« Previous page | Main | Next page »

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.

Monday, November 10, 2014

2015: the year CMS replaces the carrots with sticks

Next year will be a transformative one for some of Medicare’s incentive programs, including the Physician Quality Reporting System and the Electronic Health Record Incentive Program (i.e. “Meaningful Use”). Up to now, physicians who successfully participated in these programs have earned incentives or bonus payments. Beginning in 2015, however, Medicare will replace those bonuses with penalties if physicians do not successfully participate. For example, physicians who do not successfully participate in either program will face a 2.5 percent reduction in Medicare payments next year, and that penalty climbs to 4 percent in 2016.

Additionally, 2015 is the first year of implementation for the new Value-Based Payment Modifier program. Implementation will initially be limited to groups of 100 or more eligible professionals, and physicians in those groups could face an additional 1 percent penalty.

All of these incentives and penalties might be a little more palatable if physicians were convinced that they actually made a difference in the quality of care that they provide to patients. That does not appear to be the case, however. The Medical Group Management Association (MGMA) recently released the results of a survey showing that more than 83 percent of its members stated they did not believe current Medicare physician quality reporting programs enhanced their ability to provide high-quality patient care. In addition, physician practices reported significant challenges in complying with Medicare quality reporting requirements. More than 70 percent rated Medicare’s quality reporting requirements as “very” or “extremely” complex, and a significant majority of respondents indicated these programs negatively affected practice efficiency, support staff time, and clinician morale.

That may explain why the American Medical Association (AMA) recently told the Centers for Medicare & Medicaid Services (CMS) that it had “concern over the effect of Medicare incentive programs on physicians and their practices.” The AMA asked “for simplification of CMS’ policies” for several of the incentive programs and called on CMS to “synchronize and simplify the requirements for avoiding these penalties. . . .”

What will 2015 bring your practice? Here’s hoping it’s not a stick to replace the Medicare carrots you have been enjoying to date.

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

Friday, November 7, 2014

Chronic care, expanded telehealth, SGR covered in final 2015 Medicare rules

Late last week, the Centers for Medicare & Medicaid Services (CMS) released the final rule on the 2015 Medicare physician fee schedule. It is scheduled to be published in the Federal Register on Nov. 11, 2015. Among the items of note for family physicians:

      •    CMS finalized its proposal to pay for chronic care management (CCM) services in 2015. CMS will use Current Procedural Terminology code 99490 for this purpose rather than create its own “G” code.
      •    CMS further expanded the list of services for which it will pay when provided via telehealth. The expanded list of services includes the Medicare Annual Wellness Visit.
      •    CMS finalized its proposal to transform all 10- and 90-day global surgical codes to 0-day global surgical codes. CMS will begin with 10-day global services in 2017 and follow with the 90-day global services in 2018.

The final rule shows a 1 percent increase of the Medicare allowed charges of family physicians in 2015, based on all of the provisions in the rule. But it also reiterates that the Medicare conversion factor, which is $35.8013 through March 31, 2015, will decrease 21.2 percent to $28.2239 on April 1, 2015, under the current sustainable growth rate (SGR) unless Congress acts to change that in the interim. Lawmakers have typically made that change in past years, but the changing politics of Congress makes this an uncertainty.

Look for an article and tools to help take advantage of Medicare’s CCM payment in the January/February 2015 issue of Family Practice Management. You can find a fuller summary of these and other provisions of the final rule on the American Academy of Family Physicians’ web site.

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

Tuesday, October 14, 2014

Forewarned is forearmed: Using comparable compensation data in employment contract negotiations

For many employed physicians (and there are an increasing number of you), the annual rite of contract negotiations with payers has given way to the annual rite of contract negotiations with employers. One of the key elements in those negotiations is compensation.

The driving concern will be whether you are being compensated fairly, and solving that riddle means knowing whether the compensation you’re being offered is comparable to that of physicians in your region with similar skills and experience.

But, where can you find that information? One option is national medical specialty societies. For instance, the American Academy of Family Physicians has data on individual income (before taxes) of family physicians segmented by employment status, primary employer, practice size, number of years since residency, region, and primary location (i.e., metropolitan versus non-metropolitan).

Another option is data published by trade groups such as the Medical Group Management Association (MGMA) and recruiting firms like Merritt-Hawkins. Those data have their limitations, but to the extent that physicians’ employers are consulting them already, it is often useful for physicians to be aware of them too.

Knowing what other physicians in similar circumstances are earning is no guarantee that you will earn the same. However, as Kofi Annan, former secretary-general of the United Nations once observed, “Knowledge is power. Information is liberating.”

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

Thursday, October 9, 2014

Medicare Part D policy changes could confuse patients

With the end of the year rapidly approaching, Medicare prescription drug plans are notifying their enrollees of changes for 2015. If an example shared with me by one family physician is any indication, those enrollees are getting some bad information.

Express Scripts included the following in its Medicare Annual Notice of Changes for 2015:

“Effective June 1, 2015, before your drugs can be covered under the Part D benefit, CMS [Centers for Medicare & Medicaid Services] will require your doctors and other prescribers to either accept Medicare or to file documentation with CMS showing that they are qualified to write prescriptions.”

This statement has its origins in section 6405(c) of the Affordable Care Act, which allows the Department of Health and Human Services to require that prescriptions for covered Part D drugs be prescribed only by a physician or other eligible professional who is enrolled in the Medicare program. CMS published its final rule on this matter in the Federal Register on May 23, 2014. In the final rule, CMS said that, beginning June 1, 2015, a prescriber of Medicare Part D drugs must have an approved enrollment record in the Medicare program or have a valid opt-out affidavit on file with one of the Part A/Part B Medicare administrative contractors (MACs).

Based on this information, the notice that Express Scripts (and others, possibly) is sending to Medicare patients is technically incorrect. CMS is not in the business of determining whether physicians are qualified to write prescriptions. By law, CMS is only requiring that physicians be enrolled with Medicare or otherwise have a valid opt-out affidavit on file with Medicare in order for Part D to pay claims for prescriptions written by them.

The vast majority of physicians are already enrolled in Medicare for purposes of billing their services under Medicare Part B. Among those who are not, many have a valid opt-out affidavit on file with the MAC in their area. Thus, it will be the rare physician whose Part D prescriptions are affected by this change in Medicare policy. With luck, this information will help you reassure any Medicare beneficiary concerned by what their Part D drug plan is telling them.

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

Tuesday, October 7, 2014

Survey shows practices spending more for business staff

Physicians are spending more for staff that support the business side of their practices, according to a new survey.

Respondents reported a 4.6 percent increase in spending compared with last year on total business operations staff for each full-time equivalent (FTE) physician. The Medical Group Management Association’s (MGMA) 2014 Cost Survey said multispecialty practices spent a median of $52,009 per FTE on business operations staff. That includes general administration, information technology, accounting, and managed care administrative employees.

Family physicians spent a median of $32,772 per FTE. That's a 17 percent increase from the previous year, but MGMA cautioned that only a third of family physicians taking the survey provided information on this question. The organization noted that business administrative staff costs for family physicians rose 4.59 percent between 2009-2013.

MGMA didn’t ascribe a specific reason for the increases, crediting everything from practices simply wanting to make themselves more efficient and business savvy to offices reacting to regulatory changes in the medical and insurance communities.

The survey involved 2,518 medical groups across the country, including 475 family medicine practices.

Tuesday, September 30, 2014

PQRS incentive payments for 2013 now available

Incentive payments under the 2013 Physician Quality Reporting System (PQRS) are now available for eligible professionals and group practices who successfully submitted data for Medicare Part B Physician Fee Schedule (PFS) services between Jan. 1 and Dec. 31, 2013. The payments are payable regardless of whether the eligible professional or group practice also participated in a Medicare Shared Savings Program Accountable Care Organization, the Comprehensive Primary Care Initiative, or other programs.

The incentive payment is 0.5 percent of the eligible professional’s estimated total allowed charges for covered Medicare Part B PFS services provided during 2013. An additional 0.5 percent is available to those working with a Maintenance of Certification entity and meeting certain requirements.

Remember that PQRS payments are subject to a 2 percent cut, part of the sequestration order that President Obama signed in 2013 and applied to most federal programs.

The Centers for Medicare & Medicaid Services (CMS) issues PQRS incentive payments separately as a single consolidated amount. CMS issues the payments to the first valid group location listed under the tax identification number (TIN). For solo practitioners, it goes to the first valid practice location listed under the TIN.

The Medicare claims-processing contractors will make the payment electronically or via check, depending on how the TIN normally receives payment for Medicare Part B PFS covered professional services. If the TIN submits claims to multiple Medicare claims-processing contractors, the TIN will likely receive payments from each contractor equal to the share of Medicare Part B PFS claims the contractor processed in 2013. However, if a contractor’s share of the incentive payment would be less than $20, that amount will be rolled into another contractor’s payment. Also, CMS can reduce the amount of PQRS incentives if the TIN owes an outstanding debt to Medicare.

Contractors will issue the incentive payment along with a corresponding remittance advice and identify it as a separate payment under the PQRS. Specifically, Medicare contractors will indicate federally mandated payments with the label LE ("Levy"). For further clarification, a four-digit code will appear on the remittance along with LE to indicate the type of incentive and reporting year.

If an incentive payment does not arrive or the amount does not match what is reflected in the PQRS feedback report, the physician or practice should contact their Medicare claims-processing contractor. Note that the incentive amount may differ by a penny or two from what is reflected in the feedback report because of rounding. Eligible professionals, designated support staff/vendors, and group practices can request to have an informal review of their PQRS reporting performance through the CMS Communication Support Page if they believe they should have received a PQRS payment and didn’t or they believe the amount is incorrect. CMS will accept informal review requests for 2013 from Jan. 1, 2015 through Feb. 28, 2015.

For more information, please visit the Analysis and Payment webpage of the CMS website. If needed, you can also contact the QualityNet Help Desk for assistance. They can be reached at 1-866-288-8912 (TTY 1-877-715-6222) or via qnetsupport@hcqis.org from 7:00 a.m. to 7:00 p.m. CST Monday through Friday.

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

Tuesday, September 23, 2014

Volunteers wanted for ICD-10 testing in January 2015

The Centers for Medicare & Medicaid Services (CMS) plans to hold a week-long test early next year of the new ICD-10 coding that goes into effect next October. And the agency is looking for test subjects.

During the week of Jan. 26-30, 2015, a sample group of physicians and other Medicare providers will participate in the end-to-end testing with Medicare Administrative Contractors (MACs) and the Common Electronic Data Interchange (CEDI) contractor.

CMS plans to select approximately 850 volunteer submitters to participate in the test. It wants volunteers representing a broad cross-section of provider, claim, and submitter types, including claims clearinghouses that submit claims for large numbers of providers.

To volunteer as a testing submitter, you will need to complete a volunteer form by Oct. 3, 2014. Volunteer forms are available on your MAC website. CMS will review the applications, and the MACs and CEDI will notify the selected volunteers by Oct. 24, providing them with the information needed for the testing.

Additional opportunities for end-to-end testing will be available in 2015. CMS has indicated that it will address any issues identified during testing prior to ICD-10 implementation and that it will develop educational materials for providers and submitters based on the testing results. For more information, see the Medicare Learning Network article “Medicare FFS ICD-10 Testing Approach.”

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

Wednesday, September 17, 2014

Time to get feedback on 2013 PQRS and possible Medicare penalties

The Centers for Medicare & Medicaid Services (CMS) has just released feedback reports from the 2013 Physician Quality Reporting System (PQRS). The reports permit physicians to see how they did on PQRS in 2013, a factor in determining whether or not the physicians will be subject to a 1.5 percent Medicare payment adjustment (cut) in 2015.

To find your own feedback report, follow the instructions beginning on page 25 of the PQRS user guide

The feedback reports themselves will not say whether a physician is subject to the 2015 payment adjustment. CMS will do that with notices sent to physicians in late October or early November. CMS staff did note, however, that physicians could avoid the penalty if they successfully reported just one measure for one patient in 2013, and that should be apparent on the feedback reports.

Physicians in large groups will have added interest in the feedback reports. Next year is the first year the CMS will implement the value-based payment modifier, which the agency is initially applying only to groups of 100 or more eligible professionals.

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

Want to use this article elsewhere? Get Permissions

Current Issue of FPM

Search This Blog


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.