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Friday, November 30, 2012

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:

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 

Thursday, November 29, 2012

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 

Thursday, November 8, 2012

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

Friday, November 2, 2012

'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:

Code

Descriptor

Payment allowance

90655

Influenza virus vaccine, split virus, preservative free, when administered to children 6 to 35 months of age, for intramuscular use

$16.46

90656

Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use

$12.40

90657

Influenza virus vaccine, split virus, when administered to children 6 to 35 months of age, for intramuscular use

$6.02

Q2035

Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular (Afluria)

$11.54

Q2036

Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)

$9.83

Q2037

Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin)

$14.05

Q2038

Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)

$12.05


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

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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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