Time running out for PQRS and eRx incentives

It's not too late to participate in a pair of federal incentive programs targeting clinical quality and computerized prescriptions. But you need to move fast.

The Centers for Medicare and Medicaid Services (CMS) this week hosted a national call to discuss how physicians and other eligible health care professionals can submit 2012 program year data for the Physician Quality Reporting System (PQRS) and the Electronic Prescribing (eRx) Incentive Program.

In case you missed it, below are some of the highlights.

For individual eligible professionals, you still have time to participate in the 2012 PQRS if you report your information either through a qualified registry or through a qualified electronic health record (EHR). The EHR option can communicate either directly or through a data submission vendor.

Registry vendors can submit data between Feb. 1 and March 31. EHR users can already submit their data, but they only have until Feb. 28. No submissions after the end dates will be allowed.

You may potentially qualify to receive a full-year incentive payment. But even if you don't, it's good experience in reporting PQRS measures before tackling 2013, which is the reporting period CMS will use in determining PQRS penalties in 2015.

The same options and dates apply with respect to the eRx Incentive Program. As with the PQRS, you may potentially qualify to receive a full-year incentive payment, and you may potentially qualify to avoid the 2014 eRx penalty. However, to avoid a penalty this year, you had to have complied with the program by June 30, 2012.

For more information on the programs, you can find the presentation from the national call online.

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

Posted at 11:09AM Jan 23, 2013 by David Twiddy, Associate Editor  |  Comments[0]

Avoiding Medicare cliff still has initial consequences for payment

With the Medicare payment cliff averted for now, Medicare and its contractors are beginning to implement payments for 2013 services. Here is what you can expect, based on information provided by the Centers for Medicare and Medicaid Services (CMS).

First, CMS is revising the 2013 Medicare Physician Fee Schedule (MPFS) to reflect the new law's requirements as well as technical corrections identified since publication of the final rule on the 2013 MPFS in November 2012. Officially, the 2013 conversion factor is $34.0230.

Second, to allow sufficient time to develop, test, and implement the revised MPFS, Medicare contractors were able to hold MPFS claims with January 2013 dates of service for up to 10 business days (i.e., through Jan. 15). CMS expected those claims to be released into processing no later than Jan. 16. The claim hold should have minimal impact on your cash flow, however, because, under current law, clean electronic claims are not paid sooner than 14 calendar days (29 for paper claims) after the date of receipt anyway. Claims with dates of service prior to Jan. 1, 2013, are unaffected.

Medicare contractors will be posting the correct MPFS payment rates on their websites no later than Jan. 23. If you have downloaded or will be downloading the fee schedule from your local Medicare contractor's web site, double-check to ensure that it reflects the correct rates, based on the recent change in the law.

Finally, the 2013 Annual Participation Enrollment Program allowed eligible physicians, practitioners, and suppliers an opportunity to change their Medicare participation status by Dec. 31, 2012. Given the new legislation, CMS is extending the 2013 annual participation enrollment period through Feb. 15, 2013. Therefore, you have until Feb. 15, 2013, to postmark any participation changes (both elections and withdrawals) that you want to make. The effective date for any participation status changes during the extension remains Jan. 1, 2013, and will be binding for the rest of the year.

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

Posted at 01:35PM Jan 17, 2013 by David Twiddy, Associate Editor  |  Comments[0]

Webinar to discuss what's new in Medicare and Medicaid payment in 2013

With the Medicare payment cliff averted for now, Medicare payments should be fairly stable for a while. However, that does not mean there are no changes in store for Medicare and Medicaid this year.

From Medicare adding two new codes for transitional care management to Medicaid payments for some primary care services rising to the level of Medicare to the continuing use of Physician Quality Reporting System (PQRS) bonuses, it's going to be a busy year for family physicians understanding and taking advantage of the new payment rules.

My colleague Debra Seyfried and I will be covering these and other aspects of Medicare payment in 2013 during a live webinar at 1:00 p.m. (Central Standard Time) on Jan. 23, 2013. I would invite you to join us by registering online. It could make a difference to your bottom line this year and in years to come.

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

Posted at 03:42PM Jan 07, 2013 by David Twiddy, Associate Editor  |  Comments[0]

Medicare's fiscal cliff averted ... for now

They waited until the very last second, but members of Congress on Tuesday approved legislation that preserves Medicare physician payment rates for another year and delays planned budget cuts until March.

In the waning hours of New Year's Day, the U.S. House of Representatives passed House Resolution 8, the American Taxpayer Relief Act, which had previously been approved by the Senate. Under the act, current Medicare physician payment rates (i.e., the conversion factor) are extended through Dec. 31, 2013, thus avoiding the 26.5 percent cut required by the sustainable growth rate (SGR) formula. The act also delays, for two months, implementation of the Budget Control Act's sequestration provision, which could reduce payments by an additional 2 percent.

The $25 billion cost for the SGR patch was offset by an array of provisions. One of those included extending the statute of limitations from three to five years for recoupment of Medicare overpayments.

So, what does this mean for your Medicare payments in 2013? Well, for the next two months at least, you should not see any substantial changes. The actual payment allowance for some services may vary slightly, based on changes in relative value units assigned to those services and other elements of the Medicare physician fee schedule. If Congress fails to further address the sequestration cut, you may see a 2 percent drop in your Medicare allowances in early March. Otherwise, things should be stable through the end of the year. 

The American Academy of Family Physicians and the rest of organized medicine continue to push for a permanent solution to the SGR problem. In the meantime, Congress has provided another of its annual patches to this perennial issue.

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

Posted at 05:29PM Jan 02, 2013 by David Twiddy, Associate Editor  |  Comments[0]

Medicare's impending fiscal cliff for physicians

If the federal government does go over the "fiscal cliff" in a little more than a week, don't expect those overseeing physician reimbursements to pad the fall.

The Centers for Medicare and Medicaid Services (CMS) on Dec. 19 announced in an email and conference call with physicians that Medicare claims filed after the first of the year will be processed as normal, which means likely including a planned 26.5 percent reduction in the Medicare physician services conversion factor.

Physicians are also facing an additional 2 percent cut in the Medicare physician payment rate because of the Budget Control Act's sequestration provision.

Under current law, clean electronic claims are not paid sooner than 14 calendar days (29 days for paper claims) after the date of receipt. In similar past situations, CMS has taken advantage of that provision to have its contractors hold claims for up to 10 business days before processing them, in order to give Congress more time to act and to avoid processing claims twice when the conversion factor is in flux.

“The negative update of 27 percent under current law for the 2013 Medicare Physician Fee Schedule is scheduled to take effect on January 1, 2013,” CMS wrote in the email. “Given the current progress with the legislation, CMS must take steps to implement the negative update.”

CMS did say that it would notify physicians on or before Jan. 11, 2013, about the status of Congressional action to avert the negative update and next steps. Claims with dates of service on or before Dec. 31, 2012, will be unaffected in any case.

Ongoing efforts to avoid the cliff and override the planned rate reduction have so far failed and won't resume until after Christmas at the earliest.

In the meantime, you are advised to start taking steps to mitigate the disruption and meet your own financial obligations in January, in case the cuts actually take effect. This includes re-assessing your Medicare participation options and the extent to which you can continue to afford to care for Medicare beneficiaries. If you decide to limit your involvement with the Medicare program, notify your Medicare patients promptly, so that they, too, can explore other options to seek health care and medical treatment. Finally, you are encouraged to contact your Congressional representatives about this matter, and the American Academy of Family Physicians has provided a convenient means to do so.

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

Posted at 04:10PM Dec 21, 2012 by David Twiddy, Associate Editor  |  Comments[0]

Begin the Beguine, or loosening up for some ICD-10 dance steps

Is it necessary to love big band jazz in order to properly understand the new ICD-10 coding? No, but it would certainly help with the fancy footwork involved.

The "Getting Paid" blog will address in coming posts what major changes to look for in specific chapters of ICD-10. In the meantime, we'll look at the new coding system's Conventions and Guidelines. These are all available for download on the CDC website.

First off, ICD-10-CM has 21 chapters, up from 17 in ICD-9-CM as codes for certain conditions either break off to form their own sections or get roped in with others. The V and E codes, which detail supplemental factors influencing a patient's health and the external causes of injury, will be incorporated in the main classification under ICD-10-CM. Meanwhile, diseases and conditions of the eyes and ears will get their own chapter, separated from their current home in the nervous system section.

Injuries will now be classified by site, and then by type. Postoperative complications have been moved to procedure-specific body system chapters. Also, some codes have been combined. For example, coding for type 1 diabetes mellitus with diabetic neuropathy will no longer require two codes (one for the diabetes and one for the neurological manifestation) but a single code of E10.21.

In ICD-10-CM, as with ICD-9-CM, notes and parenthetical instructions are still present. The manual will still use "code first" and "use additional code," as well as "includes" and "excludes" notes. Also remaining are "not otherwise specified (NOS)" and "not elsewhere classified (NEC)." The term "and" is interpreted to mean "and/or" when it appears in a code title within the tabular list. The word "with" is interpreted to mean "associated with" or "due to" when appearing in a code title.

On the other hand, certain symbols, such as the lozenge, section mark, and braces are disappearing. Instead, ICD-10 will use dashes at the end of a code to signal that it requires additional characters. One example is M84.47-, which could represent any fracture to an ankle, foot, or toe (M84.472 is a fractured left ankle). ICD-10 does two types of "exclude" notes to modify some codes. "Excludes 1" lists condition codes that can't be used at the same time as the primary code. "Excludes 2" notes conditions that are not part of the primary code but that a patient could present at the the same time, meaning that both codes being used together are acceptable.

The alphabetic index of ICD-10 is divided into two parts – the index to diseases and injuries and the index to external causes – while the type and format layout uses the same mechanics as ICD-9.  Morphology codes are no longer listed in the alphabetic index, and they no longer have a separate appendix in ICD-10.

As I said earlier, the tabular list is divided into 21 chapters. Some of the reclassifications of diseases to different chapters were done for better alignment.  Each chapter is then divided into subchapters that contain three characters and are similar to the ICD-9 foundations.  Each chapter in ICD-10 begins with a summary of the blocks and an overview of the categories within the chapter. Some of the subchapters are divided into even more specific subchapters. 

The takeaway? With all of the changes ahead with ICD-10, getting up to speed will likely be less of a graceful waltz and more of a frantic jitterbug. But the AAFP is here to help you get through it.

–Debra Seyfried, MBA, CMPE, CPC, Coding and Compliance Strategist for the American Academy of Family Physicians

Posted at 06:47PM Dec 20, 2012 by David Twiddy, Associate Editor  |  Comments[0]

New rule would let more family physicians treat veterans

While many family physicians want to treat the military veterans in their communities, the Department of Veterans Affairs (VA) hasn't always made that easy. Thankfully, the VA recently began taking steps to loosen its regulations in such a way that family physicians could have greater ability to serve veterans and get paid by the VA for doing so.

Under current law, private physicians can provide certain hospital care and medical services to eligible veterans when VA facilities either are not accessible or aren't able to provide the necessary care. These services are provided under the Non-VA Care program. However, the program allows that non-VA care only if the veteran initially received treatment during a period of hospitalization.

Last month, the VA published a proposed revision to this regulation in the Federal Register. The change would enlarge the list of eligible providers where the veteran initially received care to include nursing homes, domiciliary care, or other medical services. The VA could authorize non-VA treatment under the program for up to 12 months, with the option of additional reauthorizations as needed.

The American Academy of Family Physicians (AAFP) enthusiastically supports this step since it improves health care access for veterans and will allow the VA to better utilize community resources. Separate from this proposed regulation, the AAFP is encouraging the VA to identify and remove additional barriers that inhibit the way community-based family physicians are able treat their patients who also happen to be veterans. Specifically, the AAFP is urging the VA to reexamine a burdensome regulatory requirement that in order for a veteran to obtain a prescription at the VA's discounted price it has to be written by a VA-affiliated provider. Instead, AAFP believes the VA should recognize the validity of a community-based physician's prescription.

The VA’s recent proposal won’t eliminate all of the barriers that community family physicians face in trying to serve veterans. However, it appears to be a step in the right direction for both veterans and their family physicians.

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

Posted at 11:29AM Dec 18, 2012 by David Twiddy, Associate Editor  |  Comments[0]

Rethinking your Medicare participation options?

With just a little more than three weeks left before the wheels could fall off Medicare payments, you may be rethinking your level of involvement with the program.

Congress may step in again this year to avoid the scheduled 26.5 percent cut tied to the Sustainable Growth Rate formula. But if not, here is a brief look at the options open to you and ways to reduce your Medicare exposure, even if you remain a participating physician.

You have three Medicare contractual options. You can sign a participating (PAR) agreement, accepting Medicare's allowed charge as payment in full; elect to be a non-PAR physician, which allows you to take Medicare patients on a case-by-case basis and bill patients for more than the Medicare allowance for unassigned claims; or opt out and become a private contracting physician who bills Medicare-eligible patients directly for your services.

You have until Dec. 31 to change your Medicare participation or non-participation status for 2013. Before making a change in status, you should first determine that you are not bound by any contractual arrangements with hospitals, health plans, or other entities that require you to be a PAR physician.

Even if you choose to continue being a PAR physician, there are ways that you can limit your Medicare exposure. For instance, you can refuse to treat Medicare patients except on an emergency basis. Medicare is a voluntary program, and nothing requires you to treat Medicare patients in your practice if you do not wish to do so. You can also limit your practice to existing Medicare patients only and accept no new Medicare patients. Lastly, you can reduce the number of Medicare patients in your practice.

For more information, see Family Practice Management's previously published articles on opting out of Medicare and preparing for a Medicare fee cut.  

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

Posted at 03:38PM Dec 06, 2012 by David Twiddy, Associate Editor  |  Comments[0]

Medicare releases its final rule on the 2013 physician fee schedule

On November 16, the Centers for Medicare and Medicaid Services (CMS) published the final rule on the 2013 Medicare Physician Fee Schedule, changing the physician fee schedule and other Medicare Part B payment policies and implementing certain provisions of the Affordable Care Act.

The regulation also discusses:

• 2013 Physician Quality Reporting System


• Electronic Prescribing Incentive Program


• Implementation of the Physician Value-Based Payment Modifier

Among the highlights in the final rule:

• In 2013, CMS will pay for new Current Procedural Terminology transitional care management codes, 99495 and 99496, with some small modifications. Based on the relative value units that CMS finalized and assuming that Congress averts the pending 26.5-percent reduction discussed below, code 99495 performed in a facility will pay approximately $135; in a non-facility setting, 99495 will pay approximately $164. Code 99496 performed in a non-facility will pay approximately $231.12, and when performed in a facility setting, it will pay approximately $197.76.


• CMS delayed to July 1, 2013, the effective date of its requirement that a face-to-face visit be a condition of payment for certain high-cost durable medical equipment (DME) covered items. The list included many items that have historically been targets of Medicare fraud as identified by various program integrity experts. The encounter must occur within six months before the written order for the DME. CMS is not mandating additional documentation beyond what the physician or other qualified health professional would normally document during the actual face-to-face encounter.


• CMS is limiting the applicability of the value-based payment modifier to groups of 100 or more eligible professionals during 2015, the first year it will be effective. This means that most family physicians will not have to worry about it for now.

CMS estimates that, all things being equal, family physicians will experience a 7-percent increase in their Medicare allowed charges in 2013 as a result of what is in the final rule.

Unfortunately, that assumes no change in the Medicare conversion factor from 2012. However, as noted in the final rule, the conversion factor under current law will decrease 26.5 percent to approximately $25 (from the current $34.04), effective with dates of service on or after Jan. 1, 2013. That means, unless Congress intervenes in the interim, the drop in the conversion factor will more than wipe out the projected 7-percent increase.

So, there is good news and bad news in the final rule this year. Only time will tell which will prevail, so stay tuned. In the meantime, for more information on the final rule, please visit the American Academy of Family Physicians' web site.

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

Posted at 11:24AM Nov 30, 2012 by David Twiddy, Associate Editor  |  Comments[0]

CMS approves new codes for Transitional Care Management

CMS has approved paying two new codes for care management of patients transitioning from an inpatient hospital setting (including acuity, rehabilitation, or long-term acute care), partial hospitalization, or observation status in a hospital, skilled nursing facility, or other nursing facility to the patient’s community setting (home, domiciliary, rest home, or assisted living).

These new codes are based on the complexity of medical decision-making and the amount of time between discharge and the patient’s first face-to-face visit with the physician or other qualified health care provider. Code 99495 requires moderately complex medical decision-making and a face-to-face visit within 14 days. Code 99496 requires highly complex medical decision-making and a face-to-face visit within seven days.

Transitional care management (TCM) is based on the CMS Evaluation and Management Guidelines. Medical decision-making consists of three components: (1) Diagnosis and Management, (2) Data Reviewed, and (3) Table of Risk. Ideally the first place to look is the table of risk. If the patient falls under the minimal or low section of the table of risk it is highly unlikely they will qualify for either of these codes. However, you need to review all three components to determine the appropriate level.

Both codes require communication with the patient or caregiver within two business days of discharge by telephone, direct contact, or electronic means, and that, by the first face-to-face visit following discharge, the patient’s medications be reconciled with the medications listed on the patient’s chart.

The physician or other qualified health care provider may provide the following non-face-to-face services:

• Obtaining and reviewing the discharge information (e.g., discharge summary or continuity of care documents).

• Reviewing and follow-up of pending diagnostic tests and treatments.

• Interaction with other qualified health care professionals who will assume or re-assume care of the patient’s system-specific problem.

• Education of patient, family, guardian, and/or caregiver.

• Establishment or re-establishment of referrals, and arranging community services, if needed.

• Assistance in scheduling any required follow-up with community providers and services.

Clinical staff under direction from a physician or other provider can provide such non-face-to-face services as communicating aspects of care, self-management and treatnment regimen adherence with the patient, caregiver, or other decision maker, as well as communicating with home health agencies or other community services the patient is using. They can also help identify available community resources for the patient and help get them access.

You cannot charge an office visit on the same day as your face-to-face visit for TCM. However, you can be the discharging physician and bill the discharge and then the TCM. Only one physician may bill the TCM and it can only be billed once per 30 days, even if the patient has another hospitalization and discharge.

CMS has valued Code 99495 at 4.82 total RVUs, or about $163. Code 99496 is valued at 6.79 RVUs, or approximately $230.

These codes are ideal for a strong team approach, covering services many family physicians are providing on a regular basis, and recognizing that primary care physicians take care of many time-consuming issues of care coordination for patients.This is a start in the right direction. Happy Transitioning!

–Debra Seyfried, MBA, CMPE, CPC, Coding and Compliance Strategist for the American Academy of Family Physicians 

Posted at 02:46PM Nov 29, 2012 by David Twiddy, Associate Editor  |  Comments[1]

Who is your ICD-10 champion?

The time has come to begin planning for implementation of ICD-10 diagnosis codes. The implementation deadline is Oct. 1, 2014. Think of ICD-10 like a favorite food dish, best served in smaller portions over time. You should begin by identifying a capable leader who can oversee an ICD-10 project team. This should be someone with an understanding of ICD-10 who is able to communicate clearly about the reason for and implications of the change. With the team leader in place, an implementation team can be appointed. Be sure to have a good representation from both the clinical and business sides of your practice. ICD-10 will affect everyone in your office, and having input from staff with varying job duties will save headaches in the long term.

Once you have your team in place, begin delegating different areas of focus to your team members. These areas may include medical records, billing, front desk check-in, check-out, procedure scheduling, and ancillary services. Ask team members where they see, speak, hear, or write ICD-9 codes. Challenge them to assess these areas and determine if there is a policy or procedure that will need updating to include ICD-10 nomenclature. You should create a master list that contains the names and the positions of those who are affected and describes the impact ICD-10 will have on them. Keep this list on display to build awareness and prepare staff for future discussions about their involvement in the implementation of ICD-10. It will also be a helpful resource as you move forward in the implementation process. Next steps will involve analysis, revisions, restructuring, and training. Establish a regular meeting schedule for the next two years to help keep your group on track.

For more information and a timeline for ICD-10 implementation, see the American Academy of Family Physicians ICD-10 website.

–Debra Seyfried, MBA, CMPE, CPC, Coding and Compliance Strategist for the American Academy of Family Physicians

Posted at 02:28PM Nov 08, 2012 by Lindsey Hoover, Asst. Editor  |  Comments[0]

'Tis the season...influenza season, that is

The Centers for Medicare & Medicaid Services (CMS) released its annual update to influenza vaccine payments in early October, effective for dates of service on or after Aug. 1, 2012. Here’s an overview of what your Medicare contractor should be paying you.

CMS has payment allowances for several CPT and HCPCS codes for seasonal influenza virus vaccines. These allowances are typically based on 95 percent of the average wholesale price. However, when physicians furnish the vaccine in a hospital outpatient department, rural health clinic, or federally qualified health center, payment is based on reasonable cost and other allowances may apply.

The following table shows the payment allowances (based on 95 percent of the average wholesale price) for the most common codes:

Note that CMS has permitted payment allowances for some influenza vaccines to be set by the local claims processing contractor. Specifically, local contractors set the payment amounts for Q2034, Influenza virus vaccine, split virus, for intramuscular use (Agriflu), and Q2039, Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified).

Medicare payment for some other influenza vaccine codes is available only after the local claims processing contractor determines that the vaccine in question is medically reasonable and necessary for the beneficiary. These include:

•    90654 – Influenza virus vaccine, split virus, preservative-free, for intradermal use (Fluzone ID); Part B allowance of $18.981,
•    90660 – Influenza virus vaccine, live, for intranasal use (FluMist); Part B allowance of $23.456,
•    90662 – Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use (Fluzone High-Dose); Part B allowance of $30.923.

The additional scrutiny that Medicare is giving these codes is probably due in part to their costs compared with the traditional injectable influenza vaccine. Beyond that, code 90654 is a new code reflecting a new route of administration (i.e., intradermal), and the “enhanced immunogenicity” represented by code 90662 is probably not universally needed, leading Medicare to make sure that those who receive it do so appropriately. Finally, an article published by the Medicare contractor in Florida suggests that 90660 is only indicated for healthy individuals between 2 to 49 years of age, again leading Medicare to ensure that those who receive it do so appropriately.

In closing, it is worth pointing out that the allowances above are effective with dates of service on or after Aug. 1, 2012; however, Medicare contractors have until Dec. 28, 2012, to implement these allowances, so it is possible that some of your influenza vaccine claims may not be paid at the correct rate in the interim. Medicare contractors will not search their files to either retract payment for claims already paid or to retroactively pay claims. However, contractors will adjust claims brought to their attention, so if you submitted a claim that is not paid at the correct allowance, you need to bring that claim to the contractor’s attention for adjustment.

For more information, check out the MLN Matters article (MM8047) "Influenza Vaccine Payment Allowances: Annual Update for 2012-2013 Season.”

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

Posted at 11:30AM Nov 02, 2012 by Lindsey Hoover, Asst. Editor  |  Comments[0]

Audit alert: Notable items in the 2013 OIG work plan

Oct. 1, 2012 represents the start of the federal fiscal year. That makes now a good time to look at the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) work plan for the current fiscal year, especially as it relates to physician services under the Medicare program. Knowing what the OIG is examining can sometimes provide a useful “heads up” on issues that Medicare itself may focus on during the coming 12 months.

First, OIG has no fewer than five items on its work plan aimed at diabetes testing supplies:

• Supplier compliance with payment requirements for blood glucose test strips and lancets,
• Effectiveness of system edits to prevent inappropriate payments for blood-glucose test strips and lancets to multiple suppliers,
• Potential questionable billing for test strips in 2011,
• Improper supplier billing for test strips in competitive bidding areas,
• Supplier compliance with requirements for nonmail order claims.

Although most of these items are aimed at suppliers, it is reasonable to expect that such attention may prompt those suppliers to be more demanding of physician prescribers. Given the incidence of diabetes among family medicine patients, family physicians are among the most common prescribers of such supplies.

For those practices that have office laboratories, the OIG’s work plan has at least three items of interest:

• Billing characteristics and questionable billing in 2010,
• Reasonableness of Medicare payments compared to those by state Medicaid and Federal Employees Health Benefit programs,
• Part B payments for glycated hemoglobin A1C tests.

Finally, in the particular area of physician services, the following items stand out:

• Noncompliance with assignment rules and excessive billing of beneficiaries,
• Error rate for incident-to services performed by nonphysicians,
• Place-of-service coding errors,
• Evaluation and management (E/M) services—potentially inappropriate payments in 2010.

Regarding the last item on this list, the OIG work plan states:
We will determine the extent to which the Centers for Medicare & Medicaid (CMS) made potentially inappropriate payments for E/M services in 2010 and the consistency of E/M medical review determinations. We will also review multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Medicare requires providers to select the code for the service on the basis of the content of the service and have documentation to support the level of service reported.

The OIG’s review will focus on 2010 services, but it is reasonable to expect that this will be an area of focus going forward. Since E/M services represent the “bread and butter” of family medicine, and in light of the increasing use of EHRs in family medicine practices, this is one area that probably merits an internal review for most family medicine practices now and in the future.

Of course, the OIG’s work plan is more extensive than just the items listed above, so a scan of the table of contents for that work plan would probably be in order to see if there are other items that may be relevant to your particular practice.  Explanations of all items are included in the OIG work plan.

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

Posted at 04:09PM Oct 24, 2012 by Lindsey Hoover, Asst. Editor  |  Comments[0]

No shows = lost revenue

Medical practices average a 5 to 7 percent no-show rate, according to the Medical Group Management Association (MGMA). No-show appointments are a reality of every medical practice. While you may not be able to eliminate them, there are ways to reduce no-shows and the negative effect they have on your practice.

Maintain patient access. The longer you require a patient to wait to be seen, the more likely they will find care from another provider, especially if it is something they need to be seen for right away such as an ear infection or strep throat. In these cases many patients do not call to cancel the future appointment with you, they just don’t show up as they have received care somewhere else.

Make sure you have assigned acute appointment slots in your schedule every day to see these patients the same day they call. Seeing just one more patient per day can accumulate into a large amount of additional revenue each year.  According to Michael O'Connell's MGMA Connexion article, "10 ways to manage better during difficult financial times," adding just one more patient to your schedule each day can add $25,000 to the annual bottom line for primary care (estimating $100 for a new patient visit).

Remind patients. Remind patients that they have an appointment with your practice. Assign staff to remind patients at least 48 hours in advance of their appointment or consider using an automated appointment reminder service if it makes financial sense for your practice.

Require appointment confirmations when appropriate. Long appointments such as procedures or complete physicals take up a lot of time on a physician’s schedule. For these types of encounters you may want to require that the patient confirms the appointment with you. Confirming long appointments can prevent huge gaps that can have a negative effect on your day. Confirmations can be done using automated reminder systems or personally asking patients to call back to confirm the appointment rather than leaving a message and hoping they received it.

Manage chronic offenders. Identify the patients who chronically miss appointments. Place a note in the patient’s record for the schedulers to see during the scheduling process. If a chronic no-show patient requests an appointment, try double-booking them with a quick visit or give them an appointment at the end of the day where the missed appointment will not disrupt patient flow.

Dismiss chronic offenders from your practice. Patients that repeatedly no-show for appointments can be terminated from your patient panel. Develop a policy for your practice to dismiss these patients and be consistent with every patient. For example, allowing a specific number of no-shows prior to dismissal gives the patient an opportunity to accidentally miss appointments before being terminated from the practice. Three missed appointments prior to termination is a reasonable policy to put in place.

Consider charging no-show fees. If you have tried other methods to decrease your no-show rates and are not seeing results, you may want to implement a policy to charge a fee for patients that do not show up for appointments to recoup some of that lost revenue. 
There are some important aspects to consider before moving forward with a no-show fee policy:

• Some payers allow charges for no-shows.  Is your office capable of tracking who can and cannot be charged the no-show fee?
• What is your patient population like? Can the average patient afford to pay the fee for a no-show appointment? Will they ignore these charges and make it difficult for you to collect the fee? You don’t want the implementation of a no-show policy to lead to a more complicated problem of collecting the fees from your patients.
• Will the amount of the fee charged compensate for the amount of time it takes to bill and collect from no-show patients, or will you be losing money on this effort?
• Your patients may seek care from another physician. If the patient does not approve of the no-show fee, they may leave your practice voluntarily and you could lose that patient and the revenue of future visits.

How do you keep no-shows from ruining your day in your medical practice? Click on “Comments,” below, and share your ideas and best practices.

–Renae Moch, MBA, CMPE, Practice Management Strategist for the American Academy of Family Physicians

Posted at 04:16PM Oct 12, 2012 by Lindsey Hoover, Asst. Editor  |  Comments[0]

Recovery audit contractors get a new fishing license

In a previous blog post, I discussed the Centers for Medicare & Medicaid Services’ (CMS) decision to allow one of its recovery audit contractors (RAC), Conolly, to begin auditing claims for evaluation and management codes, specifically code 99215. Earlier this month, the U. S. Court of Appeals for the 9th Circuit gave RACs and other Medicare contractors even more discretion in this regard. Specifically, in Palomar v. Sebelius, D.C. No. 3:09-cv-00605-BEN-NLS (Sept. 11, 2012), the court upheld that a decision by a RAC to reopen a Medicare claim for complex review was not reviewable.

The Palomar case involved a RAC's determination that services provided to a Medicare beneficiary were not reasonable and necessary. The claim in question was more than one year old and could only be reopened for "good cause" under Medicare regulations. All of the reviewers that examined the case agreed with the RAC's determination regarding medical necessity. However, the administrative law judge who reviewed the RAC determination concluded that there was not good cause to reopen the claim and reversed the RAC decision.

On appeal, the Medicare Appeals Council (MAC) reversed the administrative law judge decision. The council ruled that the Medicare regulation at 42 C.F.R. § 405.980(a)(5) makes a Medicare contractor's decision to reopen a claim unreviewable. Both the U.S. District Court and the U.S. Court of Appeals for the 9th Circuit affirmed this opinion. The courts held that the regulation expressly forecloses jurisdiction to review the reopening decision and that providers may only appeal the substance of a contractor's overpayment determination (e.g. whether or not the services were reasonable and necessary).

The Secretary for the U.S. Department of Health & Human Services argued that the review of contractors' compliance with the regulations is solely a matter for CMS's performance evaluations of the contractors. That leaves physicians at the mercy of CMS’s ability to manage its contractors.

Additionally, because the RACs get a cut of every overpayment that they find, they have incentive to reopen claims whether or not "good cause" exists under the Medicare regulations. This is especially true because most determinations finding an absence of medical necessity are based on a lack of documentation, and because it will be harder to find documentation and testimony to support older claims.

The "good cause" requirement was an important source of protection against contractor fishing expeditions. Unfortunately, the Palomar decision just gave RACs and other Medicare auditors a virtually unlimited fishing license going forward.

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

Posted at 07:43AM Sep 27, 2012 by Lindsey Hoover, Asst. Editor  |  Comments[0]