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Friday, December 21, 2012

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

Thursday, December 20, 2012

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

Tuesday, December 18, 2012

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

Thursday, December 6, 2012

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 

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