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Tuesday, January 27, 2015

Medicare simplifying face-to-face encounter requirements for home health certification

Certifying that a patient is eligible for Medicare-covered home health services got a little simpler under a rule that went into effect Jan. 1. Let’s discuss the changes and what they may mean for your practice.

Beginning in 2011, the Affordable Care Act required that before a patient was certified as eligible to receive the Medicare home health benefit, the physician or allowed non-physician practitioner had to have a documented face-to-face encounter with the patient. The federal regulations implementing the law required that the face-to-face encounter be related to the primary reason the patient needed home health services and occur no more than 90 days before or 30 days after the date the home health care started. Also, as part of the certification of eligibility, the certifying physician had to document the date of the encounter and include a clinical explanation (i.e., narrative) supporting that the patient is homebound, as defined in the law, and in need of either intermittent skilled nursing services or therapy services, as defined in the regulations.

Effective for home health episodes that began on or after Jan. 1, 2015, the Centers for Medicare & Medicaid Services (CMS) has generally eliminated the narrative requirement. All other requirements related to certifying the patient’s eligibility for the Medicare home health benefit remain in place. Likewise, CMS will continue to pay physicians for home health certification (code G0180) and recertification (code G0179), as appropriate.

The one exception is when the physician orders skilled nursing visits for management and evaluation of the patient’s care plan. Because the skilled nurse is essentially ensuring that unskilled care is achieving its purpose, CMS believes that it is still appropriate for the physician to include a brief narrative describing the clinical justification for this need as part of the certification/re-certification of home health eligibility. CMS believes such instances should be infrequent, meaning that, most of the time, physicians will not need to provide a narrative.

CMS reminds certifying physicians that they are responsible for providing the medical documentation necessary to support that the patient is eligible for the home health benefit. Indeed, Medicare plans to review only the certifying physician’s medical record for the patient to determine eligibility at the start of care. If the patient’s medical record is not sufficient, Medicare will not pay for home health services. Further, if the home health agency’s claim is not covered because of insufficient documentation, Medicare also will not cover or pay the physician’s claims for certification/recertification of eligibility for home health services.

Certifying physicians who show patterns of non-compliance with this requirement, including providing inadequate or incomplete documents, may be subject to increased reviews, including services unrelated to the home health claim being reviewed or the Medicare patient who was referred for home health services.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Monday, January 26, 2015

Medicare sets goals for value-based reimbursement

Federal officials have set an ambitious timeline to speed up adoption of Medicare reimbursement models based on value, instead of strictly volume of services.

The U.S. Department of Health and Human Services (HHS) announced Monday a goal of having at least 85 percent of all traditional, fee-for-service Medicare payments tied to some sort of quality component by the end of 2016 and 90 percent by the end of 2018. As part of that effort, it aims to have at least 30 percent of all Medicare payments tied to quality or value through alternative payment models, such as accountable care organizations or bundled payment arrangements, by the end of 2016 and 50 percent by the end of 2018.

This is the first time HHS has set distinct targets for value-based payment models, which were included in the Affordable Care Act but not tied to specific goals. Proponents say changing from the current fee-for-service model will cut costs and encourage physicians to take greater responsibility for patient outcomes. HHS officials say about 20 percent of Medicare payments are now tied to alternative payment models, compared with none in 2011. Medicare fee-for-service payments last year totaled $362 billion.

HHS Secretary Sylvia Burwell announced the new goals after meeting with a group representing physicians, insurers, large corporations, and consumers. She also announced the creation of the Health Care Payment Learning and Action Network, which will work with all of these groups, plus individual states and Medicaid programs, to develop and encourage new alternative payment models.

For more information, Medicare has provided a fact sheet.

Tuesday, January 20, 2015

Medicare updates coverage for pneumococcal vaccinations

Medicare Part B covers certain immunizations, including pneumococcal vaccines. Historically, Medicare covered pneumococcal vaccine only once in a beneficiary’s lifetime, with revaccinations covered for those at highest risk if either five years had passed since the last vaccination or the beneficiary’s vaccination history was unknown.

The Advisory Committee on Immunization Practices (ACIP) recently updated its guidelines regarding pneumococcal vaccines. The ACIP now recommends administration of two different pneumococcal vaccinations.

The Centers for Medicare & Medicaid Services, in turn, is updating the Medicare coverage requirements to align with the change. An initial pneumococcal vaccine may be administered to all Medicare beneficiaries who have never received a pneumococcal vaccine under Medicare Part B. A different, second pneumococcal vaccine may be administered one year after the first vaccine was administered (i.e., 11 full months have passed following the month in which the last pneumococcal vaccine was administered). Please note that the “interval” between the two different pneumococcal vaccines must be 11 or more months for Medicare coverage, not eight weeks or six months as recommended by the ACIP.

The implementation date for the policy change is Feb. 2, effective with dates of service on or after Sep. 19, 2014. Medicare administrative contractors will not search for and adjust any pneumococcal vaccine claims dated on or after Sep. 19, but they may adjust such a claim if the physician brings it to their attention. Additional information can be found at Medicare Learning Network Matters.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Wednesday, January 14, 2015

2015 is a year of coping with Medicaid and Medicare cuts

It’s a new year, and some family physicians are facing immediate and pending cuts to their Medicaid and Medicare payments. What can you do in response?

The Affordable Care Act increased Medicaid payments for specified primary care services to Medicare levels for certain primary care physicians in 2013 and 2014. Unfortunately, that provision has expired, and for most family physicians, Medicaid parity payments ended Dec. 31. More than a dozen states have made a commitment to continue the payment policy in 2015 at their own expense. However, that still leaves most states in the position of reverting to rates below Medicare, an effective cut in Medicaid payment from 2014 for family physicians in those states.

Some family physicians are also experiencing an immediate cut in their Medicare payments due to adjustments (i.e. penalties) associated with Medicare initiatives such as the Physician Quality Reporting System and Meaningful Use. Those who are and even those who are not also face an impending cut in Medicare payments due to the Sustainable Growth Rate (SGR). Under current law, the Medicare physician payment rate will be reduced by 20.1 percent on April 1 unless Congress intervenes in the meantime. Congress is expected to take the necessary steps to prevent this cut, but it is unclear if lawmakers will attempt to enact long-term payment reforms before the 2016 election. More likely is a 20- to 24-month extension of current payment rates in March and then an attempt at permanent repeal of the SGR in late 2016.

So, what to do? One option is to advocate with your elected representatives for both Medicaid parity and permanent repeal of the SGR. Doing so is easy and readily available online. Other options include limiting or reducing the number of Medicaid and Medicare patients in your practice or simply opting out of Medicare and privately contracting with your Medicare patients. Family Practice Management is a good source for more information on these options.

It’s a new year, but payment for Medicaid and Medicare remains an old problem. Here’s hoping that 2015 is the last year you have to deal with it.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, January 6, 2015

CMS releases latest ICD-10 test results

Late last month, the Centers for Medicare & Medicaid Services (CMS) announced the results of ICD-10 acknowledgement testing it conducted Nov. 17-21. Acknowledgement testing helps physicians and others find potential flaws in their own claims systems or that of Medicare by having them submit claims with ICD-10 codes and receive electronic confirmation that their claims were accepted.

According to CMS, more than 500 testers, including small and large physician practices, submitted almost 13,700 claims during the November testing week. Acceptance rates improved throughout the week, reaching 87 percent acceptance by Friday. Nationally, CMS said it accepted 76 percent of all test claims submitted and that testing did not identify any issues with the Medicare claims systems.

For test claims to be valid, CMS said they had to have a valid diagnosis code matching the date of service, a National Provider Identifier (NPI) that was valid for the submitter identified as making the claim, and an ICD-10 companion qualifier code to allow for processing of claims. Claims failing to have or meet one of these three criteria, such as a claim using a date of service in the future, were rejected. In many cases, testers intentionally included errors in their claims to make sure that the claim would be rejected, a process often referred to as “negative testing” – which also explains some of the 24 percent rejection rate.

Physicians and other Medicare providers are welcome to submit acknowledgement test claims anytime up to the ICD-10 implementation date of Oct. 1, 2015. However, CMS periodically designates special weeks for this purpose. The next upcoming acknowledgement testing week is March 2-6, followed by June 1-5.

For more information, physicians can contact their Medicare Administrative Contractor or read the following CMS publications:

•    "ICD-10 Testing - Acknowledgement Testing with Providers”
•    “Medicare FFS ICD-10 Testing Approach,” which also includes information on opportunities for end-to-end testing with Fee-for-service Medicare.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Monday, January 5, 2015

Five issues to watch in 2015

Family physicians spent much of 2014 wrestling with the seismic changes affecting medicine across the United States and in their practices. That won’t slow down in 2015. “The coming year will again be one of major transition for the U.S. healthcare system,” said Lou Goodman, PhD, president of The Physicians Foundation and chief executive officer of the Texas Medical Association, in a statement announcing the Foundation’s “Physician Watch List for 2013.” The list, based on the Foundation’s own research, policy papers, and physician surveys, identifies the five issues most likely to affect physicians and their patients this year.

1. Accelerating consolidation. Hospitals and health systems are buying up small practices and absorbing solo physicians at a faster pace. Besides affecting local competition, costs, and patient choice, the trend has physicians worried about clinical autonomy. The Foundation’s 2014 Biennial Physician Survey found that 69 percent of those participating said they had concerns about autonomy and being able to make the best decisions for their patients. It said that as the consolidation isn’t expected to slow down, hospitals and physicians must work together to prevent bureaucracy or other organizational factors from influencing medical decision-making.

2. The physician-patient relationship is stressed. The increased documentation of value-based reimbursement systems and perceived interference of health care employers are considered key external pressures on the relationship between patients and their physicians. In particular, physicians have told the Foundation that these factors are eating into their face-to-face interactions with patients while also limiting their choices of practice types and requiring more time spent negotiating with payers and vendors. These pressures will call for more reliance on practice support staff to help the physician retain as much focus on the patients as possible.

3. ICD-10 finally arrives. Physicians were given a one-year reprieve when the Centers for Medicare & Medicaid Services (CMS) postponed the implementation date for the new ICD-10 coding structure to Oct. 1, 2015. But the extra time likely won’t improve many physicians’ outlook or support. According to the Foundation’s survey, half of respondents expected ICD-10 to cause severe administrative problems in their practices and three-quarters said it will unnecessarily complicate coding. Still, it’s highly unlikely CMS will delay ICD-10 again, so practices need to make the necessary investment of time and money to be ready for the change.

4. Patients demanding the true cost of care. Medical costs were once a hidden algebra to the public, deciphered only by payers and health care administrators. But media focus in recent years on the lack of transparency in billing practices, as well as higher out-of-pocket costs for patients, has the public much more frustrated. The seeming arbitrariness of what certain procedures actually cost stands to make it harder for physicians to make the best clinical decisions and calls for policymakers, providers, and payers to build a more straightforward cost of care structure.

5. Patient access to care. As more people are gaining access to health insurance through the Affordable Care Act and demanding health care services, the overall number of physicians is declining or reducing the amount of time available to see patients. According to the Foundation, 44 percent of respondents in its survey said they were planning to reduce access to their services, such as shrinking their panels, retiring, going to part-time work, or taking non-clinical jobs. This could reduce patient access to care by tens of thousands of full-time equivalents (FTEs) in the future. The Foundation, along with the University of North Carolina-Chapel Hill, has developed a tool to help analysts and lawmakers to better gauge future shortages of physicians.

Goodman said the list shows the continued threat to small medical practices and that policymakers must “bring physicians into the fold to ensure the policies they implement are designed to advance the quality of care for America’s patients in 2015 and beyond.”

Wednesday, December 24, 2014

Chronic care management: lots of questions and a few answers

Since the Centers for Medicare & Medicaid Services (CMS) published its final rule on the 2015 Medicare physician fee schedule – and especially since Family Practice Management (FPM) published its article “Chronic Care Management and Other New CPT Codes” – I have been inundated with questions. I will try to answer at least some of them:

Q1.     Does doing prior authorizations for medications and tests over the phone or ordering them electronically satisfy the Chronic Care Management (CCM) scope of service?
A1.    The CCM scope of service includes “medication reconciliation with review of adherence and potential interactions” as well as “oversight of patient self-management of medications.” It is debatable whether time spent on the phone doing prior authorization for medications and tests or time sending in such prior authorization electronically would count for this purpose. At this point, it is probably safer not to count time spent on prior authorizations as CCM time, although CMS has not explicitly addressed the question.

Q2.      If we don't do 20 minutes of CCM in a month, but our work over two or three months adds up to 20 minutes, can we bill at that time for a month?
A2.    No. Code 99490 is for 20 minutes “per calendar month.” You cannot add time up over multiple months to report 99490.

Q3.     Can the case manager of a Medicare Shared Savings Program accountable care organization (MSSP ACO) who works under the physician's direction be counted for doing work outside of the office? It appears so as long as we record it.
A3.    If the MSSP ACO case manager is a clinical staff person and the work that he or she does otherwise meets Medicare’s “incident to” rules relative to the physician who will be reporting 99490 (understanding that, for CCM, CMS allows “incident to” services to be provided under general, rather than direct, supervision), then his or her time may be counted toward the 20 minutes necessary to report code 99490, where appropriate.

Q4.     When billing 99490, do we use the diagnosis codes for the two chronic care conditions we are using? I would think so but haven't found guidance so far.
A4.    CMS has not specified what diagnosis codes should be reported with code 99490. Absent guidance to the contrary, it seems reasonable to report at least the two primary chronic care conditions for which you are providing 99490.

Q5.     Can CCM services related to medication management be delivered by a clinical pharmacist embedded in the clinic? If yes, I assume the billing for the CCM services would still be under the supervising physician or mid-level provider, or can the clinical pharmacist bill directly for the CCM service?
A5.    CMS has acknowledged that the services of pharmacists may be billed “incident to” those of a physician or other qualified health care professional, such as a nurse practitioner or physician assistant, as long as all of the “incident to” requirements are otherwise met. Thus, a clinical pharmacist could be counted among the clinical staff able to provide CCM services “incident to” the services of the physician or mid-level provider under whose provider number the services will otherwise be billed to Medicare. I do not believe that Medicare recognizes clinical pharmacists as providers for purposes of billing Medicare directly under Medicare Part B or the physician fee schedule.

Q6.    How many work relative value units (RVUs) are assigned to the CCM code?
A6.    The 2015 Medicare physician fee schedule assigns 0.61 work RVUs to code 99490.

Q7.    Can only the physician create the care plan, or can the physician delegate it to other clinical staff? Also, can a mid-level provider, such as a nurse practitioner or physician assistant, acknowledge/sign the care plan?
A7.    In the final rule on the 2015 Medicare physician fee schedule, in its discussion of the scope of the CCM service, CMS states, "In consultation with the patient, any caregiver, and other key practitioners treating the patient, the practitioner furnishing CCM services must create a patient-centered care plan document to assure that care is provided in a way that is congruent with patient choices and values." I interpret this to mean that the physician or non-physician practitioner who is nominally furnishing CCM services and, presumably, under whose provider number the services will be billed is responsible for creating the care plan. Also, CMS uses the word "practitioner" rather than "physician,” so I believe that a mid-level provider, such as a nurse practitioner or physician assistant, could acknowledge/sign the care plan if he or she created it.  

Q8.    I understand that I cannot bill CCM services for patients in a facility setting? How is “facility” defined?
A8.    In the final rule on the 2014 Medicare physician fee schedule, CMS stated, "The resources required to provide care management services to patients residing in facility settings significantly overlaps with care management activities by facility staff that is included in the associated facility payment." CMS did not define "facility" beyond that. I interpret facility in this context to be any health care entity (e.g., hospital, skilled nursing facility, etc.) that receives a facility payment from Medicare.

Q9.    I know CCM requires 20 minutes minimum. Is there an option to charge more if you spend a lot more time? I imagine many patients could take several hours per month.
A9.    There is no current mechanism to charge Medicare more if you spend longer than 20 minutes. CPT has complex chronic care management codes that would facilitate that, and the AAFP encouraged CMS to use those codes for just this reason. However, for 2015, CMS is only recognizing and paying 99490, which is open-ended in terms of the time involved.

Q10.     I know a patient-centered care plan is required. But must you complete it before doing any charges?
A10.    The scope of service for CCM includes creation of a patient-centered care plan. CMS also requires that you provide a copy of that care plan to the patient. I believe CMS expects both of those things to be done before you report 99490 the first time.

Q11.    Can you bill CCM for Medicare Advantage patients?
A11.    You will need to check with the Medicare Advantage plans in your area regarding whether or not they will pay for 99490 in 2015. My understanding is that, in general, patients in Medicare Advantage plans are entitled to the same benefits enjoyed by patients covered under traditional Medicare. However, I have heard from some family physicians that some Medicare Advantage plans do not plan to cover and pay 99490.

Q12:    Can you bill CCM for patients in an assisted living facility?
A12:    CMS has stated in the final rule that physicians cannot bill CCM services for patients in a facility setting. CMS said, "The resources required to provide care management services to patients residing in facility settings significantly overlaps with care management activities by facility staff that is included in the associated facility payment." CMS did not define "facility" beyond that. I interpret "facility" in this context to be any health care entity (e.g., hospital, skilled nursing facility, etc.) that receives a facility payment from Medicare. If an assisted living facility is receiving Medicare facility payments for a given patient residing in that facility, I do not believe that you can report CCM for that patient. 

Q13:    Regarding 24/7 access to care management, is this defined as a phone call? Would 24/7 access for “urgent chronic care needs” by a patient portal be acceptable under the guidelines?
A13:    Regarding 24/7 access to care management, CMS states, "To accomplish this, the patient must be provided with a means to make timely contact with health care providers in the practice to address the patient's urgent chronic care needs regardless of the time of day or day of the week." Elsewhere, CMS states that the scope of CCM services includes "Enhanced opportunities for the beneficiary and any relevant caregiver to communicate with the practitioner regarding the beneficiary's care through not only telephone access, but also through the use of secure messaging, Internet, or other asynchronous non face-to-face consultation methods." Based on this information, 24/7 access is not necessarily defined as a phone call.

Q14:    If I am reading this right, we are not being asked to be available for “urgent acute care needs” but “urgent” issues regarding their chronic care conditions. Does Medicare define how quickly the provider must respond to the patient’s urgent care needs?
A14:    As noted, CMS states, "To accomplish this, the patient must be provided with a means to make timely contact with health care providers in the practice to address the patient's urgent chronic care needs regardless of the time of day or day of the week." (Emphasis added) Thus, this access is related to "urgent chronic care needs." Medicare does not define "timely" in this context.  

Q15:    What do we use for a date of service?
A15:    CMS has not addressed this particular question. Code 99490 is intended to encompass a calendar month's worth of work. Box 24 on the CMS-1500 claim form does permit a "from" and "to" date, so I would consider putting the first day of the month as the "from" date and the last day of the month as the "to" date for 99490 as a line item. (I presume electronic claims would also support this approach.) Because code 99490 does encompass the entire calendar month, I would refrain from billing it until the last day of the month, in much the same way that CMS expects providers to wait until the end of the 30-day period to report transitional care management (TCM) codes.

Q16:    Can I bill CCM in the same month in which I see and treat a patient?
A16:    I am not aware of anything that would prohibit you from reporting 99490 in the same calendar month during which you saw the patient and reported an appropriate evaluation and management code for that encounter. The only codes of which I am aware that CMS has stated you cannot bill in addition to CCM services for a patient during the same time period are TCM services (99495 or 99496), home health care supervision (G0181), hospice care supervision (G0182), or certain end-stage renal disease services (90951-90970).

For other questions and answers, check out the list of CCM frequently asked questions on the AAFP web site.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, December 16, 2014

Volunteers wanted for ICD-10 testing in April

Are you ready to put your ICD-10 readiness to the test ahead of it going into effect next October? If so, Medicare is offering a second opportunity for providers to participate in ICD-10 end-to-end testing with Medicare Administrative Contractors (MACs) and the Common Electronic Data Interchange (CEDI) contractor next spring.  

The Centers for Medicare & Medicaid Services (CMS) will select approximately 850 volunteer submitters to participate in the testing during the week of April 26 through May 1, 2015. CMS intends to select volunteers representing a broad cross-section of provider, claim, and submitter types, including claims clearinghouses that submit claims for large numbers of providers.

The April event follows Medicare’s first week of end-to-end ICD-10 testing in January. Testers who are participating in the January event are able to test again in April without re-applying.

Volunteer forms should be available at each MAC’s website. To volunteer as a testing submitter, complete the volunteer form by Jan. 9. CMS will review the applications and select the group, and the MACs and CEDI will notify the chosen volunteers and provide them with the information needed for the testing by Jan. 30.

If selected, practices must be able to submit future-dated claims and provide valid National Provider Identifiers, Provider Transaction Access Numbers, and beneficiary Health Insurance Claim Numbers that will be used for test claims. This information will be needed by the MACs by Feb. 20 for set-up purposes. Missing the deadline will lead to volunteers being dropped from the test.

An additional opportunity for end-to-end testing will be available during the week of July 20-24, 2015. For more information, see the MLN Matters article, “Medicare FFS ICD-10 Testing Approach.”

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday, December 12, 2014

CMS enforcing new rules for Medicare Part-D prescribers – but gives more time

Physicians who prescribe Medicare Part-D drugs but do not participate in Medicare or have a valid record of opting out will face changes next year.

The good news is you'll have more time to accommodate the change.

The Centers for Medicare & Medicaid Services (CMS) earlier this year finalized a new rule under the Part-D program. The rule requires physicians and other eligible professionals who write prescriptions for Part-D drugs to:

• Be enrolled in Medicare in an approved status, or
• Have a valid opt-out affidavit on file.

The final regulation made the changes effective June 1, 2015. But CMS has announced that the deadline is being pushed back to Dec. 1, 2015.

Physicians who aren’t currently enrolled in Medicare or do not have a valid opt-out affidavit on file should plan on submitting an enrollment application or opt-out affidavit to their Part-B Medicare Administrative Contractor by June 1. This will ensure that CMS has enough time to process the paperwork ahead of Dec. 1 and will avoid patients’ Part-D prescription drug claims being denied.

For more information, including how to enroll online, CMS has issued an article, "Provider Enrollment Requirements for Writing Prescriptions for Medicare Part D," through its MLN Matters information service.

Thursday, December 11, 2014

CMS considers coverage and payment for some HPV testing

Currently, Medicare does not cover or pay for screening for human papillomavirus (HPV).

That could change soon as the Centers for Medicare & Medicaid Services (CMS) is seeking public opinion on a proposed new covered service that would link HPV screenings with a longer interval screening for cervical cancer.

Under Part B, Medicare now covers and pays for a screening pelvic examination and Pap smear test for all female beneficiaries at 12- or 24-month intervals, based on specific risk factors. In April, the American Academy of Family Physicians (AAFP) requested a new pathway that would screen female patients ages 30-65 at five-year intervals and include HPV testing. This pathway has received a grade A from the United States Preventative Services Task Force.  

A 30-day comment period on the proposal, also known as a national coverage analysis (NCA), ends Dec. 25. Additional information on the NCA, including instructions on how to comment, is available on the CMS web site.

CMS’s proposed decision memo on the matter is due on May 25, 2015, with an expected completion date of Aug. 23, 2015. If CMS agrees to extend coverage in this area, payment will likely follow, although it is unclear how quickly the payment will follow the coverage.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday, December 5, 2014

CMC-Elizabeth Family Medicine wins 2014 FPM Practice Improvement Award

A North Carolina primary care clinic has won this year’s Family Practice Management Award for Practice Improvement.

Carolina Medical Center-Elizabeth Family Medicine, based in Charlotte, was named winner Friday during the Society of Teachers of Family Medicine Conference on Practice Improvement being held in Tampa, Fla.

FPM Medical Editor Kenneth Adler, MD, MMM, presented the award to the clinic’s medical director, M. Quentin Fité, MD.
The clinic was recognized for using LEAN efficiency principles over several years to dramatically improve patient satisfaction scores, appropriate care metrics, patient visits, and overhead costs, as well as standardize clinic processes and make more choices based on data rather than gut decisions.

LEAN, first developed by automobile manufacturers, is a systemic approach to improving efficiency by eliminating waste and understanding what parts of the operation create value for the patients and staff.

CMC-Elizabeth Family Medicine is part of the Carolinas HealthCare System and primary ambulatory clinic for CMC’s family medicine residency program. The clinic handles about 25,000 patient visits a year with more than half of its payer mix made up of Medicare and Medicaid patients.

Tuesday, December 2, 2014

OIG to focus on place of service coding by physicians

As part of its Fiscal Year 2015 work plan (which began Oct. 1), the Health and Human Services Office of Inspector General (OIG) says it will examine place of service coding errors by physicians. Specifically, the OIG will review physicians’ coding on Medicare Part B claims for services performed in ambulatory surgical centers (ASCs) and hospital outpatient departments to determine whether they properly coded the places of service. Here’s what you need to know to avoid such errors in your practice:

Prior OIG reviews determined that physicians did not always correctly code places of service on Part B claims submitted to and paid by Medicare contractors. Federal regulations provide for different levels of payments to physicians depending on where services are performed. In particular, Medicare pays a physician more when a service is performed in a non-facility setting, such as a physician’s office, than it does when the service is performed in a hospital outpatient department or, with certain exceptions, in an ASC.

The correct place of service code for a service provided in a physician’s office is “11.” The Centers for Medicare & Medicaid Services (CMS) defines an office as a “location, other than a hospital, skilled nursing facility, military treatment facility, community health center, state or local public health clinic, or intermediate care facility, where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.”

The correct place of service code for a hospital outpatient department is “22.” CMS defines this place of service as “a portion of a hospital (that) provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.”

Finally, the correct place of service code for an ASC is “24.” CMS defines the ASC place of service as “a freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis.”

So be careful and accurate because reporting place of service code 11 when either code 22 or 24 is more appropriate will likely result in a Medicare overpayment.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, November 25, 2014

Comparative Billing Reports: what do they mean?

Family physicians have recently received Medicare comparative billing reports (CBRs) from Medicare contractor eGlobalTech. These reports measure an individual physician’s use of CPT codes 99211 through 99215 (established patient office visits) and CPT modifier 25 (a significant, separately identifiable evaluation and management service by the same physician on the same day). The reports have raised some questions and concerns, which I’ll try to address.

First, CBRs are nothing new. EGlobalTech has sent out eight other CBRs this year alone in other specialties such as podiatry, neurology, and pathology.

The CBR is very clear that it is for educational purposes only, showing how the recipient compares to his or her peers at both the state and national level in terms of using 99211-99215 and modifier 25. As noted in the frequently asked questions on eGlobalTech's web site, "The goal of these reports is to offer a tool that helps providers better understand applicable Medicare billing rules and improve the level of care they provide to their Medicare patients." It is not to suggest that the physician is necessarily billing incorrectly. To the best of my knowledge, no one in Medicare is using CBRs to deny claims or force physicians to downcode.

As part of the current CBR, eGlobalTech does calculate an "average allowed minutes per visit" using the typical times for 99211-99215 (as printed in CPT) multiplied by the number of times each of those codes was billed and then dividing by the sum of all 99211-99215 billed. It is a proxy that attempts to represent with a single number the physician's place in a bell curve for 99211-99215 use. Neither Medicare nor its contractor know how much time the physician actually spent on a given visit, and there is no suggestion in the CBR that the physician could not have done the number of services billed based on this average time.

For example, a CBR may show the physician billing 99214 and modifier 25 to Medicare at a rate significantly higher than that for his or her state or the country. There may be legitimate reasons for this, including the health status of the Medicare patients that the physician typically sees. As long as the physician's documentation supports the level of evaluation/management (E/M) service billed and the reporting of modifier 25 when used, there is no need for the physician to change what he or she is doing or what is reported to Medicare.

To ensure that their documentation supports what they bill to Medicare, physicians or someone on their practice staff should review their notes for a sample of the practice's Medicare E/M claims (with and without modifier 25). Actually, they may want to do this even if their CBR shows they are billing at a significantly lower rate than other family physicians because that may indicate that they are underreporting their services and depriving themselves of appropriate payment.

Additional information on the current CBR is available on the contractor’s web site, and the contractor will be hosting a related webinar on Dec. 10. A recording of the webinar will be available on Dec. 15 for those who cannot listen to the webinar live.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, November 18, 2014

Providers taking their time to e-prescribe controlled substances

Controlled substances, such as opiates or anabolic steroids, are newcomers to the field of electronic prescribing. The U.S. Drug Enforcement Agency and most states have allowed physicians to e-prescribe Schedule II-V drugs in only the last few years, namely as the technology demonstrated better security.

A new study published in the American Journal of Managed Care looked at 18 months of activity on the Surescripts Network, one of the larger e-prescription systems in the country (accounting for almost 60 percent of U.S. e-prescription activity). The study found that between July 2012 and December 2013, the number of transmitted prescriptions for controlled substances surged from a little more than 1,500 to more than 52,000. Also during that period, about one third of pharmacies in the system became capable of receiving and processing e-prescriptions for controlled substances.

The going has been much slower on the provider side, with only 1 percent of those using Surescripts able to e-prescribe controlled substances by the end of the study period. The researchers were optimistic, noting that the number of eligible providers was increasing by several hundred a month at the end of the study period. But they did say that physicians, nurses, and other providers may be dragging their feet because they don’t yet entirely trust the technology or didn't see a financial incentive to make the switch from their prescription pad. They may also view the process of getting themselves and their computer systems registered with the proper authorities as extra work. That should change going forward, the authors said, as proponents have claimed e-prescribing could actually help advance pain management by reducing concerns about fraud and abuse.

Monday, November 17, 2014

Ready for ICD-10? Find out with this week's CMS test

The Centers for Medicare & Medicaid Services (CMS) this week is offering providers, clearinghouses, and others who directly submit reimbursement claims an opportunity to test whether they’re ready for the change to ICD-10 next year.

Of course, CMS regularly offers acknowledgement testing for direct submitters to work with Medicare administrative contractors (MACs) and the Common Electronic Data Interchange contractor ahead of the Oct. 1, 2015, deadline for switching from ICD-9 to ICD-10. But dedicated acknowledgement testing weeks, like the one that ends Friday, Nov. 21, give participants access to real-time help desk support and allow CMS to analyze the testing data. The last one of these was in March before the ICD-10 deadline got delayed a year.

Any provider who submits claims electronically can participate in acknowledgement testing. Submitters do not have to register for this virtual event, and information on how to participate is available on the MAC websites or through a claims clearinghouse, if the submitter uses one.

Participants should submit their test claims containing ICD-10 codes with current dates of service because testing does not support future-dated claims. Test claims will receive the 277CA or 999 acknowledgement, confirming whether the claim was accepted or rejected in the system. Testing will not confirm claim payment or produce a remittance advice.

Additional information on acknowledgement testing and how to participate is available from Medicare Learning Network Matters. The next scheduled acknowledgment testing week is March 2-6, 2015.

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The views expressed here do not necessarily reflect the opinion of FPM or the AAFP. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. See Terms of Use.

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