 ePRESCRIPTION (eRx) & PQRI
To avoid a 1% decrease in Medicare reimbursement in 2012 eligible providers MUST become an eRx prescriber no later than 6/30/11 by submitting at least 10 events on claims using a “qualified” eRx system. The decrease becomes 1.5% in 2013. CPB has updated all Charge forms to include the eRx code – be sure to circle or “check” it so we send it with your other charges.
You can receive either the eRx or the EHR incentives, but not both. One of the EHR requirements is eRx capability, so Medicare will not pay twice for having the capability.
TRICARE NON-COVERED SERVICES
Similar to Medicare’s Advanced Beneficiary Notice (ABN), TriCare has their own form to use when the patient’s signature is required for a product or service that is not covered. And just as with Medicare, a patient with TriCare must have a written agreement to pay for a non-covered service or supplies before receiving it.
A copy of the “TriCare Non-Covered Services Waiver” form is attached.
The following items are from the TriCare Policy Manual (edited to include only services we recognize our clients provide):
31. Removal of corns or calluses or trimming of toenails and other routine podiatry services, except those required as a result of a diagnosed systemic medical disease affecting the lower limbs, such as severe diabetes (see Chapter 8, Section 11.1).
37. Preventive care, such as routine annual, or employment-requested physical examinations; routine screening procedures; immunizations; except as provided in the Preventive Services policy (see Chapter 7, Sections 2.1, 2.2, 2.5, 2.6 and Chapter 12, Section
2.2).
38. Services of chiropractors and naturopaths whether or not such services would be eligible for benefits if rendered by an authorized provider (see Chapter 7, Section 18.5).
49. Orthopedic shoes, arch supports, shoe inserts, and other supportive devices for the feet, including special-ordered, custom-made built-up shoes, or regular shoes later built up (see Chapter 8, Sections 3.1 and 11.1).
A copy of the “TriCare Non-Covered Services Waiver” form is attached.
The following items are from the TriCare Policy Manual (edited to include only services we recognize our clients provide):
31. Removal of corns or calluses or trimming of toenails and other routine podiatry services, except those required as a result of a diagnosed systemic medical disease affecting the lower limbs, such as severe diabetes (see Chapter 8, Section 11.1).
37. Preventive care, such as routine annual, or employment-requested physical examinations; routine screening procedures; immunizations; except as provided in the Preventive Services policy (see Chapter 7, Sections 2.1, 2.2, 2.5, 2.6 and Chapter 12, Section
2.2).
38. Services of chiropractors and naturopaths whether or not such services would be eligible for benefits if rendered by an authorized provider (see Chapter 7, Section 18.5).
49. Orthopedic shoes, arch supports, shoe inserts, and other supportive devices for the feet, including special-ordered, custom-made built-up shoes, or regular shoes later built up (see Chapter 8, Sections 3.1 and 11.1).
If you want to see more details of the above policies, let me know.
February 2011
Medicare – New opportunities to treat patients
As you know, each year Medicare patients must meet their annual deductible which results in a significant cash flow slow down for many providers.
An interesting way to let them meet the deductible elsewhere is for you to use the new Medicare Wellness codes.
Medicare implemented a new Annual Wellness Visit (AWV) service which does NOT require a deductible or co-insurance for the patient.
· The current Initial Preventive Physical Exam (IPPE) (CPT Code G0402), which is available within the first 6 months of Medicare eligibility, has a 2011 Allowed Amount of $158.32.
· The new Annual Wellness Visit codes have Allowed Amounts for 2011: G0438 (Initial) = $173.22, and G0439 (Subsequent years) = $115.95.
Another preventive service that will not have a deductible or co-insurance is Counseling to Prevent Tobacco Use (includes counseling to stop smoking) and is are payable in addition to a regular office visit as long as there are 2 separate services (usually separate diagnosis codes):
- G0436 pays $14.89 for 3-10 minutes of counseling, and
- G0437 pays $30.08 for more than 10 minutes of counseling).
CMS allows 2 separate attempts and up to 4 visits each attempt per year. It also does NOT require a deductible or co-insurance for the patient and can be billed in addition to whatever office visit or procedure codes are billed.
New Medicare covered services
CMS has added the following requested services to the list of Medicare telehealth services for CY 2011:
• Individual and group KDE services:
HCPCS code G0420 (Face-to-face educational services related to the care of chronic kidney disease; individual, per session, per one hour), Allowed Amount $117.28; and
HCPCS code G0421 (Face-to-face educational services related to the care of chronic kidney disease; group, per session, per one hour) Allowed Amount $27.79.
• Individual and group DSMT services (with a minimum of 1 hour of in-person instruction to be furnished in the initial year training period to ensure effective injection training):
HCPCS code G0108 (Diabetes outpatient self-management training services, individual, per 30 minutes) Allowed Amount $58.58; and
HCPCS code G0109 (Diabetes outpatient self-management training services, group session (2 or more) per 30 minutes) Allowed Amount $20.21.
• Group MNT and HBAI services, Current Procedural Terminology (CPT) codes:
- 97804 (Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes) Allowed Amount $14.86;
- 96153 (Health and behavior intervention, each 15 minutes, face-to-face; group (2 or more patients) Allowed Amount $5.02, and
- 96154 (Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present)) Allowed Amount $19.95;
Podiatrists and Nursing home visits
Effective 1/1/10, a Podiatrist can use 99304-99306 for the initial encounter. The 99304 pays about $50 more than the 99307 if the patient qualifies for the 99304.
Medicare 2011 ePRESCRIPTION (eRx) & PQRI
We have reviewed the 2011 CMS eRx requirements – the same code will be used in 2011. However, to avoid a 1% decrease in reimbursement in 2012, you must have at least 10 eRx’s in the first 6 months of 2011.
If you plan to do PQRI in 2011, be sure to check with Rich for 2011 PQRI requirements. They can change each year, and the current year’s measures and codes MUST be used in order to get paid.
EMR / EHR
Just a reminder that CMB will assist you with selection at no cost. The time to negotiate fees, including future options that you may or may not want, is before signing the purchase agreement.
Medicare prepayment review for 99204 & 99205
Highmark Medicare has announced that they will be performing prepayment reviews for all 99204 & 99205 charges. See the attached article from Highmark if you currently bill these codes.
ABN GENERAL NOTICE REQUIREMENTS
ABN requirements include:
· A minimum of two copies, including the original, must be made so the beneficiary and health care provider each have one. The beneficiary should be given a copy of the signed and dated ABN immediately and the health care provider should retain the original copy with the beneficiary’s records.
· The ABN must not exceed one page in length; however, attachments are permitted for listing additional items and services. If an attachment sheet is used, a notation such as “See Attached Page” must be inserted in the Items/Services area of the ABN. Attached pages must include the following:
- Beneficiary’s name;
- Identification number (optional);
- Date of issuance;
- Table listing the additional items/services, the reasons Medicare may not pay, and the estimated costs; and
- A space below the table in which the beneficiary inserts his/her initials to acknowledge receipt of the attachment page.
· A visually high-contrast combination of dark ink on a pale background must be used.
· Some customization of the ABN is permitted.
BENEFICIARY CHANGES HIS/HER MIND
If after completing and signing the ABN the beneficiary changes his/her mind, the health care provider should present the previously completed ABN to the beneficiary and request that he/she annotate the original ABN. The annotation must include a clear indication of his/her new option selection along with his/her signature and date of annotation. In situations where the health care provider is unable to present the ABN to the beneficiary in person, the health care provider may annotate the form to reflect the beneficiary’s new choice and immediately forward a copy of the annotated notice to the beneficiary to sign, date,and return.
Note: In both situations, a copy of the annotated ABN must be provided to the beneficiary as soon as possible.
BENEFICIARY REFUSES TO COMPLETE OR SIGN THE NOTICE
If the beneficiary refuses to choose an option and/or refuses to sign the ABN, the health care provider should annotate the original copy of the ABN indicating the refusal to sign and may list witness(es) to the refusal on the notice, although this is not required. If a beneficiary refuses to sign a properly delivered ABN, the health care provider should consider not furnishing the item/service, unless the consequences (health and safety of the beneficiary, or civil liability in case of harm) are such that this is not an option.
ABN FOR AN EXTENDED COURSE OF TREATMENT
An ABN is not needed every time for an extended course of treatment. A single ABN covering an extended course of treatment is acceptable, if the ABN identifies all items/services and duration of the period of treatment for which the health care provider believes Medicare will not pay. If the health care provider believes Medicare will deny additional services furnished during the course of treatment, a separate ABN is needed.
A single ABN for an extended course of treatment is valid for one year.
Tuesday, January 18, 2011
January 2011
HAPPY HOLIDAYS, Medicare fee schedule, and Red Flags rule
We hope you enjoyed the holidays!
Congress & President Obama did provide 2 nice “gifts” for the new year:
1) Medicare Fee Schedule changes that were to end on 11/30 have been extended thru 12/31/11, and
2) Physicians and other healthcare providers (including ambulance) were exempted from the Red Flags Rule.
As you know, Medicare payment rates under the Medicare Physician Fee Schedule (MPFS) are set according to statutory criteria. Even though the SGR rate will remain stable thru 12/31/11, there are other factors (e.g., RVU updates) that can change the amount paid for individual CPT codes. Once the new rates are published, we will know better how payments will be affected in 2011.
Medicare 2011 Preventive services
Medicare implemented a new Annual Wellness Visit (AWV) service which does NOT require a deductible or co-insurance for the patient. The current Initial Preventive Physical Exam (IPPE) which is available within the first 6 months of Medicare eligibility has a 2010 Allowed Amount of $146.88. The Allowed Amounts for all 2011 codes, including the new AWV, are being recalculated by Medicare based on the 0% change in the SGR and should be re-published any day now (still not available 1/3/11).
Another preventive service that will not have a deductible or co-insurance is Counseling to Prevent Tobacco Use (includes counseling to stop smoking) (codes G0436 & G0437). CMS allows 2 separate attempts and up to 4 visits each attempt per year.
Medicare EMs changes
As you already know from an email from me in November, beginning January 1, 2011 CMS will require ambulance services to track and report mileage to the nearest tenth of a load mile for all trips up to 100 load miles. CMS stated that ambulance services which do not currently have the ability to track tenths of miles must acquire that ability. CMS says this policy change could "save" Medicare - up to $80 million per year.
Additionally, the Rule will decrease annual reimbursement updates by a so-called "productivity adjustment." Beginning in 2011, the Ambulance Fee Schedule will be subject to this adjustment and is expected to reduce Medicare reimbursement to the ambulance industry by around $30 million in the first year that it takes effect.
The Final Rule also talks about CMS's intention to develop a "course of action" to implement the retroactive 2% urban, 3% rural, and 22.6% super rural bonus payments. Ambulance services have being waiting for months for CMS to reprocess these claims.
AMBULANCE FEE SCHEDULE
The Ambulance Inflation Factor (AIF) for 2011 is -0.1%. The AIF in 2010 was 0.0%.
Physical / occupational therapy Medicare fee cut
Just a reminder and as a follow-up to the email last month with a copy of the Medicare MLN Matters article, effective 1/1/11 Medicare will be decreasing their payment when:
· The same patient is seen the same day by more than 1 therapist in the same practice (e.g., PT & OT), or
· A patient receives more than 1 service or unit of service, or both, on the same day.
The modality with the highest RVU’s will be paid in full for the first unit, with all additional units and services paid at the lower rate to reflect the 20% reduction in the Practice Expense portion of the service(s).
Medicare 2011 ePRESCRIPTION (eRx) & PQRI
We have reviewed the 2011 CMS eRx requirements – the same code will be used in 2011.
If you plan to do PQRI in 2011, be sure to check with Rich for 2011 PQRI requirements. They do change each year and the current year’s codes MUST be used in order to get paid.
EMR / EHR
Just a reminder that CMB will assist you with selection at no cost. The time to negotiate fees, including future options that you may or may not want, is before signing the purchase agreement.
MEDICARE EDITING FOR ORDERING/REFERRING PROVIDER FOR DME
As you know, CMS backed off their 1/1/11 date to implement their requirement for all ordering and/or referring providers to be in the PECOS system due to the significant current backlog in processing provider enrollment applications. CMS announced in December 16th that the new “Placeholder” date for compliance is July 5, 2011.
We hope you enjoyed the holidays!
Congress & President Obama did provide 2 nice “gifts” for the new year:
1) Medicare Fee Schedule changes that were to end on 11/30 have been extended thru 12/31/11, and
2) Physicians and other healthcare providers (including ambulance) were exempted from the Red Flags Rule.
As you know, Medicare payment rates under the Medicare Physician Fee Schedule (MPFS) are set according to statutory criteria. Even though the SGR rate will remain stable thru 12/31/11, there are other factors (e.g., RVU updates) that can change the amount paid for individual CPT codes. Once the new rates are published, we will know better how payments will be affected in 2011.
Medicare 2011 Preventive services
Medicare implemented a new Annual Wellness Visit (AWV) service which does NOT require a deductible or co-insurance for the patient. The current Initial Preventive Physical Exam (IPPE) which is available within the first 6 months of Medicare eligibility has a 2010 Allowed Amount of $146.88. The Allowed Amounts for all 2011 codes, including the new AWV, are being recalculated by Medicare based on the 0% change in the SGR and should be re-published any day now (still not available 1/3/11).
Another preventive service that will not have a deductible or co-insurance is Counseling to Prevent Tobacco Use (includes counseling to stop smoking) (codes G0436 & G0437). CMS allows 2 separate attempts and up to 4 visits each attempt per year.
Medicare EMs changes
As you already know from an email from me in November, beginning January 1, 2011 CMS will require ambulance services to track and report mileage to the nearest tenth of a load mile for all trips up to 100 load miles. CMS stated that ambulance services which do not currently have the ability to track tenths of miles must acquire that ability. CMS says this policy change could "save" Medicare - up to $80 million per year.
Additionally, the Rule will decrease annual reimbursement updates by a so-called "productivity adjustment." Beginning in 2011, the Ambulance Fee Schedule will be subject to this adjustment and is expected to reduce Medicare reimbursement to the ambulance industry by around $30 million in the first year that it takes effect.
The Final Rule also talks about CMS's intention to develop a "course of action" to implement the retroactive 2% urban, 3% rural, and 22.6% super rural bonus payments. Ambulance services have being waiting for months for CMS to reprocess these claims.
AMBULANCE FEE SCHEDULE
The Ambulance Inflation Factor (AIF) for 2011 is -0.1%. The AIF in 2010 was 0.0%.
Physical / occupational therapy Medicare fee cut
Just a reminder and as a follow-up to the email last month with a copy of the Medicare MLN Matters article, effective 1/1/11 Medicare will be decreasing their payment when:
· The same patient is seen the same day by more than 1 therapist in the same practice (e.g., PT & OT), or
· A patient receives more than 1 service or unit of service, or both, on the same day.
The modality with the highest RVU’s will be paid in full for the first unit, with all additional units and services paid at the lower rate to reflect the 20% reduction in the Practice Expense portion of the service(s).
Medicare 2011 ePRESCRIPTION (eRx) & PQRI
We have reviewed the 2011 CMS eRx requirements – the same code will be used in 2011.
If you plan to do PQRI in 2011, be sure to check with Rich for 2011 PQRI requirements. They do change each year and the current year’s codes MUST be used in order to get paid.
EMR / EHR
Just a reminder that CMB will assist you with selection at no cost. The time to negotiate fees, including future options that you may or may not want, is before signing the purchase agreement.
MEDICARE EDITING FOR ORDERING/REFERRING PROVIDER FOR DME
As you know, CMS backed off their 1/1/11 date to implement their requirement for all ordering and/or referring providers to be in the PECOS system due to the significant current backlog in processing provider enrollment applications. CMS announced in December 16th that the new “Placeholder” date for compliance is July 5, 2011.
December 2010
CPB Holiday schedule
CPB will be closed on Christmas Eve (Friday, December 24th), and New Years Day Eve, Friday, December 31st. We hope you enjoy the holidays!
PECOS – cms just “blinked”
CMS announced on November 24th that the automated edits will not be turned on effective January 3, 2011. They are working diligently to resolve enrollment backlogs and other system issues and will provide ample advanced notice to the provider and beneficiary communities before we begin any automatic nonpayment actions.
Medicare 2011 Fee Schedule
As you know, Medicare payment rates under the Medicare Physician Fee Schedule (MPFS) are set according to statutory criteria. Medicare has released the 2011 MPFS payment rates which are reflective of the 2011 Physician Fee Schedule Final Rule and are based on current law which provides a negative update for 2011. Before Thanksgiving, the House approved a 1 month delay in a 23% decrease that will take effect on December 1, 2010. The House approved the same measure on November 29 and the President is expected to sign the bill. However, this is only a 1 month reprieve while Congress attempts a permanent fix. Highmark Medicare has suggested affected practitioners consider the possibility of this legislation as you evaluate decisions related to your annual participation election. We will notify you about the 2011 physician update as more information becomes available at the end of December.
EMR’s
I just returned from a 3 day EHR/EMR conference with multiple seminars and reviewed 7 different EMR programs. Each had its own unique approach with different features and ways to use and access them. Purchasing an EMR is a BIG decision. If you haven't already, I strongly recommend that you review at least 5 different vendors to make sure your money is well spent and you can see what the range of quality is. It is important for you to look at each as it would work for your own practice - does the workflow match your office? If you dictate, does it support it?
You and your staff that will use the EMR needs to view it - is it easy to use? Does it capture data the way you practice medicine? Does it support eRx and PQRI? Does it give you the flexibility to use any clearinghouse, patient statement vendor, or export claims to a billing service? You may not choose to use those options, but by having them you retain the ability to make changes if your payments are not what they need to be.
And, very importantly, is it certified as meeting the CURRENT "meaningful use" (MU) criteria? No 2011 certification means no incentive payment from CMS! If it has never been certified, it would be wise to be very careful.
We are also hearing that some vendors are offering to contractually "guarantee" they will meet the current MU criteria. That may not be very good - if they cannot afford to get the certification before you purchase, then what guarantee can they provide if they do not get the certification or go out of business? If they don’t you lose the incentive payment and have to buy new EMR software!
2010 PART B DEDUCTIBLE
The Centers for Medicare & Medicaid Services (CMS) announced the Part B annual deductible for 2010 is $162.00 (it was $155 in 2010). With the poor economy, it is more important than ever to make every effort to collect all co-pays, deductibles (if known), and co-insurances on the date of service. The key is getting the payment before they receive your services, or at worst, before they leave your office.
Also, just a reminder that cash flow will be slow for the first 2-3 months of the year due to the current economy and patients showing greater reluctance to visit their physicians.
Medicare ALLOWABLE FEES
Each year CPB prepares a table with the Medicare Allowable Amounts for your commonly used office CPT codes. If you would like to receive this again in 2011, please notify Rich by December 13th.
2010 MEDICARE PHYSICAL, OCCUPATIONAL & SPEECH THERAPY CAP
The Therapy Cap for 2011 is $1,870 through for 2011. The Medicare Cap Exceptions process for independently practicing physical, speech and occupational therapists appears to have been extended 2011. However, as it currently stands for 2011, Medicare PT/OT fees will be cut for multiple services during a single episode of care after the first CPT code to 75% of the Allowed Amount for the Practice Expense component of the remaining approved CPT codes. The US Senate has approved a reduction in the decrease from 25% to 20% (paying 80%) but we will need to see what the House does.
CPB will be closed on Christmas Eve (Friday, December 24th), and New Years Day Eve, Friday, December 31st. We hope you enjoy the holidays!
PECOS – cms just “blinked”
CMS announced on November 24th that the automated edits will not be turned on effective January 3, 2011. They are working diligently to resolve enrollment backlogs and other system issues and will provide ample advanced notice to the provider and beneficiary communities before we begin any automatic nonpayment actions.
Medicare 2011 Fee Schedule
As you know, Medicare payment rates under the Medicare Physician Fee Schedule (MPFS) are set according to statutory criteria. Medicare has released the 2011 MPFS payment rates which are reflective of the 2011 Physician Fee Schedule Final Rule and are based on current law which provides a negative update for 2011. Before Thanksgiving, the House approved a 1 month delay in a 23% decrease that will take effect on December 1, 2010. The House approved the same measure on November 29 and the President is expected to sign the bill. However, this is only a 1 month reprieve while Congress attempts a permanent fix. Highmark Medicare has suggested affected practitioners consider the possibility of this legislation as you evaluate decisions related to your annual participation election. We will notify you about the 2011 physician update as more information becomes available at the end of December.
EMR’s
I just returned from a 3 day EHR/EMR conference with multiple seminars and reviewed 7 different EMR programs. Each had its own unique approach with different features and ways to use and access them. Purchasing an EMR is a BIG decision. If you haven't already, I strongly recommend that you review at least 5 different vendors to make sure your money is well spent and you can see what the range of quality is. It is important for you to look at each as it would work for your own practice - does the workflow match your office? If you dictate, does it support it?
You and your staff that will use the EMR needs to view it - is it easy to use? Does it capture data the way you practice medicine? Does it support eRx and PQRI? Does it give you the flexibility to use any clearinghouse, patient statement vendor, or export claims to a billing service? You may not choose to use those options, but by having them you retain the ability to make changes if your payments are not what they need to be.
And, very importantly, is it certified as meeting the CURRENT "meaningful use" (MU) criteria? No 2011 certification means no incentive payment from CMS! If it has never been certified, it would be wise to be very careful.
We are also hearing that some vendors are offering to contractually "guarantee" they will meet the current MU criteria. That may not be very good - if they cannot afford to get the certification before you purchase, then what guarantee can they provide if they do not get the certification or go out of business? If they don’t you lose the incentive payment and have to buy new EMR software!
2010 PART B DEDUCTIBLE
The Centers for Medicare & Medicaid Services (CMS) announced the Part B annual deductible for 2010 is $162.00 (it was $155 in 2010). With the poor economy, it is more important than ever to make every effort to collect all co-pays, deductibles (if known), and co-insurances on the date of service. The key is getting the payment before they receive your services, or at worst, before they leave your office.
Also, just a reminder that cash flow will be slow for the first 2-3 months of the year due to the current economy and patients showing greater reluctance to visit their physicians.
Medicare ALLOWABLE FEES
Each year CPB prepares a table with the Medicare Allowable Amounts for your commonly used office CPT codes. If you would like to receive this again in 2011, please notify Rich by December 13th.
2010 MEDICARE PHYSICAL, OCCUPATIONAL & SPEECH THERAPY CAP
The Therapy Cap for 2011 is $1,870 through for 2011. The Medicare Cap Exceptions process for independently practicing physical, speech and occupational therapists appears to have been extended 2011. However, as it currently stands for 2011, Medicare PT/OT fees will be cut for multiple services during a single episode of care after the first CPT code to 75% of the Allowed Amount for the Practice Expense component of the remaining approved CPT codes. The US Senate has approved a reduction in the decrease from 25% to 20% (paying 80%) but we will need to see what the House does.
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