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Monday, March 28, 2016

CMS answers billing questions on advance care planning

Medicare began paying for advance care planning services on Jan. 1. As with most new reimbursement programs released by the Centers for Medicare & Medicaid Services (CMS), physicians have had questions. Last week, CMS attempted to answer some of them.

Advance care planning services are described by two Current Procedural Terminology (CPT) codes:

•    99497, Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.
•    +99498, Each additional 30 minutes (List separately in addition to code for primary procedure).

Among the highlights in the CMS’s answers:

•    CMS will follow CPT provisions regarding minimum time required to report the service; that means a unit of time is attained when the mid-point is passed.
•    CMS has not established any frequency limits for these services.
•    There are no place of service or physician specialty limitations on the codes.
•    Medicare administrative contractors will determine any documentation requirements.
•    Completion of an advance directive is not required to bill the service.
•    Advance care planning can be reported in addition to other evaluation and management services, except certain critical care services.
•    No specific diagnosis code is required with advance care planning codes.
•    These services are subject to the usual Part B deductible and coinsurance unless furnished as an optional element of the Medicare annual wellness visit.

For additional information, CMS encourages you to read pages 70955-70959 of the final rule on the 2016 Medicare physician fee schedule and Medicare Learning Network Matters article MM9271.

– Kent Moore, senior strategist for physician payment for the American Academy of Family Physicians

Thursday, March 17, 2016

Fee-for-service still dominant force in reimbursement

Federal officials want to move quickly to transition Medicare reimbursement away from models based solely on volume of services.

A new study demonstrates how far they need to go.

In results published in Health Affairs, the study found that only 5 percent of patient office visits in 2013 were paid based on capitation arrangements and the remaining 95 percent were all some form of fee-for-service.

The researchers, using data mined from the annual Medical Expenditure Panel Survey, noted that capitation, which sought to shift some or all of the financial risk for providing patient care to physicians, has seen a steady decline in acceptance since its inception in the 1990s and especially during the 2000s.

New models, such as those detailed in the Medicare Access and CHIP Reauthorization Act of 2015, are designed to reward physicians based on value and quality of patient care. Supporters believe value-based care is less expensive and could reduce the number of unnecessary tests, procedures, and other services that can go unchecked under fee-for-service. However, many physicians worry that attempts to measure value and quality will be cumbersome and ineffective, and could penalize them unfairly.

The researchers suggested that physicians may be more willing to embrace value-based care than they were to embrace capitation, but they acknowledged physicians' reluctance. “Providers’ willingness to participate in new payment mechanisms will likely be closely tied to the extent that they are required to assume risk,” the study said.

Largely because of this, fee-for-service remains a key mechanism for paying physicians even within organizations set up to emphasize value, such as accountable care organizations.

Thursday, March 10, 2016

Study: Practices spend $15.4 billion a year to measure quality

Physicians often complain about the time they have to spend filling out documentation and other forms to report quality measure information.

A new study published in Health Affairs attempted to quantify the problem and found that practices in primary care and three other common specialties spend an average of 785 hours per physician annually on entering quality information into computers, reviewing quality reports generated by external entities, tracking quality measure specifications, implementing processes for collecting data, and transmitting that information to third parties for quality measurement.

Multiplied by the average compensation for each type of physician and staff member, the study estimated U.S. practices spend more than $15.4 billion a year to report these quality measures.

Of the four specialties – which included primary care (family medicine and internal medicine), cardiology, orthopedics, and multispecialty practices that included primary care – the primary care physicians spent the most time and money on quality measures.

The study said those practices spent an average of 19.1 hours per physician per week on quality measurement with the physicians alone spending 3.9 hours. Annually, those practices spent an average of $50,468 per physician.

By comparison, cardiology practices said they spent 10.4 hours a week (1.7 hours for physician only) and $34,924 a year while orthopedic practices said they spent 11.3 hours a week (1.1 hours for physician) and $31,471 a year.

Multispecialty practices said they spent 17.6 hours a week. Researchers did not include financial information for multispecialty practices because the practices include specialties outside the study’s scope.

The study, paid for by The Physicians Foundation, was based on surveys of more than 300 practices contacted through the Medical Group Management Association database.

Researchers said 81 percent of respondents reported spending more time and money meeting quality measurement requirements now than three years ago and only 27 percent said they believed the measures actually represented quality care.

In addition, the report found that federal programs, state and regional agencies, and health insurers often use hundreds of quality measures that share very little in common with one another, compounding the work practices must perform to comply with all their requirements.

“There is much to gain from quality measurement,” the study authors write, "but the current system is far from being efficient and contributes to negative physician attitudes toward quality measures.”

Wednesday, March 9, 2016

Majority of physician groups see no change under Value Modifier program

The Centers for Medicare & Medicaid Services (CMS) has released the results of the 2016 Value Modifier (VM). The VM lowers or raises a physician’s Medicare payments based on his or her performance on quality and cost measures. The 2016 results, which apply to physician groups of 10 or more eligible professionals (EPs), are based on data reported in 2014.

Of the 13,813 physician groups with 10 or more EPs, only 128 groups exceeded the program’s quality and cost benchmarks. These groups will receive an increase of either 15.92 percent or 31.84 percent in their payments under the Medicare Physician Fee Schedule. Physicians in 59 groups will see their payments reduced by 1 percent or 2 percent based on their performance on quality and cost measures. There were 5,418 groups who failed to meet the reporting requirements and will face an automatic 2 percent cut. The remaining 8,208 groups will not face any adjustment because of their performance or because there was insufficient data to calculate their VM.

Medicare Administrative Contractors will process claims based on the updated adjustment amounts beginning March 14. Claims with a date of service prior to this will automatically be reprocessed. Groups should see the adjustments on their claims within the next six weeks.

Beginning in 2017, the VM will apply to solo physicians as well as those in groups of two or more physicians. To avoid an automatic payment decrease, physicians should report to the Physician Quality Reporting System (PQRS). Physicians can pull their annual Quality Resource and Use Report (QRUR) to review their performance on quality and cost measures and see how they will fare under the VM.

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

Monday, March 7, 2016

Medicare contractor clarifies "incident-to" rules for allergy therapy

Medicare’s “incident-to” rules become less mysterious the more you learn about them. But that doesn’t mean physicians and practice administrators aren’t still sometimes baffled by how they work.

Earlier this year at a forum, Wisconsin Physician Services (WPS), a Medicare administrative contractor, answered a question about providing allergy therapy that surprised many. In essence, the question was: If a nurse in the practice administers allergy injections to a patient, can the practice bill the service under the physician's Medicare provider number, even though the physician is not treating the allergy?

In its response, WPS referenced Medicare Learning Network Matters article Special Edition (SE) 0441, which addresses incident-to rules. WPS noted that one of the requirements of incident-to billing is that the billing physician is the one treating the patient for that condition or situation. So, if the physician in question is treating the patient for the allergy (not just providing the injections), then this situation could meet the incident-to requirements.

If the physician is not treating the patient for the allergy, then, according to WPS, this situation does not meet the incident-to requirements, and the physician cannot bill for the administration of the injection. WPS advises notifying the patient of non-coverage in this scenario.

Even if this particular situation wasn’t on your radar, it should show that incident-to rules are definitely being scrutinized by Medicare administrative contractors.

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

Thursday, March 3, 2016

You’ve made the switch to ICD-10 coding. Now what?

It’s been more than five months since ICD-10 became the required standard for coding and billing patient encounters in the United States, and the Centers for Medicare & Medicaid Services (CMS) wants to make sure your office is using ICD-10 not just correctly but productively. CMS has released the Next Steps Toolkit, a free resource that offers specific suggestions and recommendations in these areas:

Assessing your progress. Practices should compare current performance to a pre-ICD-10 baseline or establish a baseline for making future comparisons. Tracking key performance indicators such as rates of rejection and denial is the first step to improvement.

Addressing your findings. Systematically collecting and answering questions from staff and analyzing your clinical documentation and code selection as needed can help head off future problems and fix current ones.

Maintaining your progress. Physicians should make sure their systems capture annual ICD-10 updates, which take place in October.

For more information, visit CMS’s ICD-10 website and other resources, including this list of contacts, by state, for Medicare and Medicaid questions. 

Tuesday, March 1, 2016

Deadline for meaningful use hardship exception extended

The Centers for Medicare & Medicaid Services (CMS) has extended the deadline for physicians and other providers to submit hardship exceptions for the meaningful use (MU) program. Providers now have until July 1 to apply for an MU exception. An exception would allow them to avoid the 2017 payment adjustment for failure to meet the reporting requirements in 2015. The previous deadline was March 15. CMS encourages providers to submit their applications electronically as soon as possible to avoid delays.

Applying for and receiving an exception does not prevent a provider from potentially receiving an incentive payment if they successfully attest for 2015 later. The exception simply protects the provider from the payment adjustment should they be unsuccessful in their attestation. Those who are unable to attest at all and fall into any of the exception categories may also submit an application.

The Meaningful Use attestation deadline is March 11. Additionally, providers can satisfy the Clinical Quality Measure (CQM) requirement of MU by reporting on Physician Quality Reporting System (PQRS) measures using the Electronic Health Record (EHR) method. The deadline for this is also March 11.

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

Monday, February 29, 2016

CMS beefing up screening of Medicare-enrolled providers

To help combat Medicare fraud – and weed out those most responsible for it – the Centers for Medicare & Medicaid Services (CMS) is making changes in how providers enroll and remain in the Medicare system.

CMS plans to publish a new rule in the Federal Register tomorrow that creates added requirements for those enrolling to become Medicare providers and gives the agency tools to find and terminate enrolled providers who have shown a history of fraud. This has added significance as many physicians are coming up on the end of their five-year Medicare revalidation cycle and will be submitting information to maintain their billing privileges.

Among the changes:
• Providers would have to disclose connections to other providers or suppliers who have had their Medicare, Medicaid, or CHIP enrollment denied or revoked; have uncollected debt to those programs; or have had their payment suspended under a federal health care program or because of an Office of Inspector General exclusion.
• CMS could deny or revoke Medicare enrollment if it discovered a provider's Medicare enrollment has been revoked under a different name or identity. Also, it could deny or revoke Medicare enrollment if a provider’s license has been revoked in one state and he or she is applying or enrolled in a different state or if the provider has been terminated from a state Medicaid or other federal health care program under a current or different name or identity.
• The agency could revoke the physician's enrollment for what CMS considers an "abusive" or dangerous pattern or practice of ordering, referring, certifying, or prescribing Medicare Part A or B services, items, or medications.
• The length of time someone can be barred from re-enrolling in Medicare would increase, including a maximum 20-year ban for a second revocation.
• CMS would require that physicians and others who order, certify, refer, or prescribe any Part A or B service, item, or medication must be either enrolled in Medicare or have a valid opt-out.

Meanwhile, CMS is boosting its existing methods for screening Medicare providers by increasing site visits to Medicare-enrolled providers, replacing the current Provider Enrollment Chain and Ownership System (PECOS) with software that can also look for invalid addresses, and deactivating on a monthly basis enrolled providers who have not billed Medicare in the last 13 months.

The upshot is that while physicians have always needed to be careful when submitting documentation to accept Medicare patients, you may now need to increase those efforts, even if you don't have any Medicare skeletons lurking in your past.

Monday, February 22, 2016

New insurer database tool could cut back on phone calls to physicians

The Council for Affordable Quality Healthcare (CAQH) has created a centralized way for physicians to update their information in insurance plan directories and reduce the amount of time they spend talking to insurance companies.

The nonprofit alliance of insurers and health care providers has created DirectAssure, a database that coordinates with CAQH’s current ProView tool used by more than 800 health plans for such things as credentialing.

CAQH said it will contact physicians designated by participating health plans at least once a quarter to ask them to review and update their information. Physicians can then log on to the system for free and update their location, contact information, specialty, and group/institution affiliation, as well as whether they’re accepting new patients.

CAQH said the health plans can check the DirectAssure system to make sure their directories are correct, instead of a physician receiving several calls from the plans themselves.

Besides making things easier for physicians, the new system is aimed at meeting new federal and state requirements that health plans do a better job of keeping their provider databases current and accurate and more useful to patients.

Tuesday, February 16, 2016

Medicare: Physicians are mixing up E/M codes for skilled nursing facilities

It seems there’s room for improvement in how many physicians code for evaluation and management (E/M) services provided to patients in skilled nursing facilities (SNFs).

The Centers for Medicare & Medicaid Services (CMS) recently said its auditors found that physicians and non-physician practitioners (NPPs) are reporting incorrect codes for E/M services provided to SNF Medicare patients.

Specifically, physicians and NPPs are using CPT codes 99221-99223 (initial hospital care), 99231-99233 (subsequent hospital care), and 99238-99239 (hospital discharge day management) to bill for E/M services supplied to SNF patients. However, those codes are for E/M services supplied to hospital patients.

As described in the Medicare Claims Processing Manual Section 30.6.13, E/M services provided to patients residing in an SNF must be reported using the appropriate CPT level of service code within the range identified for initial nursing facility care (99304-99306) and subsequent nursing facility care (99307-99310). The annual nursing facility assessment is billed using CPT code 99318, and SNF discharge services are billed using CPT codes 99315-99316. Using an inpatient hospital E/M CPT code represents inappropriate billing when you render E/M services in an SNF.

Part of the confusion may stem from the fact that the patients in question are in hospital “swing beds,” which can represent either inpatient hospital or nursing facility care, depending on how the hospital is billing Medicare for its services. Section 30.6.9.D of the Medicare Claims Processing Manual advises that if the hospital is billing Medicare for the patient’s inpatient care as inpatient hospital care, the hospital care CPT codes apply for purposes of reporting physician services to the patient. If the hospital is billing Medicare for the patient’s inpatient care as nursing facility care, then the nursing facility CPT codes apply for physician services. So, if in doubt about the status of a Medicare patient in a “swing bed,” check with the hospital regarding how it is billing Medicare for the patient’s inpatient care and adjust your coding accordingly.

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

Monday, February 15, 2016

CMS gives physicians more time to attest to 2015 meaningful use

The Centers for Medicare & Medicaid Services (CMS) has extended the attestation deadline for the meaningful use program. Eligible Professionals (EPs) now have until 11:59 PM ET on Friday, March 11, to attest to the 2015 reporting year. The previous deadline was Feb. 29. Failure to attest will result in a 3 percent cut to your 2017 Medicare Part B payments.

EPs must attest to a continuous 90-day period between Jan. 1, 2015, and Dec. 31, 2015. Those scheduled to attest to Stage 2 will report on 10 objectives, while EPs scheduled to attest to Stage 1 will have alternate measures and exclusions available to them for 2015. Attestation is completed through the online Registration and Attestation System. You must have a National Plan and Provider Enumeration System (NPPES) web user account to log on. If someone is attesting on your behalf (such as a practice administrator) that individual must have an Identity and Access Management web user account and must be granted the appropriate authorizations to complete the attestation.

This announcement is the latest of many regarding meaningful use in recent months. In October, CMS released a final rule that, among other things, condensed Stages 1 and 2 into Modified Stage 2 and announced the Stage 3 objectives. Last month, CMS was granted the authority to streamline its exception process. Providers have until March 15 to submit a hardship application to avoid the 2017 payment adjustment. Also in January, acting administrator Andy Slavitt announced that the meaningful use program will be ending as a standalone program as the Medicare Access and CHIP Reauthorization Act (MACRA) is implemented in 2019.

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

Friday, February 12, 2016

CMS finalizes rule for returning Medicare overpayments

It’s been four years since the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule for how physicians should identify and return Medicare overpayments. The Feb. 11 release of the final rule, which pertains to overpayments involving Medicare Part A and Part B, was delayed by the complexity of the issue and the volume of comments received, CMS said.

The Affordable Care Act and now the CMS rule requires physicians to report and return overpayments within 60 days of identifying them. Failure to return them could lead to prosecution under the False Claims Act, including fines and financial damages. 

The rule defines “identification” of an overpayment as when the physician “has or should have, through the exercise of reasonable diligence, determined that (they have) received an overpayment and quantified the amount of the overpayment.” The exact moment when the 60-day clock starts had been the subject of legal action in recent years.

The final rule also specifies that physicians are liable for overpayments going back six years. This period is shorter than the proposed 10-year period, which attracted opposition from several physician groups who said that would create a significant burden in terms of record retention.

CMS estimates the annual cost to all health care providers of complying with the new rule will range between almost $121 million and $201 million.

Tuesday, February 9, 2016

CMS encourages you to register now to review “Open Payments” later

The Centers for Medicare & Medicaid Services (CMS) has given members of the health care industry until March 31 to submit information on all payments and “transfers of value” they made to physicians and teaching hospitals in 2015.

Under the “Open Payments” program, the information from pharmaceutical and medical device manufacturers and group purchasing organizations will be compiled and released later this year in a database available to the public.

Once the information is submitted, physicians and teaching hospitals can review any payments or transfers of value attributed to them and dispute items they believe are incorrect before the database is made public. But to do so, physicians must register in the Open Payments system.

If you registered last year, you are not required to do so again. However, if it has been more than 180 days since you logged onto the Enterprise Identity Management System, the account has been deactivated for security purposes.

You can visit the Open Payments Resources webpage for more information, including a fact sheet for physicians. For questions, you can contact the related Help Desk at 855-326-8366, Monday through Friday, from 7:30 a.m. to 6:30 p.m. CT.

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

Friday, February 5, 2016

Diabetes foot exams among changes in 2016 PQRS

The 2016 version of the Physician Quality Reporting System (PQRS) included a number of changes, but the revised diabetes foot exam is especially important to note because it requires more work than the measure it replaced.

The previous measure, “Diabetes: Foot Exam,” asked for a visual inspection of the foot along with a sensory exam using a monofilament and a pulse exam. The new measure, “Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation,” specifies that the sensory exam include a monofilament plus one of the following: vibration using 128-Hz tuning fork, pinprick sensation, ankle reflexed, or vibration perception threshold. This exam only needs to happen once a year, but it is important to document correctly.

In addition, the new measure, with some exceptions, applies to all patients with diabetes over the age of 18. The previous measure covered patients ages 18-75.

Remember, physicians who do not meet PQRS requirements in 2016 face a 2-percent cut in Medicare payments in 2018.

– Amy Mullins, MD, Medical Director of Quality Improvement, American Academy of Family Physicians

Tuesday, February 2, 2016

CMS aligning Medicaid and Medicare home health requirements

Last week, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that adds new requirements for Medicaid home health services. Among the new requirements is that physicians document a face-to-face encounter with Medicaid patients before ordering the home health services or certain related medical equipment. This rule aligns Medicaid with similar regulatory requirements for Medicare.

Specifically, the final rule requires that when first ordering home health services (nursing services and home health aide services) the physician must document that a face-to-face encounter related to the primary reason the patient needs home health services took place no more than 90 days before or 30 days after the start of services. If initially ordering medical supplies, equipment, or appliances, the physician or an authorized non-physician provider (NPP) must document that the face-to-face encounter occurred no more than six months prior to the start of services. In both cases, the physician or certain authorized NPPs must be the one performing the face-to-face encounter.

The final rule is effective on July 1. However, CMS recognizes that state governments and physicians may need time to deal with the operational and financial effects of the changes. Accordingly, CMS is delaying compliance with this rule for up to one year (July 1, 2017) if a state’s legislature has met in that year or two years (July 1, 2018) if not. A CMS fact sheet offers additional information.

– 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.

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