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Thursday, February 23, 2012

Another patch and another cliff

Last week, a U.S. House-Senate Conference Committee reached a 10-month deal that would maintain current physician payment rates through the end of the year. The measure, H.R. 3630 (at the THOMAS website, type "H.R. 3630" into the search field after selecting "Bill Number"), was subsequently approved by both the House and Senate. Yesterday, the President signed the bill into law.

This latest patch to the Medicare physician fee schedule avoids the 27.4 percent Medicare physician payment cut that was otherwise scheduled to occur on March 1 as a result of the sustainable growth rate (SGR) formula. Because H.R. 3630 postpones but does not eliminate the threat posed by the SGR, physicians will face a 32 percent Medicare payment reduction when the payment patch expires at the end of this year, which makes Jan. 1, 2013, the next "cliff" that physicians will face in terms of Medicare payments.

As noted, the law does not solve the underlying problem. It only postpones its resolution and adds to the cost of a permanent solution. The cost of repealing the SGR will climb from $316 billion today to $335 billion in 2013. In the meantime, physicians are left to cope with the ongoing uncertainty and hope that Congress will find the fortitude and funds for a permanent solution before 2013 rolls around.

Wednesday, February 22, 2012

E-Prescribing codes for 2012

Wondering what codes to report to demonstrate e-prescribing in 2012? If you electronically prescribed during the eligible patient visit, submit code G8553, which denotes that at least one prescription created during the encounter was generated and transmitted electronically using a qualified e-prescribing system. Eligible patient visits are those reported with any of the following CPT or HCPCS codes:

90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90862, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0108, G0109.

To demonstrate that you are exempt from e-prescribing, submit code G8642, which connotes that "the eligible professional practices in a rural area without sufficient high-speed Internet access" and G8643, "The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing. There are no codes to report exemptions resulting from the inability to electronically prescribe due to state, federal, or local law or regulation" or as an "eligible professional who prescribes fewer than 100 prescriptions during a six-month payment adjustment reporting period." These exemptions must be requested by the physician through http://www.qualitynet.org/pqrs.

A Remittance Advice (RA)/Explanation of Benefits (EOB) with the denial code N365 is your indication that the e-prescribing G-code was received by Medicare.

Thursday, February 16, 2012

ICD-10 delay may be in the works

With 5010 implementation effective Jan. 1, 2012, the next major hurdle facing physicians and the rest of the health care system is implementation of International Classification of Diseases, 10th Edition  (ICD-10). Currently, that is slated to happen on Oct. 1, 2013.

Or is it? This week, officials at the Centers for Medicare and Medicaid Services (CMS) and Health and Human Services (HHS) announced that a delay in implementation may be forthcoming. First, on Tuesday, acting CMS Administrator Marilyn Tavenner told reporters that the CMS will "re-examine the timeframe" for ICD-10 implementation through a rulemaking process. She did not say when that rulemaking process will begin, and she did not actually say that implementation will be delayed.

Then, on Wednesday, HHS Secretary Kathleen G. Sebelius announced that HHS will initiate a process to postpone the date by which certain health care entities have to comply with ICD-10. In a press release, the agency stated, "HHS will announce a new compliance date moving forward."

So, it appears that a delay in implementation is in the works. However, how much of a delay and to whom it will apply remain unknown. Pending answers to those questions in the form of a posting in the Federal Register, physician practices are probably best advised to continue preparing for implementation on Oct. 1, 2013. Like the Boy Scouts, it is better to be prepared, lest the anticipated delay does not come to fruition.

Friday, February 10, 2012

Prior authorization: It's not just for private payers anymore

Prior authorization has been a longstanding tool used primarily by private payers for a variety of purposes, including controlling costs. To date, public payers, such as Medicare, have used it less frequently. Based on a recent announcement from the Center for Medicare & Medicaid Services (CMS), that may be changing. CMS is getting ready to launch two new demonstration programs that may impact physicians and make them further justify claims submitted for payment.

First, CMS will conduct a demonstration program, called Fee-for-Service Recovery Audit Prepayment Demonstration, to allow Medicare Recovery Audit Contractors (RACs) to review claims on a prepayment basis in certain states to ensure that the provider complied with all Medicare payment rules. The RACs will conduct prepayment reviews on certain types of claims that historically result in high rates of improper payments (e.g., inpatient hospital claims for short stays). These reviews will focus on seven states with high populations of fraud- and error-prone providers (FL, CA, MI, TX, NY, LA, IL) and four states with high volumes of claims for short inpatient hospital stays (PA, OH, NC, MO) for a total of 11 states. 

The agency also will conduct a demonstration program to establish a prior authorization for power mobility device claims (electric wheelchairs). This demonstration project is for all people with Medicare who reside in seven states with high populations of fraud- and error-prone providers (CA, IL, MI, NY, NC, FL, TX). Under the prior authorization program, documentation to support a claim must be submitted before the power mobility device is delivered.

Both demonstrations are expected to begin on or after June 1, 2012. A notice about the demonstrations appeared in the Federal Register on Feb. 7, 2012.

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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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