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Tuesday, November 24, 2015

CMS extends QRUR informal review period again

The Centers for Medicare & Medicaid Services (CMS) announced last week that it has again extended the deadline for practices to request an informal review of their Quality and Resource Use Reports (QRURs). The QRURs contain data used for both the Physician Quality and Reporting System (PQRS) payment adjustment and the Value-Based Payment Modifier (VBPM) calculation. Practices now have until 11:59 p.m. EST on Dec. 16 to request an informal review. Results of an informal review will be emailed within 90 days of the original request. All results of the informal review are final.

This announcement comes on the heels of the updated release of the 2014 QRURs, which corrected previous issues with validating the accuracy of data submitted using the Electronic Health Record (EHR) or Quality Clinical Data Registry (QCDR) reporting methods.

For additional information on interpreting your QRUR, see the November/December issue of Family Practice Management.

-Erin Solis, Regulatory Compliance Strategist for the American Academy of Family Physicians

Friday, November 20, 2015

CMS updates 2014 QRURs to correct data

Two months after their release, the 2014 Quality and Resource Use Reports (QRURs) – which will help determine if physicians and practices get Medicare bonuses or penalties in coming years – have been updated.

The Centers for Medicare & Medicaid Services (CMS) said it identified problems with data submitted by providers through electronic health records and the Qualified Clinical Data Registry. The agency also found technical issues with claims used to determine claims-based measures.

CMS says it has fixed these problems and has released revised 2014 QRURs, which are now available through the CMS Enterprise Portal. The agency said the corrections did affect the Value-Based Payment Modifier for a small number of providers who will be notified. The modifier affects Medicare reimbursement in future years based on whether providers meet quality and cost of care requirements.

Thursday, November 12, 2015

Deadline extended for Medicare Part D prescribing

Physicians who prescribe medications to Medicare patients with Part D plans are getting more time to comply with new rules requiring that they either enroll in Medicare or have a valid record of opting out.

The deadline is now Jan. 1 to either enroll or opt out, although the Centers for Medicare & Medicaid Services (CMS) doesn’t plan to begin enforcing the new rules until June 1, 2016. This is the second time CMS has extended the deadline.

For those choosing to opt out, a word of caution: the opt-out period is for two full years and there is not an option for early termination. CMS has a very useful tool to help you make this decision and to know what form to fill out.

If you are not sure if you are enrolled or have opted out, CMS has published a public file to check. You can use the “Find in this Dataset” box in the upper right-hand corner to search by your National Provider Identifier or your last and then first name. The list will also tell you if you are in an opt-out status. If you are not on the list, you can apply through the Provider Enrollment, Chain, and Ownership System (PECOS). For information on how, there is a comprehensive step-by-step manual.

For more information on Part D, you can go to the Part D Prescriber Enrollment home page, which includes all of the above links as well as how to contact your local Medicare Administrative Contractor (MAC) for additional assistance.

– Barbara Hays, CPC, CPMA, is a Coding and Compliance Strategist for the American Academy of Family Physicians

Tuesday, November 10, 2015

Chronic care management services: adoption lagging

Physicians and health care organizations are still moving slowly to offer chronic care management (CCM) services to their Medicare patients under a reimbursement program that began in January.

A new survey found that only 26 percent of respondents said they or their organizations had launched a CCM program by late summer. Of those, slightly less than half said they had successfully submitted a claim and been paid.

Under CCM, a practice can receive additional reimbursement for providing non-face-to-face services to Medicare patients with two or more chronic conditions. The practices must meet a number of requirements, including documenting at least 20 minutes of service per patient per month.

Pershing, Yoakley & Associates, a health care consulting firm, and Enli Health Intelligence conducted the survey between Aug. 3 and Sept. 21. Researchers used responses from 309 clinical, administrative, and financial staff.

Despite the low number of early CCM adopters, the respondents indicated there was interest in the program. Almost two-thirds said they or their organizations had analyzed the program and 23 percent said they intended to launch a program within 12 months. Eleven percent said they had no plans to participate in CCM.

Respondents said the main obstacles to participating included payment amounts that don't cover the additional time and effort required to offer the services. In fact, respondents who were already offering CCM reported providing a median of 35 minutes of services per patient per month, not 20. They also blamed a lack of awareness about CCM and concerns about the steps needed to show compliance. Sixty percent of respondents also were worried that they would have to hire additional staff to handle CCM duties.

Among those who had already started a CCM program, most were from large organizations. For example, 18 percent of practices employing between one and five physicians were providing a CCM program compared with 38 percent of organizations employing more than 100 physicians.

Small organizations reported lack of infrastructure, organizational support, and familiarity with the program as being the primary barriers to adoption. Small organizations that were offering CCM also experienced less patient resistance and higher levels of physician engagement compared with larger organizations.

Friday, November 6, 2015

What's changing in the new Medicare Physician Fee Schedule?

The Centers for Medicare & Medicaid Services (CMS) has released the 2016 final Medicare Physician Fee Schedule. The regulation reflects the end to the now-repealed Sustainable Growth Rate (SGR), which often threatened a double-digit cut in Medicare physician payments. It also incorporates the beginning steps of moving health care delivery away from fee-for-service and toward value-based payment, as envisioned in the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. Under MACRA, it is hoped, primary care services will be more appropriately valued, the quality of care will improve, and the cost of care will be better controlled. Of note to family physicians, the 2016 final rule:

     • Sets the 2016 conversion factor, which stipulates Medicare physician payments, to $35.8279, a decrease from the current $35.9335. MACRA was originally expected to provide a 0.5 percent increase in payments, but federal laws to address overvalued codes will lead to an overall reduction for many physicians. For family physicians, however, the combined estimated impact of the fee schedule changes to allowed charges is expected to be zero.

     • Begins Medicare payment for Advance Care Planning (ACP) services for Medicare beneficiaries who seek them. In 2016, CMS will reimburse CPT codes 99497 and 99498 based on values recommended by the Relative Value Units Update Committee (RUC). Payment for the codes are approximately $86 for 99497 (initial 30-minutes) and $75 for 99498 (subsequent 30 minutes).

     • Sets the 2018 Medicare penalty at 2 percent for physicians and groups that don’t satisfactorily report Physician Quality Reporting System (PQRS) measures in 2016, revises the definition of certified Electronic Health Record (EHR) technology for the purposes of the Medicare Electronic Health Record (EHR) Incentive Program, and updates the type of information publicly available through the Physician Compare website.

     • Modifies payment for Part B drugs and biosimilar biological products, makes code changes for radiation therapy and lower gastrointestinal endoscopy services that had been misvalued, phases-in significant relative value units reductions, updates the physician self-referral policy, changes the Medicare physician and practitioner opt-out policy, and requests input on other changes.

This just touches the surface of the many changes contained in the new physician fee schedule. Besides the text of the actual final rule, posted above, CMS has also issued a press release, a fact sheet, and a fact sheet specific to the PQRS.

– Robert Bennett, Manager of Federal Regulatory Affairs for the American Academy of Family Physicians

CMS extends deadline for QRUR informal reviews

Physicians who have not yet requested an informal review of their Quality and Resource Use Reports (QRURs) are getting more time.

The Centers for Medicare & Medicaid Services (CMS) has extended the deadline to request a review of the QRUR, which is a key piece of both the Physician Quality Reporting System (PQRS) and the Value-Based Payment Modifier (VBPM). Eligible professionals (EPs) now have until 11:59 Eastern Time on Nov. 23 to request an informal review. Under the VBPM, groups of 10 or more EPs can request a review if they feel their 2016 value modifier was incorrectly calculated. Under PQRS, EPs can request a review if they feel they have been assigned a penalty erroneously.

The 2014 QRURs were released in September and contain performance information related to the quality and cost measures used to calculate the 2016 VBPM. The reports also indicate if a provider satisfactorily reported under PQRS for 2014. A provider who did not satisfactorily report should have received a letter from CMS last month indicating that they will receive a 2 percent cut in all of their 2016 Medicare physician fee schedule payments.

CMS allows a 60-day review period of QRURs; however, CMS announced on Oct. 30 that it was granting a two-week extension. Providers can contact the Physician Value Help Desk (1-888-734-6433 option 3 or for additional information on how to request an informal review. It is important for providers to note that the result of the informal review is final and cannot be appealed. CMS submits its final decision by email within 90 days of the request.

In addition, look for an article on QRURs in the November/December issue of Family Practice Management.

– Erin Solis, Regulatory Compliance Strategist for the American Academy of Family Physicians

Wednesday, November 4, 2015

Ten percent of claims filed under ICD-10 rejected

One in 10 reimbursement claims filed under the new ICD-10 codes has been denied since the codes became active Oct. 1. But only a fraction of those denials were the result of coding errors.

The Centers for Medicare & Medicaid Services (CMS) recently released statistics from the first 27 days of ICD-10. It said it received 4.6 million claims per day. Of those, 2 percent were rejected for having incomplete or invalid information.

Including an invalid ICD-10 code caused the rejection of 0.09 percent of claims submitted. End-to-end testing conducted earlier this year had estimated 0.17 percent of total claims would be rejected for this reason.

Having an invalid ICD-9 code caused the rejection of 0.11 percent of claims submitted, compared with the expected 0.17 percent, again based on end-to-end testing.

Of all claims processed, 10.1 percent were denied.

CMS and the American Medical Association earlier announced that physicians would have more leeway when filing claims under ICD-10 in the first year, which may explain the low rejection rate for invalid ICD-10 codes.

The agency said it expects to release more information on the ICD-10 rollout this month. It takes Medicare several days to process claims, and the law requires CMS to wait two weeks before issuing payment. Meanwhile, states can take up to 30 days to process Medicaid claims.

Overall, implementation of ICD-10 has been much smoother than some had expected.

Thursday, October 29, 2015

CMS fixing processing errors on vaccine and mammogram claims

The Centers for Medicare & Medicaid Services (CMS) is correcting a pair of systems errors it says led to the inappropriate rejection of some physician claims for vaccinations and mammograms with dates of service on or after Oct. 1.

Condition code A6 is required only for reporting pneumococcal and influenza vaccines, but claims for other vaccine services were erroneously rejected on this basis. These claims were returned with a reason code of 32200.

The agency also said it erroneously rejected claims for mammography services with diagnosis code Z1231 for dates of service on or after Oct. 1. These claims were returned with a reason code of 32016.

In both cases, your Medicare Administrative Contractor (MAC) will correct the claims and you don’t have to take any action, according to CMS.

Tuesday, October 27, 2015

A month in, how is ICD-10 doing?

Implementation of ICD-10 will be a month old at the end of this week. On average, that represents about one billing cycle for the typical family medicine practice, so this is a good time to assess the initial impact.

Despite some dire predictions, implementation has not led to mass chaos or brought claims processing to a halt. In fact, preliminary reports suggest implementation is proceeding relatively smoothly. For instance, insurers such as Humana and UnitedHealth Group have reported smooth transitions, according to a report by Forbes. Communications from the Centers for Medicare & Medicaid Services (CMS) suggest things are running equally smoothly on Medicare’s end. Physician complaints about the actual implementation have been sparse to non-existent.

That does not mean that implementation has been universally positive. For instance, there are reports that coder productivity has dropped between 20 percent and 40 percent. Also, there are anecdotal stories that some payers, including at least one state Medicaid agency, are not paying for “not otherwise specified” codes under ICD-10.

What should you do if you are among those experiencing challenges in implementing ICD-10? CMS suggests that you take the following steps to locate ICD-10 information and contacts quickly:

•    Step 1 Find resources on the CMS ICD-10 website and Road to 10 online tool.
•    Step 2 Contact your Medicare administrative contractor (MAC) for Medicare claims questions. Your MAC is your first line for Medicare claims help. MACs cannot respond to questions about Medicaid or commercial health plans.
      o    If you have a Medicaid claim question, contact your state Medicaid agency.
      o    If you have a commercial or private health plan claim question, please contact your health plan directly.
      o    The new ICD-10 Resource Guide and Contact List gives MAC and Medicaid contact info organized by state.
•    Step 3 Contact the ICD-10 Ombudsman for questions. The ICD-10 Ombudsman is an impartial advocate with a dedicated team of experts to answer your questions. Responses will typically be sent within three business days of receipt.

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

Tuesday, October 20, 2015

Your chance to influence MACRA implementation

Among other things, the Medicare and Children’s Health Insurance Program Reauthorization Act (MACRA) lays the groundwork for two new tracks of physician payment, beginning in 2019. One track is the Merit-Based Incentive Payment System (MIPS) and the other is alternative payment models (APMs).

The Centers for Medicare & Medicaid Services (CMS) is developing regulations to implement these payment alternatives and, through a request for information, is asking physicians and others for help.

Regarding MIPS, CMS says that it is most interested in comments on how to identify MIPS eligible professionals (EPs) and how to measure an EP’s performance on quality, resource use, clinical practice improvement activities, and meaningful use of certified electronic health records (EHRs).

CMS’s questions for APMs are more complicated, including:

•    How should CMS define services furnished by an eligible alternative payment model (EAPM) entity?
•    What types of data and information can EPs submit to CMS to determine if they meet the non-Medicare share of the Combination All-Payer and Medicare Payment Threshold, and how can EPs share that information securely with the federal government?
•    What criteria could the secretary of Health and Human Services consider for determining if a state Medicaid medical home model is comparable to medical home models expanded under the Center for Medicare & Medicaid Innovation Center?
•    Which states’ Medicaid medical home models might meet those Innovation Center criteria now?
•    How should CMS define “use” of certified EHR technology by participants in an APM?
•    What criteria should the Physician-focused Payment Model (PFPM) Technical Advisory Committee use for assessing PFPM proposals submitted by stakeholders?
•    In lieu of payments, how should CMS attribute or count patients for EPs to determine whether they are qualifying full or partial APM participants?
•    What types of appropriate “financial risk” should a physician or practice face to be considered an EAPM entity?
•    What criteria could be used to compare the quality measures used to identify an EAPM entity with that of MIPS?

CMS is accepting comments through Nov. 17, and instructions on how to respond are available at the request for information link above. This is your opportunity to tell CMS how you think the new payment alternatives should work.

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

Thursday, October 15, 2015

MACRA eases face-to-face visit requirement for durable equipment

Much of the attention generated by the Medicare and Children’s Health Insurance Program Reauthorization Act (MACRA) focused on the repeal of the Sustainable Growth Rate and creation of the future Merit-based Incentive Payment System. However, another provision of MACRA reduces the face-to-face visit requirements for prescribing some durable medical equipment (DME).

As a condition for payment, section 6407 of the Affordable Care Act (ACA) requires that a physician, physician assistant, nurse practitioner, or clinical nurse specialist conduct a face-to-face examination with a Medicare beneficiary within the last six months before writing an order for certain items of DME. Section 6407 also required that a physician co-sign this examination if it was performed by a non-physician.

MACRA has eliminated this requirement.

All other aspects of the face-to-face requirement for DME prescriptions remain in place. Medicare requires a face-to-face examination each time a new prescription for one of the specified items is ordered, and Medicare requires a new prescription:

•    For all claims for purchases or initial rentals.
•    When there is a change in the prescription for the accessory, supply, drug, etc.
•    If a local coverage determination requires periodic prescription renewal (i.e., policy requires a new prescription on a scheduled or periodic basis).
•    When an item is replaced.
•    When there is a change in the supplier.

The face-to-face examination must document that the beneficiary was evaluated or treated for a condition that supports the need for the prescribed DME. Remember that all Medicare coverage and documentation requirements for DME also apply, which means that there must be sufficient medical information included in the medical record to demonstrate that the applicable coverage criteria are met.

The treating physician or other qualified health care professional that conducts the face-to-face examination does not need to be the prescriber for the DME. However, the prescriber must verify that the qualifying in-person visit occurred within the six months prior to the date of their prescription and have documentation of the qualifying face-to-face examination. The prescriber must also provide a copy of the qualifying face-to-face examination and the prescription for the item or items to the DME supplier before the supplier can deliver them.

You can find additional information on these requirements on the Centers for Medicare & Medicaid Services web site.

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

Monday, October 12, 2015

Survey: Many physicians still unaware of chronic care management benefit

The ability to receive payment for providing chronic care management (CCM) services to Medicare patients is more than nine months old, but many physicians still don’t know about it.

A new survey found that almost half of 500 physician respondents said they were not aware of the Medicare program, which is aimed at patients with two or more chronic conditions. Yet 62 percent of those surveyed said they, their staff, or a third party contact their Medicare patients with multiple chronic conditions between visits.

The CCM program provides additional payments for those services to eligible patients if they total at least 20 minutes of staff and physician time during the month.

SmartCCM, a Dallas-based company that provides outsourced CCM services to practices, surveyed the physicians online this summer. Forty-four percent of those surveyed were in family medicine or general practice; the remainder were internists and geriatricians. More than eight out of 10 were in private practice.

The survey also asked the physicians about the biggest challenges they face in treating patients with two or more chronic conditions. The challenges raised most often were a lack of time to provide these patients extra guidance and reinforcement on dealing with their conditions (63 percent) and the overall complexity of dealing with multiple conditions (56 percent). Other physician complaints included patients inconsistently adhering to treatment or medication plans, balking at the cost of tests and medication, and calling or visiting too frequently, as well as the practice being unable to monitor patients between visits.

Wednesday, October 7, 2015

Preview your Physician Compare data now – before everyone else does

The Centers for Medicare & Medicaid Services (CMS) later this year will post physician quality data from 2014 on its Physician Compare website. The data is a subset of the 2014 Physician Quality Reporting System (PQRS) measures.

Beginning this week, physicians have 30 days – until Nov. 6 – to preview their data before it is published. The public reporting of the data won’t directly affect your Medicare payments. But some Medicare consumers may use the data to choose, keep, or change their physician, which could affect your bottom line.

You can access the secured measures preview site through the Provider Quality Information Portal. To learn more about which measures will be publicly reported and how to preview your measures, visit the Physician Compare Initiative page on the CMS web site.

If you have any questions about Physician Compare, public reporting, or the 2014 quality measure preview period, please contact CMS through its contractor at

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

Monday, October 5, 2015

CMS updates meaningful use guidance for providers changing EHR vendors

Physicians and other health care providers who are unable to demonstrate meaningful use because they have recently changed vendors for their electronic heath record (EHR) – or worse yet, have seen their EHR system decertified by the Centers for Medicare & Medicaid Services (CMS) – have to work fast to avoid penalties to their Medicare payments.

CMS has updated its guidance for practices wanting to continue participating in the EHR incentive program or apply for a hardship exception:

If a practice changes certified EHR technology vendors and is unable to demonstrate meaningful use, the practice may apply for an extreme or uncontrollable circumstances hardship exemption before the deadline for a particular program year. If approved, the practice would not incur a Medicare penalty.

If the practice’s EHR has been decertified, the practice can still use it to attest to meaningful use as long as the EHR reporting period ended before the system became decertified. However, if the reporting period ended after the decertification, the practice must apply for a hardship exemption.

If the EHR was decertified after the hardship exception period for the payment adjustment year had already passed, the practice will need to contact the CMS Hardship Coordinator at to apply for an exception under CMS's discretion.

You can get more information from the EHR incentive programs website.

Friday, September 25, 2015

CMS issues more clarification on ICD-10 flexibility

On July 6, the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association released a joint statement about their efforts to help physicians get ready for the Oct. 1 switch to ICD-10 coding. This statement included guidance from the CMS that allows for flexibility in the claims auditing and quality reporting processes.

CMS released a series of frequently asked questions and answers about the changes in late July. The agency has now reissued those questions and answers with revisions to questions 1 and 9, as well as adding nine new questions and answers.

Revised question 1 provides the name and email address for the new ICD-10 ombudsman, William Rogers, MD. Revised question 9 makes it clear that the new flexibility of the ICD-10 Medicare fee-for-service audit and quality program does not extend to any Medicare fee-for-service prior authorization requests. Among the topics addressed in the new questions and answers are:

•    How does the guidance and flexibility relate to Medicare Advantage?
•    How can physicians access advance payments if their Part B Medicare Administrative Contractors are unable to process claims within established time limits because of administrative problems?
•    Will Medicare’s processes change regarding what elements are crossed over to supplemental payers (including commercial payers and state Medicaid agencies)?

Please visit the CMS ICD-10 website for all of the latest news related to ICD-10 implementation.

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

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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.