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.

July 2012

CPB BACKUP GENERATOR
In response to the changing weather elements, and to support all clients with the highest level of service possible, CPB will be installing a back-up generator by Sunday, July 15th to ensure that we will not be without power. Many CPB clients use our scheduler, or connect with our billing software, so this will add another layer of security to ensure our daily operations are not interrupted.
If you have any questions, please feel free to contact me.
COMBATING HIGH DEDUCTIBLE HEALTH PLANS
When patient’s have a high deductible, it is worth considering requiring the patient to sign an agreement to use their credit card to pay any deductible or co-insurance balance not covered by insurance. Your credit card company vendor should have a document that can be signed by the patient permitting this. Then if they fail to pay their patient statements, the credit card would be a next option.
If anyone else is interested in Patient Payment Portals and/ or Credit Cards, please contact Rich.
OUT-OF-NETWORK PATIENTS
As the Summer approaches, we occasionally get calls asking how to handle patients who are tourists and far from their home network physician. We STRONGLY recommend that such patients be seen on a CASH basis (or debit/credit card if you accept those) only. Collecting payment ($125?) PRIOR to seeing the provider assures that you will at least be paid something. The patient can be told that you will bill their insurance and refund any overpayment. It is a lot easier to refund than to collect from a patient who has returned home. If they do not want to pay when they need a service, it is not likely they will pay later. And, no need to wait for payment.
MEDICARE TIMELY FILING EXCEPTIONS
The time limit for filing all Medicare fee-for-service claims (Part A and Part B claims) is 12 months, or 1 calendar year from the date services were furnished. Exceptions to the 1 calendar year time limit for filing Medicare claims are as follows:

(1) Error or misrepresentation by an employee, Medicare contractor, or agent of the Department of HHS that was performing Medicare functions and acting within the scope of its authority;

(2) Retroactive Medicare entitlement to or before the date of the furnished service;

(3) Retroactive Medicare entitlement where a State Medicaid Agency recoups money from a provider or supplier 6 months or more after the service was furnished;

(4) A Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) provider organization recoups money from a provider or supplier 6 months or more after the service was furnished to a beneficiary who was retroactively disenrolled to or before the date of the furnished service.
NJMVA FEE SCHEDULE
Please be advised that the NJ MVA Fee Schedule has a $99.00 per day limit for all providers. You are STRONGLY urged to ask patients if they were seen by any other provider each day or will be seeing another provider the day they see you. The Code states:
“NJ Administrative Code 11.3-29.4

(m) The daily maximum allowable fee shall be $99.00 for the Physical Medicine and Rehabilitation CPT codes listed in subchapter Appendix, Exhibit 6, incorporated herein by reference, that are commonly provided together. 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, the insurer shall reimburse in excess of the daily maximum. Such injuries could include, but are not limited to, severe brain injury and 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 N.J.A.C. 11:3-4.. Unless already provided to the insurer as part of a decision point review or precertification request, the billing shall be accompanied by documentation of why the extraordinary time and effort for treatment was needed.”
If you have an MVA pt, you may want to make sure to verify they have not seen another provider on the same day of service. If they have, send us their billing information (including any required reports) so we can get their billing sent ASAP.