Main | Next page »

Monday, May 22, 2017

How to avoid the unpaid Medicare annual wellness visit

One of the challenges of getting paid for Medicare annual wellness visits (AWVs) is that Medicare reimburses only one AWV a year per Medicare patient – and your patient may get that visit elsewhere without you knowing it. Even worse, you will not discover that fact until after you have provided the service and received a claim denial from Medicare. What’s a practice to do?

One strategy is to encourage your Medicare patients to receive their AWVs from you. A letter to your patients could emphasize that the AWV is part of the ongoing relationship between the patient and your practice, a relationship that enables you to provide them with continuity of care. It could then explain how Medicare pays for only one wellness visit per year and that you can’t provide it if they receive an AWV somewhere else.

Another strategy is to check a Medicare patients’ billing history to see if Medicare has paid for an AWV within the past 12 months. You can do this a couple of ways. One way is to contact your local Medicare administrative contractor (MAC) to verify whether enough time has passed since the patient’s last AWV for you to get reimbursed. If the patient has moved or spends part of the year in another part of the country (e.g., is a “snowbird”), you may also need to contact the MAC for the part of the country where the patient lived previously. You can identify the relevant MAC and their contact information through an interactive map from the Centers for Medicare & Medicaid Services (CMS).

Alternatively, you may want to access the CMS HIPAA Eligibility Transaction System (HETS) Help (270/271), a secure website that provides Medicare information for patient eligibility and liability. HETS is available to you for free at any time with limited functionality outside of normal business hours.

There are many frequently asked questions about the Medicare AWV. Don’t let “Am I going to get paid for this?” be one of them.


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

Monday, November 28, 2016

New code required in 2017 for telehealth services

Beginning Jan. 1, the Centers for Medicare & Medicaid Services (CMS) is creating a new place of service (POS) code for physicians who provide telehealth services from a distant site. POS code 02 is described as “The location where health services and health related services are provided or received, through telecommunication technology.”

Under HIPAA, non-medical code sets, such as POS, are paid based on what code set was in effect on the date of the transaction, not the date of service. So even if the date of service was in 2016, if you initiate the claim on or after Jan. 1, you should use the new POS code.

Note that you must still use modifiers GT (via interactive audio and video telecommunications systems) and GQ (via an asynchronous telecommunications system) when billing Medicare for telehealth services. If you bill POS code 02 but without the GT or GQ modifier, your Medicare administrative contractor (MAC) will deny the service. Your MAC will also deny the service if you bill for telehealth services with modifiers GT or GQ but without POS code 02.

CMS has provided additional information on this change through the Medicare Learning Network.

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

Tuesday, November 15, 2016

New influenza vaccine code delayed until Jan. 1

If you are dispensing influenza vaccines under a new CPT code this fall, the Centers for Medicare & Medicaid Services (CMS) is suggesting that you do not send those claims in for payment right away.

This summer, CMS was scheduled to accept a new CPT code for influenza vaccine. The code, 90674, describes “Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use.” The CPT Editorial Panel accepted the code at its February meeting, and it will appear in the 2017 CPT book. CMS previously disclosed a payment allowance of $22.936 for code 90674, beginning for services provided on or after Aug. 1.

But CMS recently announced that Medicare claims processing systems will not be able to accept code 90674 until Jan. 1.

In the meantime, CMS advises that you hold claims containing that code until then. Also, if you bill institutional claims, CMS says that code 90674 will be implemented on Feb. 20.

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

Thursday, November 10, 2016

New pay increases in the 2017 Medicare physician fee schedule

The Centers for Medicare & Medicaid Services (CMS) has released its final rule on the 2017 Medicare physician fee schedule. Some of the several increases for care management services in 2017 will interest family physicians. For example, CMS next year will begin paying for:

• Non-face-to-face prolonged evaluation and management services

• Comprehensive assessment and care planning for patients with cognitive impairment

• Primary care practices to use interprofessional care management resources to treat behavioral health conditions

• Chronic care management (CCM) for patients with more complex conditions

In addition, CMS is trying to encourage more practices to offer and bill for CCM services by reducing the administrative burden associated with those codes.

CMS also will revalue existing codes describing face-to-face prolonged services. For 2017, CMS has set the Medicare conversion factor at $35.8887, which is slightly higher than the 2016 conversion factor of $35.8043. CMS expects that the provisions of the final rule will generate an estimated 1 percent increase in Medicare allowed charges for family physicians.

CMS has provided additional information in a fact sheet on the final rule.

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

Monday, July 11, 2016

CMS releases proposed rule on 2017 Medicare physician fee schedule

Earlier this month, the Centers for Medicare & Medicaid Services (CMS) released its proposed rule on the 2017 Medicare physician fee schedule. Primary care physicians should be interested that the rule includes several proposed increases for care management services. Specifically, CMS is proposing to pay for:

•    Non-face-to-face prolonged evaluation and management services
•    Comprehensive assessment and care planning for patients with cognitive impairment
•    Primary care practices to use interprofessional care management resources to treat behavioral health conditions
•    Resource costs of furnishing visits to patients with mobility-related impairments
•    Chronic care management (CCM) for patients with more complex conditions

In addition, CMS proposes to reduce the administrative burden associated with the CCM codes to encourage more practices to furnish and bill for these services. CMS also will revalue existing codes describing face-to-face prolonged services.

For 2017, CMS estimates the conversion factor to be $35.7751, which is slightly lower than the 2016 conversion factor of $35.8043. However, CMS expects that the provisions of the proposed rule will generate an estimated 3 percent increase in Medicare allowed charges for family physicians. That would be the largest estimated update for a given specialty.

For individuals who don’t want to read the proposed rule itself, CMS has provided an abbreviated fact sheet and press release. CMS is accepting comments on its proposals through Sept. 6.

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

Thursday, July 7, 2016

JW modifier allows physicians to get paid for some discarded drugs

The Centers for Medicare & Medicaid Services (CMS) recently revised its guidance on how to use the JW modifier. Specifically, the revision will make it easier for physicians to get paid for leftover medication or biologicals that are properly thrown out.

Beginning Jan. 1 of next year, physicians must use the JW modifier for claims with unused drugs or biologicals from single-use vials or single-use packages that are appropriately discarded (except those provided under the Competitive Acquisition Program for Part B drugs and biologicals). The physician must also document the discarded drug or biological in the patient's medical record when submitting Part B claims.

For example, imagine you administer 95 units of a drug from a single-use vial that is labeled to contain 100 units and discard the remaining five units. You bill the 95-unit dose on one line of the claim and bill the discarded five units on another line by using the JW modifier. Both line items would be processed for payment. You apply the JW modifier only to the amount of drug or biological that is discarded.

You may not use the JW modifier when the billing unit is equal to or greater than the total actual dose and the amount discarded. For example, if one billing unit for a drug is 10 mg in a single-use vial and you administer 7 mg and discard the remaining 3 mg, you can bill the 7 mg dose as one 10 mg unit. You could not also bill the discarded 3 mg on a separate line item with the JW modifier because that would result in overpayment.

Medicare administrative contractors currently have discretion over whether to require the JW modifier for any claims with discarded drugs or biologicals, and how the discarded drug or biological information should be documented. CMS is revising this policy to create more uniformity for these types of claims.

For additional information on billing Medicare for discarded drugs and biologicals, see section 40 of chapter 17 of the Medicare Claims Processing Manual.

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

Tuesday, June 28, 2016

CMS places some limits on review of Medicare claim denials

If you’ve ever appealed a Medicare claim denial only to see it struck down for new reasons that the reviewers found in the course of their review, help may be coming.

The Centers for Medicare & Medicaid Services (CMS) recently told its Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) to change how they review certain claim denials. Specifically, CMS says they should limit their review of redeterminations and reconsiderations of claims denied following a complex prepayment review, a complex post-payment review, or an automated post-payment review to the reason or reasons the claim or line item was denied in the first place.  

CMS acknowledged that MACs and QICs generally have discretion while conducting appeals to develop new issues and review all aspects of coverage and payment related to the claim or line item. As a result, while the original reason for the denial may be resolved, this expanded review may result in a denial of the appeal for new reasons. The revised instructions prohibit the contractors from doing that in certain situations, which is good news for physicians and others who initiate such appeals.

However, MACs and QICs will still have the discretion to develop new issues and evidence for claims denied as a result of automated pre-payment review. MACs will also continue to follow existing procedures for adjusting claims after successful appeals, meaning CMS will process the adjustments and may suspend them because of system edits. Claim adjustments that remain unpaid because of additional system-imposed limitations (e.g., frequency limits or Correct Coding Initiative edits) may result in new denials with full appeal rights.

In addition, if a MAC or QIC conducts an appeal of a claim or line item that was denied on pre- or post-payment review because of insufficient documentation, the contractor will review all applicable coverage and payment requirements for the item or service at issue, which means the claim could subsequently be denied for lacking medical necessity. If you receive requests for additional documentation, please be careful to respond quickly and completely to prevent the possibility of expanded review of the whole claim.

Finally, CMS is applying the new guidance only to appeals received by a MAC or QIC on April 18 or later. Prior denials based on expanded evidence will not be reopened.

As noted, the CMS guidance provides some good news to physicians and other providers of Medicare services. But CMS has placed a number of limits on this guidance, and you will need to be aware of the phase and type of review (e.g., pre- or post-payment, automated or complex) to which a claim is subject and consider the possibility of subsequent system edits and denials when determining whether to appeal.   

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

Friday, May 13, 2016

Medicare physician use and payment data for 2014 now available

The Centers for Medicare & Medicaid Services (CMS) has released its annual report on Medicare physician utilization and payment data.

Covering calendar year 2014, the public file lists Medicare Part B payments and submitted charges for more than 986,000 individual physicians and other health care providers who collectively received around $91 billion. By comparison, the report for 2013 included $90 billion in payments to 950,000 physicians and other providers.  

The latest report uses Medicare standardized payment amounts, which adjusts for geographic differences to make payments to physicians in different parts of the country comparable.

As we’ve discussed in the past, these annual payment reports show not only the range and complexity of care that family physicians provide but also the variation in reimbursement among medical specialists. For example, family physicians received an average of $61,804 in total Medicare payments during 2014. By comparison, internists received an average of $92,760 and cardiologists received an average of $222,373. As in the past, physicians weren't given an opportunity to review the information tied to their names for errors and the amounts don't reflect risk-adjustment, Medicare not covering the full cost of certain treatments, or other factors.

As CMS moves to tie physician reimbursement more closely to value, presenting accurate individual physician payment and utilization data to patients and other interested parties will become more critical.

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, October 29, 2015

CMS fixing processing errors on vaccine and mammogram claims

The Centers for Medicare & Medicaid Services (CMS) is correcting a pair of systems errors it says led to the inappropriate rejection of some physician claims for vaccinations and mammograms with dates of service on or after Oct. 1.

Condition code A6 is required only for reporting pneumococcal and influenza vaccines, but claims for other vaccine services were erroneously rejected on this basis. These claims were returned with a reason code of 32200.

The agency also said it erroneously rejected claims for mammography services with diagnosis code Z1231 for dates of service on or after Oct. 1. These claims were returned with a reason code of 32016.

In both cases, your Medicare Administrative Contractor (MAC) will correct the claims and you don’t have to take any action, according to CMS.

Tuesday, June 2, 2015

Not all valid vaccine codes are in the book

Vaccine development and subsequent approval by the Food and Drug Administration (FDA) does not always nicely coincide with publication of the Current Procedural Terminology (CPT) manual. Consequently, the American Medical Association (AMA) uses its website to feature updates to the codes for these products, based on actions taken by the CPT Editorial Panel and the FDA.

In general, once approved by the CPT Editorial Panel, AMA makes vaccine CPT codes available for release twice a year, on July 1 and Jan. 1. As part of this electronic distribution, there is a six-month implementation period from the initial release date (i.e., codes released on Jan. 1 are eligible for use on July 1, and codes released on July 1 are eligible for use Jan. 1). In case you missed them, we will discuss some vaccine codes and code changes that do not yet appear in the CPT manual.  

First, the AMA released new codes 90620, for “Meningococcal recombinant protein and outer membrane vesicle vaccine, Serogroup B, 2 dose schedule, for intramuscular use,” and 90621, for “Meningococcal recombinant lipoprotein vaccine, Serogroup B, 2 or 3 dose schedule, for intramuscular use,” on Nov. 1, 2014, for implementation Feb. 1, 2015. Payers may have decided to acknowledge and implement both codes for reporting purposes prior to Feb. 1, but from a CPT perspective, they are now available to use, even though they won’t appear in the CPT manual until 2016. Both vaccines are FDA-approved.

Similarly, the AMA released new code 90697, for “Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenza type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-Hib-HepB), for intramuscular use,” on July 1, 2014, for implementation on Jan. 1, 2015. This vaccine is not yet FDA-approved, and the new code will appear in the 2016 CPT manual.

The 2015 CPT manual does include a new code, 90630, for “Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use,” and a new code, 90651, for “Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (HPV), 3 dose schedule, for intramuscular use.” Both codes are designated in the manual as not yet having FDA approval. However, the product represented by 90630 received FDA approval on Dec. 11, 2014, and the product represented by 90651 received FDA approval on Dec. 10, 2014. The 2016 CPT manual will reflect their FDA approval status.

As a reminder, the codes above only identify the vaccine product. To report the administration of a vaccine/toxoid product, you will need to use an appropriate CPT immunization administration code (e.g., 90460, “Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered”) or an appropriate Healthcare Common Procedure Coding System code, such as G0008, “Administration of influenza virus vaccine.”

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

Thursday, April 16, 2015

Sustainable growth rate repeal: Now what?

As noted earlier this week, Congress has enacted the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act of 2015 (MACRA). This legislation repeals the sustainable growth rate and negates a 21.2 percent cut in Medicare physician payments that technically went into effect for dates of service on or after April 1. President Obama is expected to sign the bill. MACRA will have a significant impact on Medicare physician payment for years to come, but what does it mean for your practice in the short run?

MACRA maintains the pre-April 1 rate for dates of service through June 30. For dates of service from July 1 through Dec. 31, Medicare payments will increase by 0.5 percent. For 2016, the Medicare payments increase another 0.5 percent.

To minimize financial headaches for physicians, the Centers for Medicare & Medicaid Services (CMS) had agreed to wait 10 business days before processing all affected claims with dates of service on or after April 1. CMS has now instructed the Medicare Administrative Contractors (MACs) to implement the rates contained in MACRA; however, the MACs probably will still process a small number of claims using the reduced rate before they can adjust their claims payment systems. These will likely be claims for dates of service early in April. The MACs will automatically reprocess claims paid at the reduced rate with the new payment rate, and you don't have to do anything if you have already submitted claims that fall on the affected dates.   

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

Wednesday, April 15, 2015

Medicare legislation repeals flawed physician payment formula, avoids cuts

Last night, the U.S. Senate voted 92-8 to repeal the sustainable growth rate formula that is used to calculate Medicare physician payment rates. The vote prevents a looming 21.2 percent cut for physicians and ends 12 years of perennial short-term fixes by Congress. The House passed the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act of 2015 last month, also by an overwhelming margin. President Obama has said he will sign the bill into law.

In addition to preventing the payment cut and ensuring annual positive or flat fee updates for 10 years, the legislation, also known as MACRA, establishes new payment options that offer incentives to physicians who participate in alternative payment models. Those who remain in the fee-for-service system and meet certain performance benchmarks may also earn incentive payments.

MACRA also extends funding by two years for CHIP and other programs of importance to family medicine. Additional information about the legislation is available on the AAFP website, and additional details will be available as the regulations are developed.  

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

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

Want to use this article elsewhere? Get Permissions