April 2013

SEQUESTRATION

Now that sequestration has taken effect, unless Congress & the President can get their collective acts together, Medicare payments will be cut by 2% for dates of service April 1 and after.  So, what does that mean financially? 

The reduction applies to the amount Medicare will actually pay to the provider - AFTER - the appropriate deductible or copayment has been calculated.  So, if the allowable is $100.00, the co-payment is 20% or $20.  Medicare's payment was - pre-sequestration supposed to be $80.00 (80% of the allowable).

NOW, post-sequestration, the $80.00 will be reduced by 2% ($1.60). So instead of the Medicare payment being $80.00, it will be $78.40.  Unfortunately, providers are not authorized to collect the sequester related reduction from the patient.  The patient will still owe the full $20.00 (20%) co-insurance amount.  If the pt has no 2’ insurance, it can be collected during the office visit. 

If anyone needs to know the monthly average amount of Medicare payments or has any questions, contact Rich.  Lots of partisan politics going on for the benefit of some BIG congressional egos. 

Medicare REVALIDATION

Be sure to watch for a letter from Medicare requiring you to revalidate your information with them.  You have a very limited time period to do this.  Failure to do so results in de-activation of your provider # - and a stoppage of all payments – until the revalidation has been completed. 

The Monthly list can be found at:   http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Revalidations.html

MEANINGFUL USE

As you may know, Medicare providers who do not achieve 90 days of Meaningful Use by 12/31/2013 will lose $15,000 in Medicare EHR Incentive Funds.  This means you need to START using your EHR no later than 10/1/2013. Allowing 6-8 weeks to implement and train, you need to purchase by July.  Plus, it is expected many others will delay getting started also, thereby creating a backlog.  CPB can offer some suggested vendors. 

Transitional care management codes 99495 & 99496

So far, only Medicare & Horizon will pay.  Aetna does not.  Horizon & Medicare are allowing the same amount:  99495 = $176.73 & 99496 = $249.06.

Only one physician may bill Medicare for the TCM for any one patient’s discharge from the hospital, and the physician must wait until 30 days after the discharge to bill for the service.  The first physician who submits a claim will be paid.  

Can we bill any services during the 30-day post discharge period?   Yes. Second and subsequent E/M services after the initial bundled E/M service may be reported. Other diagnostic or therapeutic services may be billed.

Anything else we can’t report with these codes?   Yes. Some of the codes that may not be billed with the TCM codes during the time period covered by the TCM codes (29 days post discharge), are:

·         Care Plan Oversight (99339, 99340, 99474-99380)

·         Prolonged services without patient contact (99358, 99359) (with patient contact is allowed)

·         Anticoagulant management (99363, 99364)

·         End stage renal disease services (90951-90970)

Medicare & REFERRING PROVIDERS

Effective May 1, 2013, the long delay in requiring only currently validated providers to be able to refer will end.  On that date, if your referring provider is not in PECOS or in the carrier’s system, you will not be paid for any services (Radiology, Lab, etc.) or equipment, that were referred to you. 

Medicare & ICD-10

Good news, sort of.  On January 18, 2013 CMS instructed its contractors to start the process to update CPT code National Coverage Determinations to ICD-10 codes (now ICD-9).  Medicare uses that list to determine medical necessity for many CPT & HCPCS payments. 

PQRS

Just a reminder that Medicare is requiring providers to participate in the PQRS program to avoid a loss of Medicare payments.  If you need assistance with that, please let me know ASAP as the measures require more participation than in past years.

Medicare AnnuAl wellness visits required documentation

 If you need to know what Medicare requires to be documented for each of the 3 AWV codes, you can use this link:  http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/AWV_chart_ICN905706.pdf

March 2013

SEQUESTRATION

When Congress enacted the sequestration process in 2011, they specifically linked the Medicare Part A and Part B sequestration cuts to commence in a manner according to a process outlined in Section 256 of legislation enacted in 2010 called the “Pay As You Go Act.”

In that legislation, it states that any cuts mandated by the Office of Management and Budget are to take effect for Part A and Part B of Medicare, one month after the date that OMB issues the mandatory order.  Therefore, if, as expected, OMB issues the sequestration order tomorrow, the cuts will not take effect for Part A and Part B of Medicare until April 1.  So providers have a 30 day grace period before we begin to see the actual cuts. 

Government agencies do have flexibility in their spending so all of the “doom & gloom” is not accurate.  And, even at the Program level, they have discretion.  Layoffs are not a necessity.

Also on this point, the Administration and Congress are in agreement that there is $33 Billion in unnecessary farm subsidy money sitting at the Department of Agriculture that is no longer needed.  If the Administration would allow for reprogramming, that money could be taken from Ag and applied against the $85 billion for sequestration and reduce sequestration by more than 1/3.

Earlier today the Washington Post, no less, called out the Secretary of Education on one of his statements.  He said more than 30,000 teachers were going to be laid off due to the sequester.  When asked for specifics, he gave them the name of a school in West Virginia.  However, when the Post Reporter contacted the Superintendent of schools, they said no.  No layoffs.  Maybe next year, but none due to sequestration this year and probably not next year.  They would just reprogram money to avoid teacher layoffs. 

When the Post went back to the Secretary of Education to see what was up, they said that they just took the total amount of money that would have to be cut from a program account, divided it by the average teacher salary ($70,000) for that program and used that number as an example but could not actually produce any teachers who were being laid or nor did they know how local school districts might apply the cuts at a community level.

Lots of partisan politics going on for the benefit of some BIG congressional egos. 

Preventing Lost Insurance Checks

Occasionally insurance checks somehow get lost in the mail resulting in delayed payment to the provider.  The best way to avoid this is direct deposit (also known as EFT – Electronic Fund Transfer) and is the same as save way that Social Security, AARP and others require.

We STRONGLY suggest you consider Direct Deposit/ EFT for as many payments as possible since it avoids delay due to nearly all external factors, including bad weather, theft, misplacing checks, etc.  And no one needs to go to the bank to deposit those checks – just check your bank account online.

PQRI

A reminder that CMS will use 2013 as the reporting year for Medicare cuts beginning in 2015 if providers do not participate in PQRS in 2013.  Thus, if you want to insure that you do not get the 1.5% reduction in Medicare payments beginning in 2015, followed by a 2% reduction beginning in 2016 you MUST participate in 2013.

EHR’s – BY THE NUMBERS

Software Advice, a vendor neutral software research company, released the following statistics about Health IT:

• 115,918 - The number of Eligible Professionals that have successfully attested for Meaningful Use.
• 623 - The number of vendors listed on the Office of the National Coordinator's Certified Health IT Product List.

These numbers strongly support the case that the implementation of Health IT is growing quickly and is changing the way the medical community delivers quality healthcare.  But implementation of an EHR system is only the beginning.  Meaningful Use of an EHR system is the foundation upon which the growth of Health Information Exchanges (HIEs) and the movement toward Patient-Centered Medical Homes will be built upon.  NJ-HITEC urges providers throughout the Garden State to get on board before they fall too far behind.  

Medicare payment for G0444 – Annual depression screening

Medicare pays when this code is billed with an office visit, but not when billed with an Annual Wellness Visit.  Consider doing the Depression Screening during a separate visit. 

More EHR – DISCONTINUED EHR’s

 

Allscripts recently announced they were discontinuing support of Medinotes and MyWay. Why are EHRs discontinued? How can a buyer keep from purchasing an EHR that might be discontinued?

Some products that have been discontinued:

• Misys will not be certified for MU – Customers encouraged to move to Allscripts
• GE discontinued Advance EHR (Jan 2012)
• Medinotes is discontinued by Allscripts effective 12/31/2012
• Epocrates announced EHR was discontinued (May 2012)
• Allscripts MyWay will not be upgraded for Meaningful Use Stage 2 (announced Oct 2012)

Are there any common themes?

1. When a company owns several EHRs and in particular EHRs that serve the same practices sizes, they are likely to discontinue the “duplicate” EHRs.
2. Expensive EHRs are not as marketable to smaller practices and thus more likely to be shuttered and/or replaced.
3. Companies may have difficulty maintaining products that they did not build.
4. EHR is competitive – newer products that do not have full competitive functionality and/or insufficient market share to be profitable may be closed. These companies may close or other vendors may purchase them for their customers/market share and not the technology.

How can you avoid getting stuck? Some things to look for:

• How many customers do they currently have?
• Ownership. Public companies may have very high growth and profit motives vs. customer service orientation. Companies funded by venture capital generally have very high growth expectations with the goal of being purchased by another company.
• How long has the company been in business?
• When was the last version of the software released?
• Does the vendor charge extra for new releases?
• Is there a Meaningful Use guarantee for Stage 2 and 3?
• Does it feel right? For example a “free” or really low cost EHR has to cover their costs somehow – are they just looking to hook you so they can raise their rates later or sell their company to another one looking to buy market share and then switch you to another EHR?
• How old is the technology? If the system still looks and operates much as it did 5 years ago the company may not be investing for the future.

No one has a crystal ball so no matter what you do make sure that your EHR contract gives you your data in the event you cancel or otherwise need to move to another EHR down the road.

February 2013

Slow Medicare Payments

Just a reminder that that Medicare patients must meet their annual deductible in January which causes a slowdown in cash flow.  But due to Congress’ delay in approving the Conversion factor until January 2^nd, it is even slower paying than usual.  The reason is that all of the Medicare contractors (MAC’s) could not process any claims until the fee schedules were updated.  CMS gave the MAC’s until January 23^rd to get that done.  Novitas released their fee schedule on 1/22.  So, instead of being able to process a charge to deductible and releasing it to the 2’ early in the month, all of those charges were delayed nearly 3 weeks.  Cash flow should start to pick up by mid-February and improve from then on. 

FREE Eligibility Checking for CPB Appointment System Users!

Patient eligibility is now offered to all clients using the CPB Scheduler.  If you are interested in using it, please call Rich.  At least for the next few months, CPB will cover the cost.

EHR’s – CHOOSE WISELY THE FIRST TIME

According to Medscape.com (August 13, 2012 edition) half of EHRs sold are replacements!  “Use of electronic health records (EHRs) is snowballing, and so is the number of unhappy users. Half of EHR systems sold to physician practices are now replacements, up from 30% last year, according to a recent study by research firm KLAS. The leading reason for switching systems, cited by 44% of practices, is product issues. Service issues (15%) and group consolidation (14%) - such as when a hospital converts newly hired physicians to a new EHR - are a distant second and third.

Morale of the Story:  Choose carefully and thoroughly evaluate your choice before purchasing.  It is disruptive enough to move from paper to electronic.  Switching to another EHR is a 2^nd major impact to your practice.

TherAPy Cap 2013 update

CMS announced that the Therapy Cap will be $1,900 for 2013.  Once the total gets to $3,700, then Medicare is required to perform a mandatory review the same as late in 2012. 

The other new items are the new “G” codes, Proper Modifier Reporting, and Multiple Procedure Payment Reduction (MPPR) process.

 

ICd-10

ICD-10 is still about 20 months away, but after attending an ICD-10 coding class earlier this month, thought you might enjoy some statistics.  Someone took the time to count the # of ICD-9 codes commonly used by several specialties and compare them to the same ICD-10 codes. 

Specialty	ICD-9	ICD-10	Increase
Cardiology	178	430	2.4
Family Practice	229	829	3.6
OB/GYN	220	777	3.5
Pediatrics	165	836	5.1
Orthopedics	143	5843	40.9

Aetna Medicare Advantage (MA) plans

Per Aetna, “Aetna Medicare Advantage (MA) plans now cover an annual wellness visit; no longer cover annual physicals.   Effective January 1, 2013, Aetna MA plans include coverage for an annual wellness visit. The CPT codes for a wellness visit are G0438 and G0439.

Aetna MA plans no longer cover annual physical exams. The CPT codes for the annual physical exam are 99381-99397, 99401-99404, 99201-99205 and 99211-99215 with primary diagnosis of preventive. The preventive diagnosis codes that are not covered are:  V03.0-V03.9, V04.0-V04.89, V05.0-V05.9, V06.0-V06.9, V20.0-V20.2, V70.0, V70.3, & V70.5.

 This change was made as a result of a change in coverage made by the Centers for Medicare and Medicaid Services (CMS).”

PATIENT BALANCES

According to a recent article in MGMA Connexion, $1 of every $4 owed is now paid by the patient.  That is 25% of the average practice’s revenue. 

Ways to collect these balances:

• Verify patient eligibility when the appointment is made.  At the latest, verify it a day before the appointment so you can have the appropriate discussion on the date of service. 
• Be sure patients know when the appointment is made that payment is due on the date of service.
• Collect all co-pays before the patient is seen.
• Accept credit & debit cards

Current state-of-the-art software provides features to establish and create payment plans using credit & debit cards, automatic scheduling of those payments (with patient / guarantor approval, of course), store the credit card data in a fully compliant PCI format, etc.  CPB has access to such programs.  If you are interested, please contact Rich.

January 2013

CONGRESS - & the fiscal cliff

If Congress is unable to do what they were sent to Washington to do, we will again recommend that you ask us to hold your 2013 Medicare charges until agreement has been reached.  Otherwise, Medicare will pay the charges at the approximately 26% decrease – then have to go thru reprocessing.  That works “ok” for Medicare, but the 2’ insurances often have difficulty handling that.

FREE Eligibility Checking for CPB Appointment System Users!

Patient eligibility is now offered to all clients using the CPB Scheduler.  If you are interested in using it, please call Rich.  At least for the next few months, CPB will cover the cost.

Medicare Part B Deductible for 2013

The Medicare Part B Deductible for 2013 is $147. 

TherAPy Cap 2013 update

CMS announced that the Therapy Cap will be $1,900 for 2013.  The only catch is that the Therapy Caps were only authorized thru 2012 so we’ll have to see if they are extended.

 

Refunds – Please do not send refunds until cpb verifies

Just a reminder to not accept any insurance company’s request for a refund until CPB verifies it is correct.  Many of the insurances which providers participate with (Medicare, Medicaid, Horizon, Aetna, CIGNA, United healthcare, etc.) will do an automatic offset upon request – which we can initiate for you once we confirm the refund is due.  Be sure to send us a timely copy of the refund request. 

If you pay and they do an offset, we may not be aware of your payment and you could end up short! 

MEDICARE HOME HEALTH VISITS CERTIFICATION COVERAGE

The G0180 Home Health Certification Code is only covered once per 60 days. If it is billed more frequently, patients may not be billed unless a properly completed ABN is received.

QUALCARE WILL NOT OVER AN OFFICE VISIT & WELL VISIT

QualCare will not cover both an office visit and a Well visit on the same day.  They will pay the higher of the two, but even with the usual modifier, only one of the two services is covered. We suggest in these cases that the patient be brought back for a separate visit for the Well service.

PATIENT BALANCES

According to a recent article in MGMA Connexion, $1 of every $4 owed is now paid by the patient.  That is 25% of the average practice’s revenue. 

Ways to collect these balances:

• Verify patient eligibility when the appointment is made.  At the latest, verify it a day before the appointment so you can have the appropriate discussion on the date of service. 
• Be sure patients know when the appointment is made that payment is due on the date of service.
• Collect all co-pays before the patient is seen.
• Accept credit & debit cards

 Medicare CERT Audits

Medicare continues to perform their CERT (Comprehensive Error Rate Testing) Audits.  If a provider does not respond, the money in question is automatically recouped.  The envelope containing the request letter is very distinctive:

If no response is received within 30 days, they will send three more reminders with 15 days for each.  If still no response then the claim will be denied and a demand letter sent.

December 2012

CPB Holiday closings

CPB will be closing a few hours early on Thursday, December 6^th at 1:30 for our Annual Staff Appreciation event.   CPB will be closed on December 24 & 25 for Christmas.

 

Congress and the “fiscal cliff”

Current “wisdom” is to save as much cash as you can before the end of the year.  In the Atlantic City Press last week there was discussion that the Democrats may not cut a deal until January as a way to force the Republicans to make more concessions.  Of course the Republicans & Democrats have both been unwilling to make concessions previously – thus the “fiscal cliff.”  So, better to save now to pay bills in January than to run out of cash while Congress plays games. 

CPT CODE CHANGES IN 2013

CPT Code changes for our clients affect Nerve Conduction Studies, Psychotherapy, and a couple of deleted vaccine codes (90701 & 90718).  Each client has been contacted and the new codes added to their dataset and Charge form.  Deleted codes have been indicated in Healthpac to avoid using when they are no longer valid.  

November 2012

Hurricane sandy

Hurricane Sandy has passed and we hope everyone is able to get back to normal as soon as possible.  Fortunately, CPB did not experience any service interruption.  If anyone needs assistance, please let us know. 

CHANGING MEDICAL environment – We are here for You!

As you are aware, the medical environment is changing rapidly – EHR’s, ICD-10, etc.  CPB is well prepared to help guide and support you thru all of these changes.  Most of the preparation for ICD-10 change will be handled by CPB, our software vendor, our coders, and the insurance companies.  ICD-10 is not effective until October 1, 2014 and we have already performed our Risk Analysis. 

The growing corporatization of medicine has forced many physicians to consider giving up the independence of private practice to merge with a larger practice or hospital. Unfortunately, this not only takes away from the physician’s ability to provide individualized, quality care but will not avoid problems that arise from the inevitable changes caused by ICD-10.

If you are beginning to wonder what effect the whole process will have on your practice, be comfortable knowing that CPB will be working with you well in advance to ensure your cash flow is not interrupted. Our success is tied to your success and we are partners in this challenging transformation.

We appreciate the opportunity to serve you and look forward to helping you through the upcoming 2 years of ICD-10 changes.

HOME INR TESTING & PAYMENT

Medicare covers 2 INR codes:

• G0248:  “Demonstration, prior to initiation of home INR monitoring, for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a physician; includes: face-to-face demonstration of use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results, and documentation of patient's ability to perform testing and report results.  Medicare’s Allowed Amount for southern NJ is $140.25.

• G0250:   “Physician review, interpretation, and patient management of home INR testing for patient with either mechanical heart valves(s), chronic atrial fib, or venous thromboembolism who meets Medicare coverage criteria; testing not occurring more frequently than once a week, billing units of service include 4 tests per unit.”  Medicare’s Allowed Amount for southern NJ is $9.68 and is billable every 4 weeks.

For both codes be sure to include a Diagnosis for the medical condition that requires the INR monitoring (A Fib, etc.), as well as V58.83 & V58.61.  We can update your Healthpac Charge form if it does not already have the necessary codes.

October 2012

HORIZON NJ HEALTH – NOW REQUIRING CO-PAY’S

As you may know, Horizon NJ Health is now requiring a co-pay.  We strongly recommend that it be collected on the date of service. 

Refunds

1. We reviewed the cause of refunds for the past few months – well over half are due to collecting co-pays for Well visits (99381-99397) when that was the only reason the pt was seen.  It is not necessary to collect the co-pay when the pt was only seen for a Well Visit. 

            If the pt had both a Well visit and a “sick” visit, then the co-pay should be collected for the          sick visit. 

2. Another smaller but significant # of refunds are for patients only seen and billed for a procedure (echo, surgery, injection, etc.) – no office visit was billed.  No co-pay is usually necessary then either.

Both of the above are separate from a patient’s deductible – which, if not met, still needs to be collected.

Of course, please do not pay any refund request from an insurer that has not been reviewed and confirmed by CPB as an overpayment.  For Medicare and other insurers who will do offsets, we will notify the insurer (if we agree) to do that offset.  If you send a check, they often still take the $ back and then also have your check. 

CHECKING PATIENT ELIGIBILITY & STATUS OF CO-PAY & DEDUCTIBLES

For clients using the Appointment Scheduler, we will have the ability to check patient eligibility and status of co-payments & deductibles in the near future.  If you are interested in this service, please let Rich know.

BENEFITS of patient portals

For office-based specialties, physician and non-physician, the current “best practices” emphasizes collecting the known patient balances on the date of service.  Web-based programs now offer convenience to both the offices and patients that were not available in the past.  The following is an example of the benefits:

“Boca Raton Regional Medical Center has significantly boosted collections from its patients by placing a payment portal on the hospital's website.

The 400-bed facility in Southeast Florida added the payment portal to its website in the spring of 2011 with the intent of increasing cash flow and reducing its accounts receivable days, Veronica Small, Boca Raton's patient finance services director, said at the Healthcare Finance Management Association's annual national institute in Las Vegas on Monday.

Although web-based portals for paying bills have proven immensely popular for consumers, healthcare has been slow to adapt such methods. Less than 10 percent of patient payments were made online in 2010, reported American Medical News. However, some software companies are moving toward that arena, even offering smart phone apps to process patient payments, according to Tech Crunch.

Boca Raton had performed a little more than 77,000 patient payment transactions between April 2010 and March 2011, the one-year period just prior to installing the payment portal. After its installation in April 2011, transactions increased more than 10 percent, to 84,463 during the following one-year period. Overall collections increased from $13.8 million to $14.7 million. Accounts receivable over 180 days--considered the write-off point by the hospital--dropped more than 6 percent.” 

If you want to read the full article, you can find it at:

http://www.fiercehealthfinance.com/story/hospital-boosts-patient-payments-online-portal/2012-06-26?utm_medium=nl&utm_source=internal

Medicare Influenza Vaccine Fees – 2012-13

 Payment Allowances Effective for Dates of Service between October 1, 2012 and September 30, 2013 are:

Q2035	Afluria vacc	$11.54
Q2036	Flulaval vacc	$9.83
Q2037	Fluvirin vacc	$14.05
Q2038	Fluzone vacc	$12.05
Q2039	Not otherwise specified flu vacc	Individual Consideration
90654	INFLUENZA VIRUS VACCINE	$18.98
90655	INFLUENZA VIRUS VACCINE	$16.46
90656	INFLUENZA VIRUS VACCINE	$12.40
90657	INFLUENZA VIRUS VACCINE	$6.02
90660	INFLUENZA VIRUS VACCINE	$23.46
90662	INFLUENZA VIRUS VACCINE	$30.92
90669	PNEUMOCOCCAL CONJUGATE VACCINE	$95.48
90670	PNEUMOCOCCAL CONJUGATE VACCINE	$137.03
90732	PNEUMOCOCCAL POLYSACCHARIDE VACCINES (PPV)	$65.77
90740	HEPATITIS B VACCINE (HBV)	$119.42
90743	HEPATITIS B VACCINE (HBV)	$24.22
90744	HEPATITIS B VACCINE (HBV)	$24.22
90746	HEPATITIS B VACCINE (HBV)	$59.71
90747	HEPATITIS B VACCINE, DIALYSIS	$119.42

Vaccine Administration Codes:

• G0008 - ADMINISTRATION OF INFLUENZA VIRUS VACCINE
• G0009 - ADMINISTRATION OF PNEUMOCOCCAL VACCINE
• G0010 - ADMINISTRATION OF HEPATITIS B VACCINE
• G9141 - INFLUENZA A (H1N1) IMMUNIZATION ADMINISTRATION

In NJ the Vaccine Administration Codes Allowed amount is $26.58 for southern Jersey and $27.79 for Central & northern Jersey.

September 2012

MEDICARE ANNUAL WELLNESS VISITS AND EKG’S

G0402 Initial Preventive Physical Exam (IPPE) First 12 months of Medicare eligibility

G0403 Used only with G0402 to obtain a baseline EKG

G0438 First Annual Wellness Visit after 12 months of eligibility.

G0439 Subsequent years Annual Wellness visits. Must be 12 months since the previous year’s G0438 or G0439.

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 for an EKG - and get paid- with either a G0438 or G0439 you will need one of the pathologic diagnosis indications.

COLLECTING CO-PAYS

Reminder – only collect copays for office visits – not for Well Visits (99381-99397) or if the patient only received a procedure (no office visit). They almost always are overpayments resulting in refunds.

BILLING DRUGS

Some drugs are covered by insurers. Please not the following requirements:

• The NDC #, found on the product packaging, is required by NJ Medicaid and a few other insurers. Please be sure to send a copy of the label – large enough to be readable. Be sure to provide the unit measure given (Grams, mg, ml, etc.)

• The HCPCS (J”) code description specifies how it is to be billed – which often is very different than the way it is packaged. If it says “per mg” – and there are 10 mg/ml – then if you give 1 ml you will need to indicate 10 units (mg’s) on the charge form. Then you will get paid the correct amount. If you give 1 for “1 ml” – then you will not get paid in full.

Examples:

• 1 - description of drug is per 6 mg. 6 mg administered. Therefore - 1 unit is billed.

• 2 - description of drug is per 50 mg. 200 mg administered. Therefore - ◦ 4 units are billed.

• 3 - description of drug is per 1 mg. 10 mg vial of drug administered. Therefore - 10 units are billed

For Medicare, it is specifically stated that they will not cover an injection (96372) “if the provider is paid for any other physician fee schedule service (includes any office visit) furnished at the same time.” (August 29, 2012 Novitas Webinar.

Drug Waste:

• If the remainder of a vial must be discarded after being administered, the program covers the amount discarded as well as the amount administered.

• The amount ordered, administered, and the amount discarded must be documented in the

medical record.

• Coverage of discarded drugs applies only to single use vials. (CMS 100-02, Chapter 17, Section 40)

Let me know if we need to change your charge form.

RAPID STREP REIMBURSEMENT (2012)

Insurance Allowed Amount

Horizon $ 13.17

AmeriHealth $ 15.00

Aetna $ 9.29

CIGNA $ 10.94

Out-of-State Blue Shield $ 13.94

United Healthcare $ 7.70

In all cases, insurance paid the lab fee in full. Be sure the Dx code shows medical necessity.

EHR & PQRI Penalties

EHR penalties begin in 2015 at 1% based on 2013 performance for those that have successfully attested in a prior year and must use an EHR for a full year to comply. For those that are in their first year, they can use an EHR for 3 months in 2014 to avoid the 2015 penalty as long as they attest by July 2014.

The EHR penalties increase by 1% per year between 2015 and 2019 maxing out at 5%. By 2016 the PQRS penalties max out at 2%.

The total penalty assessment beginning in 2019 will be 7% of Medicare revenue.

AMBULANCE

Dizziness

Dizziness is covered if the patient has

• a Glasgow score of 15, or

• Transient symptoms of dizziness associated with neurologic or cardiovascular symptoms and/or signs, or abnormal vital signs (e.g., hypotension)

Be sure to document the additional signs & symptoms in order for dizziness to be covered.

Medicare Policy:

“Complaint or Symptom: Altered level of consciousness (non-traumatic)

Condition Requirement: Neurologic dysfunction in addition to any baseline abnormality


Examples of Systems and Findings Necessary for Coverage (and Documentation):  Acute condition with Glasgow Coma Scale <15 abnormal="abnormal" and="and" associated="associated" cardiovascular="cardiovascular" dizziness="dizziness" nbsp="nbsp" neurologic="neurologic" of="of" or="or" p="p" signs="signs" symptoms="symptoms" transient="transient" vital="vital" with="with">

Complaint or Symptom: Neurologic dysfunction

Condition Requirement: Acute or unexplained neurologic dysfunction in addition to any baseline abnormality.

Examples of Systems and Findings Necessary for Coverage (and Documentation): Signs include facial drooping, loss of vision without ophthalmologic explanation, aphasia, dysphasia, difficulty swallowing, numbness, tingling extremity, stupor, delirium, confusion, hallucinations, paralysis, paresis (focal weakness), abnormal movements, vertigo, unsteady gait/balance.”

The scale comprises three tests: eye, verbal and motor responses. The three values separately as well as their sum are considered. The lowest possible GCS (the sum) is 3 (deep coma or death), while the highest is 15 (fully awake person).

Best eye response (E)

There are four grades starting with the most severe:

1. No eye opening
2. Eye opening in response to pain. (Patient responds to pressure on the patient’s fingernail bed; if this does not elicit a response, supraorbital and sternal pressure or rub may be used.)
3. Eye opening to speech. (Not to be confused with the awakening of a sleeping person; such patients receive a score of 4, not 3.)
4. Eyes opening spontaneously

Best verbal response (V)

There are five grades starting with the most severe:

1. No verbal response
2. Incomprehensible sounds. (Moaning but no words.)
3. Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange)
4. Confused. (The patient responds to questions coherently but there is some disorientation and confusion.)
5. Oriented. (Patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month, etc.)

Best motor response (M)

There are six grades starting with the most severe:

1. No motor response
2. Extension to pain (abduction of arm, external rotation of shoulder, supination of forearm, extension of wrist, decerebrate response)
3. Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response)
4. Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched)
5. Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.)
6. Obeys commands. (The patient does simple things as asked.)

August 2012

CPB BACKUP GENERATOR
I am pleased to announce that the office backup generator installation was completed on July 17th ! This is a substantial commitment to our clients and staff to ensure that our ability to service clients and perform our daily work will not be interrupted by a loss of electric. Very few billing services have gone to this level of backup.
In the event of a power outage, the individual hardware battery backups will carry the equipment for the 10 second delay until the generator starts. Since it is fueled by natural gas, it should never run out. We also protect your data with both an automatic onsite and offsite data backup every 2 hours.
We thank all of you for allowing us to serve you!
OBAMACARE
There has been speculation & discussion about the real effects of the Patient Protection and Affordable Care Act (aka Obamacare) now that the Supreme Court has upheld most of that law.
First, no one can say for certain what will happen with physician or other payments over the next few years. Much depends on whether people actually will purchase the insurance since there are essentially no penalties if they do not (withholding tax return money can easily be avoided by not having as much withheld).
Second, what might happen to physician payments in one specialty may not be what is realized by physicians in other specialties. With increased emphasis on "primary care" it is entirely conceivable that payments for primary care services and primary care providers will increase over the next few years whereas payments for certain specialists could go down.
Finally, there is strong pressure both from government and employers to get healthcare costs under control and that appears to be translating into changing how healthcare is delivered & paid for.
Any time there is change, there will be winners and losers and healthcare is no different. Some specialties (physician and non-physician) may see improved revenues and others see reduced revenues.
ERX – TWO NEW EXEMPTIONS
CMS announced 2 New Exemptions to Avoid the 2013 eRx Payment Adjustment

CMS has created two additional hardship exemptions to avoid the 2013 Medicare e-Prescribing Payment Adjustment. The new exemptions are:

• Eligible Professionals (EPs) that have achieved or are planning on attesting to Meaningful Use on or before October 14, 2012.

• Eligible Professionals that show intent to be part of the EHR incentive program through registration and adoption of a certified EHR.

The deadline for these new exemption categories is October 15, 2012. To request a significant hardship exemption, EPs and group practices must submit their hardship exemption requests through

https://www.qualitynet.org/portal/server.pt/community/communications_support_system/234
OIG PROBES PHYSICIAN MEDICARE BILLING FOR OFFICE VISITS
“Physicians are billing Medicare for far more intensive evaluation and management services than they did a decade ago, according to a Dept. of Health and Human Services Office of Inspector General report released in May.
Use of the two highest-level codes for established patient office visits has increased by 17%, as doctors have billed Medicare for fewer low- and mid-level codes from 2001 to 2010, the OIG said. Utilization of the high-level code for billing an emergency department visit also has risen 21%, while the top code for subsequent inpatient hospital care has increased 9%.
The OIG concludes in the report that several factors have led to these increases, including a boost in the overall number of services provided to patients and the average payment for evaluation and management services. “However, changes in physicians’ billing of E&M codes also contributed to this increase,” the report states.
The inspector general did make note of aberrant billing patterns during its review and sent the Centers for Medicare & Medicaid Services a list of 1,669 physicians who billed many more complex and expensive codes than their peers. The Medicare agency will forward the list to its contractors and direct them to focus on the top 10 billers in each jurisdiction for further review, according to a March 28 memo from acting CMS Administrator Marilyn Tavenner.
The health professionals singled out in the report had billed high-level codes at least 95% of the time and could find themselves in trouble with the government, Nicoletti said. The three specialties with the largest percentage of physicians using high-level codes were Internal Medicine, Family Practice and Emergency Medicine.
Medicare plans to publish its own report targeting 5,000 physicians who billed high-level evaluation and management services consistently. The report is not intended to be an indication of fraud. “The intent is to be proactive and provide statements that will support helpful insights into physician coding and billing practices,” Tavenner said. That report was scheduled for release in June.”
Ambulance Clients
Obtaining insurance information is key to getting paid. Hospitals provide information (tho often a week or more later). Patients often ignore both phone calls and statements which often results in them going to collections – and no or less money for the municipality. It is harder for patients to ignore when you are face-to-face.
We recognize that patient care is your first priority, as it should be.
But when you are obtaining other information from the patients, if you could get insurance information it would greatly help the municipality and avoid collections for some patients.
Just a reminder to please get not only the Name of the insurance company, but also the policy and Group #’s.
Many insurers, including MVA & W/C, service claims out of multiple offices. In those cases, getting the address of the correct office is critical to billing the claim – we can then call the adjuster and get the required Claim #’s.
We appreciate your assistance.
Medicare Billing Issues
The information below is intended to assist EMTs with the nuances of the new Medicare ambulance payment policy. It is not intended to suggest documenting signs or symptoms that are not present. It is intended to encourage:

1. Documenting all signs or symptoms that are found.

2. Asking more probing questions to support the patient’s condition as found and include those answers in the Run Report.
The codes selected are based on what is written in the Run Reports.
“Weakness and Dizziness”
For weakness to be covered, the patient must not be able to walk or stand – which needs to be documented in the Run Report. Dizziness is not considered clinically to be the same as altered mental status
Page 26 of the Medicare Ambulance Policy:

“Statements such as the following, absent supporting information, are insufficient to justify Medicare payment for ambulance services:
■ Patient complained of shortness of breath.

■ History of stroke.

■ Past history of knee replacement.

■ Hypertension.

■ Chest pain.

■ Generalized weakness.

■ Is bed-confined.”
If possible, try to determine what might be causing the weakness.
Shortness of Breath vs. Respiratory Distress

Shortness of breath (786.05) is not covered. Respiratory “insufficiency/distress” (786.09) is covered. Be sure to differentiate. Providing oxygen is covered.