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Thursday, March 26, 2015

Congress races calendar to repeal Medicare pay cut

Update: On April 14, Congress enacted the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act of 2015 (MACRA), repealing the sustainable growth rate and negating the 21.2 percent cut in Medicare physician payments that technically went into effect for dates of service on or after April 1.


Barring a legislative fix by Congress, Medicare physician fees are scheduled to begin shrinking next week. But it’s likely physicians won’t feel the pinch immediately – and possibly never again.

Current law requires the Centers for Medicare & Medicaid Services (CMS) to cut Medicare physician payments by 21.2 percent effective with dates of service on or after April 1. CMS said the payment cut wouldn’t affect Medicare physician fee schedule claims for services rendered on or before March 31, which will be processed and paid under normal procedures and time frames.  

To avoid the cut or yet another patch to the payment system, Congress is working to repeal the sustainable growth rate (SGR) formula, a portion of the law that has threatened drastic reductions in Medicare fees for years. On Tuesday, members of the House of Representatives unveiled a bipartisan package to repeal the SGR formula, which the House then approved Thursday. The package now goes to the Senate, where its future is uncertain. The AAFP and others are encouraging their members to contact their members of Congress in support of SGR repeal.

In the meantime, expect CMS to do what it can to give Congress some breathing room. Under current law, it takes at least 14 calendar days for Medicare to pay electronic claims once they are received (at least 29 days for paper claims). In the past, CMS has ordered its contractors to hold Medicare claims for part of this statutory payment window to give Congress more time to act and thus avoid processing claims at a discounted rate that is later overturned. It seems reasonable to expect CMS will do something similar this time if Congress does not act by April 1.

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

Thursday, March 19, 2015

ICD-10 test identifies problem with remittance advice

Some more information about Medicare’s January end-to-end testing of the upcoming switch to ICD-10 coding: About 6 percent of the test claims couldn’t generate a remittance advice for the testing health care provider.

The Centers for Medicare & Medicaid Services says its ICD-10 system generated remittance advice letters for the vast majority of test claims. It blamed the rare miscues on technical problems in the Medicare Administrative Contractors (MACs) testing environments and said that some of the problems were not connected to ICD-10 coding.

Physicians and other providers who didn’t get a remittance advice in January will be able to resubmit those claims during the upcoming end-to-end testing weeks in April and July.

CMS said the MACs are setting up their systems for the next test and are expected to resolve all of the technical issues by then. Physicians and other providers must switch to ICD-10 coding on Oct. 1.

If you would like to participate in the July 20-24 end-to-end test, volunteer forms are due April 17. Those forms are available through your local MAC.

If you want to learn more about how to code using ICD-10, this collection of ICD-10 articles from Family Practice Management can help.

Thursday, March 12, 2015

CMS reveals results of Value Modifier program's first year

The Center for Medicare & Medicaid Services (CMS) has gotten back the results of the first year of the Value-based Payment Modifier program and recently blogged about them.

The Value Modifier, included in the Affordable Care Act, is intended to encourage physicians and practice groups to provide high quality and cost-effective care. While it will eventually apply to all health care practitioners in the country, the Value Modifier is being phased in gradually and applied only to groups of 100 or more eligible professionals in 2015. Those groups that met at least minimum standards were given the option of electing “quality-tiering,” which boosts, cuts, or leaves stable those physicians’ Medicare payments based on how they performed against national quality and cost benchmarks in 2013. Those who met minimum standards but did not elect quality-tiering – 564 groups – were not subject to any adjustments this year based on their performance.

According to CMS, nearly 7,000 physicians in 14 group practices across the country are receiving an increase in their Medicare payments in 2015 as a result of this quality-tiering. The group practices receiving increases fell into two categories:

1.    Groups that produced high quality care at average cost (the majority of groups receiving increases).
2.    Groups that produced average quality care at lower-than-expected cost.

Physician groups getting increases had, on average, better hospital readmissions rates –14.3 per 100 admissions – than the national benchmark of 16.4. These groups also had, on average, lower hospital admissions rates for acute and chronic ambulatory care sensitive conditions. Another 102 groups electing quality-tiering will see no change either because they met the national benchmarks or there was insufficient data.

Meanwhile, 330 groups are slated to see their Medicare payments cut in 2015 because of the Value Modifier program. Eleven groups subjected themselves to quality-tiering but failed to meet national benchmarks for quality or cost. Another 319 failed to meet the minimum requirements of the program and didn't have an option to elect quality-tiering.

Beginning in 2016, the Value Modifier will apply to groups with at least 10 or more eligible professionals, and quality-tiering will automatically apply to all of them. In 2017, the Value Modifier will apply to all groups and to solo practitioners who are physicians. Beginning in 2018, CMS will apply the Value Modifier to non-physician eligible professionals as well.

Physician groups and physicians can find information about their quality and cost performance in their Quality Resource and Use Reports  that were made available last fall.

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

Thursday, March 5, 2015

Physicians get a little more time for PQRS reporting

Some physicians are getting more time to submit 2014 data for the Physician Quality Reporting System (PQRS). Last week, the Centers for Medicare & Medicaid Services (CMS) announced it was giving physicians until 8 p.m. (Eastern Time) on March 20 (up from Feb. 28) to report their information if they were using either of these reporting methods:

•    A Direct Electronic Health Record (EHR) product or Data Submission Vendor using certified EHR technology
•    Qualified clinical data registries reporting for PQRS and components of meaningful use for the Medicare EHR Incentive Program

Individual eligible professionals (EPs) and group practices using these reporting methods to participate in other CMS programs, such as the Medicare EHR Incentive Program and Comprehensive Primary Care Initiative, can follow the new deadline as well. In addition, March 20 is the new deadline for eligible professionals wanting to attest to meaningful use for the 2014 EHR reporting period in the Medicare Electronic EHR Incentive Program.

Physicians who satisfy the PQRS reporting requirements for 2014 earn an incentive payment while those who don’t face a penalty on all Medicare Part B physician fee schedule services provided in 2016. For questions, please contact the Quality Net Help Desk at 866-288-8912 or by email at qnetsupport@hcqis.org from 7 a.m.-7 p.m. Central Time.

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

Monday, March 2, 2015

CMS says ICD-10 billing system test successful

The Centers for Medicare & Medicaid Services says a recently completed end-to-end test shows its billing systems are prepared for the switch to ICD-10 in October.

Between Jan. 26 and Feb. 3, 661 physicians, other health care providers, and billing companies volunteered to send test claims to the Medicare Administrative Contractors (MACs) and the Durable Medical Equipment MAC Common Electronic Data Interchange (CEDI) contractor. Unlike ICD-10 acknowledgement testing, which simply determines if the tester’s claim is accepted or rejected, the end-to-end tests process the claims through all Medicare system edits and provide an Electronic Remittance Advice.

Of the total 14,929 test claims, Medicare’s billing system accepted 12,149, or 81 percent. CMS said in a news release that most of the rejected claims failed for technical reasons, such as using an incorrect National Provider Identifier (NPI) number, using a date of service outside the study range, or submitting an incorrect ICD-10 code. The agency said it found and will address a system issue that caused a handful of home health claims to process incorrectly. But officials said they found no issues affecting front-end CMS systems for professional and supplier claims.

“Testing demonstrated that CMS systems are ready to accept ICD-10 claims,” CMS said.

CMS is planning two more end-to-end tests this year. While the agency has already chosen volunteers for the April 27-May 1 test, it is still looking for providers to test the system July 20-July 24. Volunteer forms will be made available at MAC and CEDI websites on March 13.

For more information, download the following Medicare Learning Network (MLN) articles:
“ICD-10 Limited End-to-End Testing with Submitters for 2015,”
“FAQs – ICD-10 End-to-End Testing,”
“Medicare FFS ICD-10 Testing Approach.”

Tuesday, February 24, 2015

Another opportunity for ICD-10 acknowledgement testing

The Centers for Medicare & Medicaid Services (CMS) is offering acknowledgement testing next week (March 2-6) to help physicians prepare for the transition to ICD-10 this fall.

Registration is not required, and any provider who submits claims electronically can participate. Participants, which include Medicare claims clearinghouses, will have access to real-time help desk support through their Medicare Administrative Contractors (MACs) and the Durable Medical Equipment MAC Common Electronic Data Interchange (CEDI) contractor. CMS will be also analyze the testing data. Information on how to participate is available on local MAC websites or through a clearinghouse, if the practice uses a clearinghouse to submit Medicare claims.

Here’s what physicians can expect during testing:
•    Test claims will receive the 277CA or 999 acknowledgement, as appropriate, to confirm that the claim was accepted or rejected in the system.
•    Test claims will be subject to all current front-end edits, including edits for valid National Provider Identifiers (NPIs), Provider Transaction Access Numbers (PTANs), and codes, including Healthcare Common Procedure Coding System (HCPCS) and place of service.
•    Testing will not confirm claim payment or produce a Remittance Advice.
•    MACs and CEDI will be staffed to handle increased call volume during this week.

CMS offers the following testing tips:
•    Make sure test files have the "T" in the ISA15 field to indicate the file is a test.
•    Send ICD-10 coded test claims that closely resemble the claims that the practice currently submits.
•    Use valid submitter identification, NPI, and PTAN combinations.
•    Use current dates of service on test claims (i.e., Oct. 1, 2014 through Mar. 1, 2015); do not use future dates of service or the claim will be rejected.
•    Use ICD-10 companion qualifier codes when submitting ICD-10 diagnosis codes.

If a physician is not prepared to do ICD-10 acknowledgement testing next week, CMS is planning another dedicated test June 1-5. In the meantime, practices can do acknowledgement testing on their own anytime up to the Oct. 1 implementation date.

For more information, check out the following Medicare Learning Network (MLN) articles:
•    “FAQs – International Classification of Diseases, 10th Edition (ICD-10) Acknowledgement Testing and End-to-End Testing"
•    “ICD-10 Testing - Acknowledgement Testing with Providers
•    “Medicare FFS ICD-10 Testing Approach

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

Monday, February 23, 2015

CMS continues addressing questions about CCM

Last week, the Centers for Medicare & Medicaid Services (CMS) hosted a national provider call on payment of chronic care management (CCM) services, codes for which went into effect this year. The call reaffirmed a lot of what CMS has previously stated in the Federal Register and that the AAFP has summarized on its web site.

One new piece of information gleaned from the call is the fact that rural health clinics and federally qualified health centers are not authorized to bill Medicare for CCM at this time. CMS staff indicated that they hope to change that in 2016. On the call, CMS staff also highlighted that they have published a fact sheet on CCM.

For those who missed the call, an audio recording and written transcript of it will be posted in approximately two weeks. A copy of the slide presentation used during the call is already available.

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

Thursday, February 12, 2015

Study shows lower than expected ICD-10 costs for small practices

One of the leading concerns about the scheduled change to ICD-10 coding later this year is the potentially high price tag.

The American Medical Association (AMA) last year published an updated study estimating that small practices could spend between $56,639 and $226,105 on transitioning to ICD-10 while medium and large practices would see much larger costs.

But a new survey by the Professional Association of Health Care Office Management shows the actual numbers may be much lower, at least for small practices.

Published this week in the Journal of AHIMA (American Health Information Management Association), the survey asked 276 medical practices with six or fewer physicians to total the cost of all activities connected to ICD-10, including what they’ve already spent and what they plan to spend in the future.

For these small practices, the average ICD-10 expenditure totaled $8,167 per practice and $3,430 per provider.

Solo physicians reported an average expenditure of $4,372. The largest practice expenditure belonged to four-provider practices, which reported an average of $13,541. Five-provider practices reported an average of $11,960, while six-provider practices reported an average of $11,028. For the most part, the average expenditure per provider declined as the practice grew larger and the cost could be spread among more people.

The survey also found that practices spent an average of 45.5 hours per provider on tasks related to ICD-10.

Researchers noted that their financial results differed significantly from the AMA’s study, which listed a range of $25,560 to $105,506 in pre-compliance implementation costs and another $31,079 to $120,599 in productivity losses and potential payment disruption. Addressing the pre-compliance costs, researchers said some of the cost difference reflected the availability of more low-priced training, vendors offering ICD-10 system updates for free, and more practices adopting electronic health records. In any event, the information shows that the switch to ICD-10, while still a drain on time and resources, doesn't necessarily equal a crippling financial burden.

Monday, February 9, 2015

Open Payments system ready for 2014 physician payment data

The Open Payments system (created under the Sunshine Act), which gathers and publicly discloses information on all payments or transfers of value from medical manufacturers and group purchasing organizations (GPOs) to individual physicians, is entering its second year.

Between now and March 31, pharmaceutical or medical device manufacturers and GPOs must register or recertify their registration with the Open Payments system and begin submitting payment data for 2014 and corrected data for 2013.

Physicians aren’t directly involved in the manufacturers’ data submission. But they should register with the system (or make sure they’re still registered from last year) so they can be ready to review any information submitted about them and make sure it is correct. The process for reviewing and disputing any information for physicians is expected to begin in April.

The Centers for Medicare & Medicaid Services plan to publish the 2014 payment data, as well as updated 2013 data, in June. Of course, last year’s process was far from smooth and saw some delays.

More information is available on the Open Payments website.

Friday, February 6, 2015

CMS answers your questions about ICD-10 testing

Last month, we provided an update on the results of ICD-10 acknowledgement testing done by the Centers for Medicare & Medicaid Services (CMS). That post also referenced the opportunity to do end-to-end ICD-10 testing with Medicare. Recognizing that there may be some confusion surrounding these different testing methods, CMS has released some frequently asked questions (FAQs) about both.

Among the takeaways from these FAQs:

•    Physicians do not need to register for acknowledgement testing, but end-to-end testing volunteers must register on their Medicare Administrative Contractor (MAC) website during specific time periods.
•    All Medicare fee-for-service electronic submitters can participate in acknowledgement testing, but CMS and its MACs will select only 50 testers per MAC jurisdiction for each round of end-to-end testing.
•    Acknowledgement testing will not confirm payment; it will only confirm that the claim was accepted or rejected by Medicare. End-to-end testing, however, will provide an electronic remittance advice based on current year pricing.
•    There is no limit on the number of acknowledgement test claims a physician can submit, but if selected for end-to-end testing, the physician may submit only 50 claims per test week.

The FAQs include a reminder that you may submit acknowledgement test claims anytime, although CMS encourages you to do acknowledgement testing during the highlighted testing weeks of March 2-6 and June 1-5. Those chosen for end-to-end testing must submit their test claims during the testing weeks of April 27–May 1 and July 20-24.

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

Tuesday, January 27, 2015

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

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

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

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

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

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

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

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

Monday, January 26, 2015

Medicare sets goals for value-based reimbursement

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

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

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

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

For more information, Medicare has provided a fact sheet.

Tuesday, January 20, 2015

Medicare updates coverage for pneumococcal vaccinations

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

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

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

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

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

Wednesday, January 14, 2015

2015 is a year of coping with Medicaid and Medicare cuts

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

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

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

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

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

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

Tuesday, January 6, 2015

CMS releases latest ICD-10 test results

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

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

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

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

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

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

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

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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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