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Monday, November 22, 2010

Medicare preventive services: Are your patients calling?

From what I am hearing, your offices may already be getting requests from Medicare patients to schedule an appointment for the new  annual wellness visit that Medicare will begin covering on Jan. 1, 2011. We'll be bringing you a full article on this and other changes to Medicare coverage of preventive services in the January/February 2011 issue of Family Practice Management. A new encounter form for Medicare preventive service visits is also being developed.

Here are a few tips that you might want to know before scheduling appointments for annual wellness visits:

  1. Patients are being encouraged to get this service, and Part B pays at 100 percent with no out-of-pocket costs to the patient.
  2. Your staff need to verify the patient's Medicare Part B eligibility date. Patients in their first 12 months of Medicare Part B coverage are eligible for the Welcome to Medicare physical, not the new annual wellness visit.
  3. Patients who have received a Welcome to Medicare physical are not eligible for an annual wellness visit until 12 months after the date they received the Welcome to Medicare physical. If the patient has been eligible for Medicare Part B for more than 12 months but less than 24, staff should verify if and when a Welcome to Medicare physical was provided.
  4. The annual wellness visit includes a few things that the Welcome to Medicare physical does not, including:
    • A requirement to collect information on all other physicians and suppliers currently providing care to the patient,
    • An assessment of cognitive function,
    • Development of a five- to 10-year plan for obtaining recommended preventive care,
    • A list of patient risk factors that you've identified, with current or proposed treatment options including the benefits and risks associated with these options.
  5. Medicare will allow a significant and separately identifiable evaluation and management (E/M) service on the same date as the annual wellness visit when it is reported with a modifier 25. However, the Centers for Medicare & Medicaid Service (CMS) recommends against providing non-urgent acute care at the same encounter, as it may detract from the intended focus on preventive care. Patients may not appreciate making two visits, but providing information at the time of scheduling to advise patients that an annual wellness visit does not include treatment or management of problems may set expectations and limit frustration.
  6. The initial annual wellness visit payment is equal to a level-four new patient visit. Don't underestimate the time needed to provide and document these services. You may want to work with your scheduling and clinical support staff to establish new processes so that the history and other portions of the service that don't require a physician's skills can be performed and ready for your review before your with the patient begins. It will also be important to remind patients to come prepared to provide information on all the medications, supplements and vitamins they take and their personal and family history.

These services will no doubt be of benefit to Medicare patients who might otherwise not seek care beyond that for existing or bothersome new conditions. However, this ounce of prevention may feel like a ton of work for you and your staff, particularly if you don't plan ahead.

Friday, November 19, 2010

SGR relief: Let us give thanks, for now

In my last post ("The 2011 Medicare physician fee schedule is here," Nov. 5, 2010), I noted that the fee schedule conversion factor would drop from its current $36.8729 to $25.5217 in January, unless Congress and the President intervened. Thankfully, the U.S. Senate began the intervention process yesterday.

Specifically, yesterday evening, the Senate approved a one-month extension of the current conversion factor. Unfortunately, they did so after the House had recessed for the Thanksgiving holidays, so the House cannot act on the measure until legislators return. However, the House Majority Leader's Office issued this statement:  "Tonight, the Senate passed a one month extension of the current Medicare physician payment rates. It is my intention to schedule this bill for consideration when the House reconvenes on Nov. 29, so we can send it to the President's desk prior to the Nov. 30 expiration date of current SGR relief."

Thus, it appears the fee schedule conversion factor will not drop before the end of the year. Beyond that, who knows? The cost of a 12-month extension that will include some other Medicare provisions is roughly $19 billion. Where that money might be found in the federal budget is unknown, and Senate Democratic leaders have indicated that none of it should come from repealing portions of the health reform legislation. Even if (and this is a big IF) there are sufficient funds for a 12-month extension, the next issue is the legislative vehicle to make that happen. Should Congress use the Continuing Resolution (which is likely to be only two to three months, but will certainly pass to keep the government operating) or the tax bill (which is likely to be an extension for a year or two of the current tax structure, but which will be the most politically volatile bill)? Absent sufficient funds for a 12-month extension, the question will be how long should the extension be (i.e., how long an extension can be funded)? Ultimately, this may be mostly a political question about whether it is better to force a showdown on health reform sooner or later. 

In the meantime, as you prepare to enjoy your turkey (or other holiday meal of choice) next week, say a little word of thanks for the folks in Washington who have spared the Medicare physician fee schedule for another month. And if you're so inclined, say a little prayer that they will find the money (and the fortitude) to implement a longer-term fix before the end of the year. 

Wednesday, November 17, 2010

Vaccine administration: A little good news for little folks and their doctors

If you provide pediatric vaccines in your practice, you have no doubt noticed the increase of combination vaccine products and a related decrease in your payment for vaccine administration services. The good news is that the CPT Editorial Panel and the Centers for Medicare & Medicaid Services (CMS) also noticed. New codes will allow reporting of the administration service for each vaccine component beginning in 2011. Even better, CMS published relative value units (RVUs) for these codes – even though they will not typically be reported for Medicare patients.

The new codes are 90460 and 90461. These codes should be reported for physician counseling (or that of another qualified health care professional) and administration of vaccines to children through age 18. Code 90460 is reported for administration of a single component vaccine and/or for the first component of a multiple component vaccine. Code 90461 is reported for each additional component of a multiple component vaccine. For example, MMR vaccine has three components, so administration of this vaccine would be reported with one unit of 90460 and two units of 90461.

CMS assigned RVUs to these codes by crosswalking them with the values of the adult vaccine administration codes 90471 and 90472. This means that new code 90460 has the same RVUs as 90471, and each unit of 90461 has the same RVUs as 90472. Beats getting one administration fee that was valued the same as 90471!

AAFP Coding Resources web pages have been updated to provide more information on these new codes and the guidelines for reporting them.

More to come on CPT code changes for 2011 in your January/February issue of Family Practice Management!

Friday, November 5, 2010

The 2011 Medicare physician fee schedule is here

This week, the Centers for Medicare and Medicaid Services (CMS) unveiled its final rule on the 2011 Medicare physician fee schedule

An initial review shows positive news with respect to the primary care bonus that is effective in 2011. CMS apparently responded positively to comments from the American Academy of Family Physicians and others to change the primary care incentive payment implementation rules to make it more inclusive. As a result, CMS estimates that, under the new, less restrictive rules, about 80 percent of family physicians will qualify for the bonus. 

On the downside, the final rule with comment period announces a reduction to payment rates for physicians' services in 2011 under the sustainable growth rate (SGR) formula. The Medicare physician fee schedule rates are currently scheduled to be reduced under the SGR system on Dec. 1, 2010, and then again on Jan. 1, 2011 under current law. The total reduction in rates between November and January under the SGR system will be 24.9 percent. That means the conversion factor will drop from its current $36.8729 to $25.5217 in January, unless Congress and the President intervene. Of course, this week's Congressional election results may impact what happens in this regard, so stay tuned. 

The final rule will appear in the Federal Register on Nov. 29, 2010, and CMS will accept comments on certain aspects of it until Jan. 2, 2011.

Thursday, November 4, 2010

Transparency and Medicare auditing: Who's cheating whom?

I might not always agree with a speed limit that seems too high or too low. In fact, some seem to serve to disrupt a smooth traffic flow or fail to recognize areas where a slower speed might be more practical. However, I appreciate clear and accurate signs of what the speed limits are so that I have the opportunity to obey and avoid inadvertently breaking the law.

Earlier this year, I wrote in Family Practice Management about differences in the guidance given about evaluation and management (E/M) coding and documentation by Medicare Administrative Contractors. I have since learned that one contractor, with the support of the Centers for Medicare & Medicaid Services, still refuses to post their speed limits. 

Under the guise of protecting the Medicare program from fraud and abuse, one Medicare contractor refused a request for information from a group of coding professionals who want to be sure that the physicians they work with are selecting their E/M codes with the same criteria as the Medicare contractor who might audit them.

The coders know that other Medicare contractors routinely provide this information on their web sites:




Some private payers' score sheets are also transparent:


Needless to say, the contractor's refusal didn't sit well with folks who are dedicated to trying to help physicians understand and follow the rules. The coders used the Freedom of Information Act (FOIA) to request the information they needed, first by filing a formal request to the contractor's FOIA contact and then to CMS, after being advised by the contractor to apply directly to CMS. More than a year later, here is the response the coders received:

"Exemption 2 of the FOIA (5 U.S.C. 552(b)(2)) protects documents or portions thereof 'related solely to the internal rules and practices of an agency.' It also protects administrative enforcement manuals the disclosure of which would harm the agency’s ability to properly administer the program. The auditing guidelines are for the use of government reviewers and examiners.  Release of these guidelines would risk circumvention of agency regulations without detection by parties subject to such regulations."

Perhaps the people who responded to this request have never seen the first and last of Medicare's four strategies for paying claims correctly:

"The Centers for Medicare & Medicaid Services (CMS) follows four parallel strategies in meeting this goal: 1) preventing fraud through effective enrollment and through education of providers and beneficiaries, 2) early detection through, for example, medical review and data analysis, 3) close coordination with partners, including PSCs, ZPICs, ACs, MACs, and law enforcement agencies, and 4) fair and firm enforcement policies." (Source: Program Integrity Manual Chapter 4, accessed 10/27/10)

Shouldn't education of providers include full disclosure of the measures they need to meet? Is it fair to determine that a level of service is incorrect without disclosing the criteria on which the determination was based?

If anyone from CMS or the Medicare contractor who made this decision happens to read this blog, please recognize that even using the score sheets for E/M services, many physicians find the rules difficult to interpret, and few have the time or desire to figure out how to use these to "circumvent" the regulations. If you will provide clear and easily accessible information on what you expect, I think you will find that the majority of physicians will follow your lead. Anyone who purposefully charges for higher levels of service than they provide or document probably thinks they will never be audited anyway.

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