Date of service decides whether you use ICD-9 or ICD-10
With the Oct. 1, 2014, deadline for implementing ICD-10 coding approaching, you may be wondering how you will treat a claim that you submit in October 2014 for a service that your practice provided in September 2014? Do you use ICD-10 because the claim is filed after the implementation deadline, or do you use ICD-9 because the service was provided before the deadline?
The short answer is that the date of service determines which code set you use. Thus, even if you submit your claim on or after the ICD-10 deadline, if the date of service was before Oct. 1, 2014, you will use ICD-9 to code the diagnosis. Conversely, for dates of service on or after Oct. 1, 2014, you will use ICD-10. That means you need to make sure that your systems, third-party vendors, billing services, and clearinghouses can handle both ICD-9 and ICD-10 codes for claims filed in the months following Oct. 1, 2014.
While some trading partners may allow that ICD-9 and ICD-10 codes be submitted on the same claim when dates of service span the compliance date, not all of them will. This may mean splitting services into two claims: one claim with ICD-9 diagnosis codes for services provided before Oct. 1, 2014, and another claim with ICD-10 diagnosis codes for services provided on or after Oct. 1, 2014. Check your trading partner agreements.
For additional help, visit the American Academy of Family Physicians website for tools and articles to assist your practice with the preparation and change to this new system. You can also find news and resources on the Centers for Medicare & Medicaid Services' (CMS) ICD-10 website, which also includes the ICD-10 continuing medical education modules developed by CMS in partnership with Medscape.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
Posted at 01:51PM May 16, 2013 by David Twiddy, Associate Editor | Comments[0]
Changes coming to Medicare payments for durable medical equipment
If you prescribe durable medical equipment (DME) for your Medicare patients, you should be aware that, effective July 1, Medicare will expand its competitive bidding program for DME, prosthetics, orthotics, and other supplies. The expansion may affect where your patients can fill their prescriptions and how much they and Medicare end up paying for the DME.
The Centers for Medicare & Medicaid Services (CMS) introduced its competitive bidding program in nine areas of the country in 2011. Based on the program's success in those areas, CMS is extending it to 91 new areas across the country. CMS will also implement a national mail-order program for diabetic testing supplies on July 1.
The program affects Medicare payments for wheelchairs, oxygen, mail-order diabetic supplies, and more. Historically, Medicare based its payment for most of these items on historical charges, adjusted for inflation over time. However, many studies have shown that the prices Medicare has paid for certain medical equipment and supplies are excessive – sometimes three or four times retail prices and the amounts paid by commercial insurers.
Under the competitive bidding program, suppliers submit bids for certain medical equipment and supplies that must be lower than what Medicare pays for these items currently. Medicare then uses the bids to set the amount it will pay for those items and chooses the qualified, accredited companies with winning bids as Medicare contract suppliers. The lower Medicare payment amounts also lower a Medicare beneficiary’s co-payment.
The competitive bidding is part of CMS's efforts to fight fraud and waste in the Medicare program. Media reports have noted that, from 2009 to 2012, Medicare paid $43 billion for DME, more than 60 percent of which may have been improper. Similarly, CMS has introduced a pilot program that requires approval before Medicare will pay for power wheelchairs and scooters for beneficiaries in seven states with high rates of fraud and errors: California, Illinois, Michigan, New York, North Carolina, Florida, and Texas.
You and your patients can find a list of Medicare contract suppliers in your area by visiting Medicare's supplier directory tool or by calling 1-800-MEDICARE. For additional information, visit the Medicare DME Competitive Bidding Program's website, which includes all of the products and items that are covered under the program.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
Posted at 04:49PM May 14, 2013 by David Twiddy, Associate Editor | Comments[0]
Medicare delays penalties for claims with invalid or missing NPIs
In a recent post, I referenced that the day of reckoning was finally coming for those who order or refer items or services for their Medicare patients but who lack the proper identification. As it turns out, that day has been pushed back.
The Centers for Medicare & Medicaid Services (CMS) announced late last week that, due to technical issues, implementation of phase 2 of the ordering and referring denial edits is being delayed from May 1 to an unspecified future date. As a reminder, these edits would have denied certain claims from physicians and other eligible professionals who lacked a valid individual National Provider Identifier. Those claims include Medicare Part-B claims involving laboratories, imaging centers, durable medical equipment, orthotics, and supplies that have an ordering or referring physician/nonphysician provider as well as Part-A home health agency claims that require an attending physician.
CMS will advise physicians and other qualified health professionals of the new implementation date in the near future. In the interim, the agency will continue to attach warnings to those claims that would have been denied had the edits been in place.
All of this means that if you order or refer items or services for Medicare beneficiaries and you do not have a Medicare enrollment record, you have a little more time to submit an enrollment application to Medicare using the Internet-based Provider Enrollment, Chain, and Ownership System. As noted previously, physicians who have a valid opt-out affidavit on file are not required to enroll in Medicare for this purpose; CMS has a special, shorter enrollment form, known as the CMS-855O, for use by physicians and other health professionals who just refer and order services but do not bill Medicare directly.
More information on the new edits can be found here.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
Posted at 03:15PM Apr 30, 2013 by David Twiddy, Associate Editor | Comments[0]
Update on Medicaid payment parity with Medicare
Medicaid payments were supposed to rise to the level of Medicare this year, but chances are that you haven't seen it yet. Here's an update.
Section 1202 of the Affordable Care Act increases Medicaid payments for specified primary care services to Medicare levels for certain primary care physicians in 2013 and 2014. The provision was nominally effective Jan. 1, 2013.
However, the Centers for Medicare & Medicaid Services (CMS) gave states until March 31, 2013, to file the necessary state plan amendments. CMS then gave itself up to 90 days to review and approve those amendments.
Last week, I participated in a conference call with staff from CMS to discuss implementation of this provision. The good news is that CMS staff reported that all of the states submitted the necessary state plan amendments by the March 31 deadline, and CMS expects that most will be approved in the 90-day timeframe allowed to CMS. The bad news is that, so far, CMS has approved only three.
CMS has been clear that the provision is retroactive to Jan. 1, 2013, and states are required to give physicians two to three months to attest that they qualify to receive the enhanced payment once a) the state’s attestation process is operational AND b) the state has provided notice to physicians. Unfortunately, CMS is not tracking state efforts and deadlines in this regard, and CMS itself will not conduct any physician outreach on attestation. Instead, CMS will leave it to the states.
So, what do you need to do? First, if you accept Medicaid, contact your state Medicaid agency and the state chapter of your specialty society regarding the status of your state’s implementation of this provision. You want to be aware of when the attestation process begins and the deadline for attestation. Second, when that process is operational in your state, follow the procedures mandated by your state in the timeframe given.
The American Academy of Family Physicians' website contains additional information on the program, if necessary.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
Posted at 10:10AM Apr 26, 2013 by David Twiddy, Associate Editor | Comments[0]
A limited time opportunity on eRx penalties
Time is running out for physicians to avoid having their Medicare Part B fees cut next year under a federal initiative that encourages electronic prescribing.
The Centers for Medicare & Medicaid Services (CMS) has given practices until June 30, 2013, to show that they have met e-prescribing (eRx) requirements during the first six months of this year (or during the 12-month eRx reporting period of Jan. 1, 2012-Dec. 31,
2012) or to request a hardship exemption from the requirements to avoid the 2014 penalty. (CMS calls it a "payment adjustment.")
Practices can also avoid the 2014 penalty if they do one of the following by June 30, 2013:
• Register to participate in the Medicare or Medicaid Electronic Health Record (EHR) Incentive Program and adopt certified EHR technology; or
• Attest achievement of meaningful use under the EHR Incentive Program during either the 12-month eRx reporting period (Jan. 1, 2012-Dec. 31, 2012) or the six-month eRx reporting period (Jan. 1, 2013-June 30, 2013).
If you are currently subject to the eRx payment adjustment or have been in the past, you are not alone. CMS reports that 135,931 eligible professionals were subject to the 2012 eRx payment adjustment because they did not qualify for an exemption, meet exclusion criteria for the adjustment, or comply with eRx reporting requirements in the first half of 2011.
The payment adjustment in 2014 will be 2 percent, which means if you are subject to the adjustment, you will only receive 98 percent of your Medicare Part B physician fee schedule amount for covered professional services, assuming you are not subject to any other payment adjustments under Medicare.
On March 1, CMS re-opened the Quality Reporting Communication Support Page to allow individual eligible professionals and group practices the opportunity to request a significant hardship exemption for the 2014 eRx payment adjustment. As noted, hardship exemption requests will be accepted through June 30, 2013. After that, you're out of luck. Also, please note this applies only to hardship exemption requests for the 2014 eRx payment adjustment. The reporting period to avoid the 2013 eRx payment adjustment, or to submit hardship exemption requests, has ended.
The following resources are available to assist individual eligible professionals and group practices in submitting their request for a hardship exemption:
• Quality Reporting Communication Support Page User Guide
• Tips for Using the Quality Reporting Communication Support Page
For additional information on the 2014 eRx payment adjustment, including who is subject to the payment adjustment and how to avoid it, please review the 2014 eRx Payment Adjustment Fact Sheet.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
Posted at 11:50AM Apr 23, 2013 by David Twiddy, Associate Editor | Comments[0]
Medicare to deny claims with no NPI
The day of reckoning is finally coming for those who order or refer items or services for their Medicare patients but who lack the proper identification.
On May 1, the Centers for Medicare & Medicaid Services (CMS) will begin instructing its contractors to deny Medicare claims from individuals who don't include a valid National Provider Identifier (NPI).
Section 6405 of the Affordable Care Act requires physicians or other eligible professionals to be enrolled in the Medicare program to order or refer items or services for Medicare beneficiaries. Also, Medicare requires that a physician or supplier that bills Medicare for a service or item show the name and unique identifier (i.e., the NPI) of the attending physician on the claim if that service or item was the result of an order or referral.
Beginning in October 2009, Medicare contractors began alerting billing providers if the identification of the ordering/referring provider was missing, incomplete, or invalid, or if the ordering/referring provider was not eligible to order or refer. The alerts were merely warnings, however, that the claims lacked the required information, and the claims were paid anyway. Beginning next month, however, CMS will deny Part B, durable medical equipment, and Part A home health agency claims that fail the ordering/referring provider edits.
Physicians and others who want to continue ordering and referring items and services need to establish their Medicare enrollment record and make sure they're of a specialty that is eligible to order and refer. You can enroll in the Medicare program here: Internet-Based Provider Enrollment, Chain, and Ownership System (PECOS). Physicians who have a valid opt-out affidavit on file are not required to enroll in Medicare. CMS also has a shorter enrollment form, known as the CMS-855-0, for use by physicians and other health professionals who refer and order services but do not bill Medicare directly.
More information on the new edits can be found in this Medicare bulletin.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
Posted at 01:18PM Apr 10, 2013 by David Twiddy, Associate Editor | Comments[0]
Sequestration takes effect, but how will it affect you?
Like a cruel April Fool's joke (without the joke), sequestration began Monday with big implications for you and your practice.
Under the current sequester, Medicare payments to doctors, hospitals, and other health care providers, as well as to health plans and drug plans, are to be reduced by 2 percent for services provided on or after April 1. This also covers physician-administered drugs included on your claims.
Medicare contractors will apply the cut to the payment itself, not the underlying "allowed charge" in the Medicare fee schedule. As a result, beneficiary copayments and deductibles will not change. In other words, Medicare imposes the 2 percent cut only on the 80 percent of the allowed charge that a participating physician would receive directly from Medicare. The 20 percent copayment amount (and any applicable deductible) that the physician collects from the patient will be based on the full allowed charge amount.
With respect to unassigned claims for services provided by nonparticipating physicians, the 2 percent cut will be applied to the Medicare payment made to the beneficiary (but not to the limiting charge amount). If you are a nonparticipating physician, reducing your charges on unassigned claims will not insulate your Medicare patients from the cut; it will only take money out of your own pocket.
The Budget Control Act requires that $1.2 trillion in federal spending cuts be achieved over the course of nine years. This means federal spending will be subject to sequestration until 2022 unless Congress takes action to change the law or reaches a new budget agreement to address deficit and spending concerns. (The Medicare cut will never be higher than 2 percent, however, and the Medicare cuts each year are not cumulative.)
With all the fiscal deadlines facing Congress this year, the sequester will remain a subject for debate. However, it is not expected that the sequester cuts will be lifted before Sept. 30, which is the end of the current federal fiscal year.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
Posted at 12:37PM Apr 03, 2013 by David Twiddy, Associate Editor | Comments[0]
Physicians' ability to provide DOT physicals gets added twists and turns
If you're one of the thousands of family physicians who provide commercial truck and bus driver patients with their Department of Transportation-mandated physical examinations, change is coming.
New regulations going into effect May 21, 2014, will, for the first time, require that all medical professionals who provide these examinations be certified and registered by the Federal Motor Carrier Safety Administration (FMCSA).
Medical professionals have long performed the examinations to ensure drivers are physically qualified to operate a commercial motor vehicle. Typically, examiners had to be licensed, certified, and registered only according to laws in their respective states.
But the National Transportation Safety Board recommended creating a National Registry of Certified Medical Examiners to unify medical oversight of commercial drivers and ensure examiners understand and are trained on FMCSA physical qualifications and standards.
Officials said some examiners were certifying drivers with serious medical conditions that should have disqualified them from commercial driving, and some of those drivers were involved in fatal wrecks or crashes causing serious injury.
The new rule states that, in order to issue a DOT medical certificate, a medical professional must be either a doctor of medicine, doctor of osteopathy, doctor of chiropractic, physician assistant, advanced practice nurse, or any other medical professional authorized by the particular state's law to perform physical examinations. In addition, the individual must pass an examination of the FMCSA to become certified. Once certified and registered, a medical examiner must be recertified every 10 years and must complete periodic refresher training every five years.
The final rule establishing the national registry went into effect on May 21, 2012, and medical examiners have two years to become compliant.
For more information regarding this new rule and to find training opportunity locations, see the FMCSA's FAQ page.
– Renae Moch, MBA, CMPE, Practice Management Strategist for the American Academy of Family Physicians
Posted at 02:02PM Mar 26, 2013 by David Twiddy, Associate Editor | Comments[10]
The biggest driver of health care spending
Earlier this month, the National Commission on Physician Payment Reform released a report that listed the four factors it singled out as the biggest drivers of high health care system spending.
Topping the list was fee-for-service reimbursement. The commission recommended that payers should largely eliminate stand-alone fee-for-service payments to medical practices over the next five years, blaming the scheme's inherent inefficiencies and negative incentives toward more care. Instead, the commission advocated "an approach based on quality and value" and "fixed-payment models."
Does this mean that the commission expects fee-for-service to disappear in five years? Not necessarily. In fact, the commission said it expects that "fee-for-service will remain an important mode of payment into the future," which is why it also has recommendations on how to "recalibrate" it in the interim.
The commission's report adds to the chorus of those advocating for a reduced role for fee-for-service in the future of physician payment. Medicare is moving toward value-based payment and experimenting with blended payment approaches in approaches in its Comprehensive Primary Care Initiative. Other payers are doing the same. While there is no suggestion that we will ever completely cure ourselves of fee-for-service, there is every indication that it is a treatable condition whose adverse effects, especially on primary care physicians’ quality of life, can be reduced.
(In case you were wondering, the next three practices the commission said are contributing to high spending were a reliance on technology and expensive care, reliance on a high proportion of specialists, and insurers paying hospitals more for certain services or procedures than they would in an outpatient setting.)
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
Posted at 12:01PM Mar 14, 2013 by FPM Editors | Comments[2]
Sequestration and you
With sequestration now, apparently, a fact of life, what are the implications for your practice?
Absent further action by Congress, the current slate of required federal budget cuts is expected to reduce Medicare payments to doctors, hospitals, and other health care providers, as well as health plans and drug plans, by 2 percent for services provided on or after April 1.
That will result in $11 billion in lost revenues this year for providers, who will receive only 98 cents on the dollar for their services to Medicare beneficiaries.
The American Academy of Family Physicians, among other medical associations, is decrying the impending cuts.
However, as bad as sequestration sounds, things could be worse if President Obama and congressional Republicans actually did reach an agreement to reduce federal deficits. As the Washington Post noted last week, the sequester would reduce Medicare spending by about $100 billion over a decade. But President Obama had suggested $400 billion in health care cuts, mainly from Medicare, and Republicans reportedly wanted more.
So, unless federal leaders intervene in the interim, expect your Medicare payments to drop by 2 percent beginning next month – and be thankful it isn’t any worse than that.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
Posted at 04:46PM Mar 06, 2013 by David Twiddy, Associate Editor | Comments[0]
Lies, damned lies, and statistics
Mark Twain famously said, "There are three kinds of lies: lies, damned lies, and statistics."
I was reminded of the phrase recently when researching how the employers of some family physicians are using data from the Medical Group Management Association's (MGMA's) annual Physician Compensation and Production Survey to create compensation systems that disadvantage family physicians relative to their peers in internal medicine. MGMA's data show that the median compensation per work relative value unit (RVU) for family physicians solely in ambulatory care (i.e., no inpatient care) is less than the corresponding figure for internal medicine.
In reviewing the survey data and speaking with MGMA staff members, I learned that, in MGMA's experience, the compensation per RVU data is the most misused and misinterpreted piece of information in the annual survey. Further, a summary of MGMA's 2012 report based on 2011 data highlights the disconnect between compensation and production (as measured in work RVUs) as the relationship between the two is not constant. The summary report shows that as family physician compensation increases from one quartile of productivity to another, compensation per RVU decreases, reflecting the fact that productivity (as measured by work RVUs) increases at a greater rate than total compensation across the quartiles.
The lower compensation per work RVU for family physicians compared to general internists may simply reflect that family physicians are more productive than their general internist colleagues, relative to their compensation. For example, the median work RVUs for family physicians in ambulatory care in the MGMA data tables were 5,468, while the median for general internists were only 5,233.
Or it could be due to a number of other reasons:
• Unlike Medicare, many private payers use multiple conversion factors that vary by, among other things, types of service. If general internists provide a mix of services with higher conversion factors than those provided by family physicians – more surgical or procedural services versus evaluation and management services, for example – that could result in a higher compensation per work RVU.
• The payer mix may also impact total compensation. For instance, if family physicians treat a higher percentage of Medicaid patients, their compensation may be lower even if they provide exactly the same services (and generate the same work RVUs) as general internists.
• Some medical groups are able to negotiate higher compensation rates from private payers than other groups; if general internists disproportionately belong to such groups, they may benefit from higher compensation, even if producing the same number of work RVUs as their family medicine colleagues with less bargaining clout.
To its credit, MGMA is clear that the information contained in its report "is presented solely for the purpose of informing readers of ranges of medical practice compensation, charges, and revenue reported by MGMA-ACMPE member and nonmember organizations." They are also explicit that the data "may not be used for the purpose of limiting competition, restraining trade, or reducing or stabilizing salary or benefit levels." Finally, MGMA notes that its "publications are distributed with the understanding that MGMA-ACMPE does not render any legal, accounting, or professional advice that may be construed as specifically applicable to individual situations."
In summary, MGMA is simply reporting what its survey respondents told it. The calculated compensation per work RVU is the result of multiple factors, and it is intended to be descriptive, not prescriptive. If an employer of family physicians is using the compensation per work RVU calculations to set compensation levels for family physicians less than other primary care physicians, it would appear to be a misuse and misinterpretation of the data.
Or as Mark Twain once put it, "Get your facts first, then you can distort them as you please."
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
Posted at 04:30PM Mar 01, 2013 by David Twiddy, Associate Editor | Comments[0]
CMS refuses to halt ICD-10-CM implementation
The Centers for Medicare & Medicaid Services (CMS) has denied a request from more than 80 state and national physician organizations, including the American Academy of Family Physicians (AAFP), to halt implementation of ICD-10-CM.
The Dec. 20, 2012, letter to CMS Acting Administrator Marilyn Tavenner requesting the delay argued that the new set of outpatient diagnosis coding would create additional, unnecessary burdens for America's physicians at a time when many are overwhelmed with other health care system demands and changes.
On Feb. 6, 2013, Tavenner declined the request and said that CMS will move forward with implementing ICD-10 on Oct. 1, 2014. She noted that this already represented a year’s extension beyond the original implementation date of Oct. 1, 2013. Tavenner also said that halting implementation at this point "would be costly, burdensome, and would eliminate the impending benefits" of the investments that many in the industry have already made with respect to implementation.
So, for now, ICD-10 proponents have carried the day, and everyone needs to look for strategies to ease implementation. If you have not already developed an implementation plan, here are some resources to help you.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
Posted at 02:47PM Feb 20, 2013 by David Twiddy, Associate Editor | Comments[1]
CMS providing some help on vaccine-related E/M coding change
The Centers for Medicare & Medicaid Services (CMS) is providing some limited relief to physicians dealing with recent changes to how they're paid for vaccinations.
As this blog covered previously, the Jan. 1 round of Correct Coding Initiative (CCI) edits required that providers append modifier 25 to evaluation and management (E/M) services performed in connection with immunization administration services (90460-90474) provided on the same date to the same patient or only get paid for the immunization administration.
Subsequent to that post, I learned that CMS sent an alert on Feb. 1 to all state Medicaid agencies. The alert allows each state to deactivate the edits as they pertain to preventive medicine service codes (99381-99397) and immunization administration codes, retroactive to Jan. 1.
The deactivation is only applicable for the first quarter (Jan. 1-March 31, 2013). It's also up to each individual state Medicaid agency, and each state that does deactivate the applicable edits will have to individually decide whether to reprocess Medicaid claims already submitted since the beginning of the year.
CMS said it expects that state Medicaid agencies that choose to retain the edits will educate physicians on the proper E/M coding and use of modifier 25 to bypass the edits.
CMS has not made any unilateral decisions to deactivate these CCI edits nationally at this time, so outside of Medicaid in those states that choose to deactivate them, the new edits remain a hassle.
Still, some relief is better than none, and the American Academy of Family Physicians and other medical societies are continuing to ask CMS to rescind the edits at all levels.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
Posted at 12:36PM Feb 14, 2013 by David Twiddy, Associate Editor | Comments[0]
Decoding the new transitional care management rules
Ever since their introduction at the beginning of the year, the new transitional care management (TCM) codes have caused confusion.
The Getting Paid blog described the new codes when they were first announced last fall. But the questions have continued, and the codes are getting additional attention after the CPT Editorial Panel clarified in January that transitional care management involving new patients, and not just ones that a physician has seen within the previous 12 months, could be billed using the TCM codes.
Here are some of the more common questions:
Q. When should I bill for TCM?
A. You should submit your bill on the 30th day after discharge. TCM covers 30 days of management services with one evaluation service bundled into the code. The date of service on the claim would be the 30th day after the discharge.
Q. What happens if the patient is re-admitted before the 30 days are up?
A. The face-to-face visit would become the appropriate level evaluation and management code for the service that was rendered. You would restart your 30 days of service on the TCM once the patient was discharged.
Q. Does a discharge visit count as the post discharge contact?
A. No, a discharge visit does not count. The initial contact must be made after the patient leaves the hospital. This is to make sure that the patient has the support necessary until they have their face-to-face visit. The initial contact can be phone, e-mail, text, or face-to-face. It can involve the patient and/or the patient's caregiver.
Q. If the patient needs an unrelated evaluation and management (E/M) visit during the 30 days can I bill for this?
A. Yes, although there are some restrictions on what you can bill, such as anticoagulation management and home health care certification.
We’ve yet to hear how these codes are getting paid since the earliest billing date would have been Jan. 30, 2013. We are also waiting on the Centers for Medicare & Medicaid Services (CMS) to release guidelines on the codes, which we expect to receive by the end of February.
AAFP has created a form to help you document the requirements of TCM visits and made available for download a list of frequently asked questions. TCM was also discussed as part of an AAFP/TransforMED webinar, “What’s new in Medicare and Medicaid payment in 2013,” which is archived on TransforMED's Delta Exchange site and accessible to AAFP members upon login.
–Debra Seyfried, MBA, CMPE, CPC, Coding and Compliance Strategist for the American Academy of Family Physicians
Posted at 05:10PM Feb 12, 2013 by David Twiddy, Associate Editor | Comments[10]
Pay attention, or don't get paid for E/M services performed with vaccinations (UPDATED)
Getting fully reimbursed for vaccinations is now requiring a little extra effort.
The latest round of edits for the Correct Coding Initiative (CCI) went into effect Jan. 1 and included around 300 changes that affect evaluation and management (E/M) services and immunization administration, specifically codes between 90460 and 90474.
In each edit, the administration code trumps the E/M code. That means if you bill a vaccine administration code and an E/M code for the same patient on the same date and do not append a modifier to the E/M code, Medicare and other payers who follow the CCI edits will only pay for the vaccine administration.
The idea behind the edits is that an E/M service provided at the same encounter as a vaccine administration should be a significant and separately identifiable service. Vaccine administration by itself does not merit both the administration code and an E/M code.
If, however, the situation merits separate reporting and you have supporting documentation, you can attach a modifier (such as modifier 25) to the E/M code and report both services. The one exception is E/M code 99211 (office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician). CCI will not allow the addition of a modifier to report both 99211 and a vaccine administration. That edit is not new.
Both the American Academy of Family Physicians and American Academy of Pediatrics are protesting the new edits, saying they needlessly complicate physician billing practices and don't appear necessary under current CPT language.
They also worry that placing additional barriers to practices seeking proper payment for immunizations will lead to fewer people getting vaccinated. That's obviously a problem for both public and individual health and comes at a time when the Centers for Disease Control and Prevention has lamented the unacceptably low adult immunization rates in the United States.
Considering that the CCI is overseen by the Centers for Medicare & Medicaid Services, it appears once again that Uncle Sam’s right and left hands don’t know what each other are doing or that, even if they do, the consequences are just as disastrous.
2/14/13 UPDATE: CMS gives state Medicaid programs some leeway in following new vaccination E/M coding changes.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
Posted at 05:06PM Feb 07, 2013 by David Twiddy, Associate Editor | Comments[2]
