American Academy of Family Physicians
Wednesday Apr 16, 2014

Medicare releases physician claims data for public consumption

Last week, the Centers for Medicare & Medicaid Services (CMS) released on its website a data set detailing payments made in 2012 to more than 880,000 physicians from the Medicare Part B Fee-for-Service program.

The release of the physician claims data came in response to a legal challenge from the Wall Street Journal, which successfully argued for a federal judge to lift a 1979 injunction preventing CMS from publishing the information. CMS initially planned to evaluate requests for physician payment information on a case-by-case basis. But after receiving numerous requests for the Medicare data, CMS determined the Freedom of Information Act (FOIA) required it to make frequently requested materials available electronically and publicly release certain physician payment information on its website.

This information represents revenue from Medicare Part B services before the practice’s operating costs are deducted. It doesn't include information from Medicare Part A (Hospital Insurance), Part C (Medicare Advantage), Medicaid, Marketplace, or private insurance plans. The data also does not include information associated with clinical diagnostic laboratories or durable medical equipment. Further, this data set does not represent each medical practice’s entire patient panel, and it is not risk-adjusted for severity and complexity of patients treated by the physician. 

The file contains information on utilization, payment (allowed amount and Medicare payment), and submitted charges organized by National Provider Identifier, Healthcare Common Procedure Coding System code, and place of service.

Physicians and others can access this information by downloading files split by provider last name from the CMS web site. Alternatively, the New York Times and the Wall Street Journal have created tools to search this data by name, specialty, and city/ZIP code.

In future posts, we’ll talk about potential implications of this data release, further limitations of the data, and possible questions you may get from your patients. In the meantime, be aware that the data is out there and that CMS is not the only one looking at it anymore.

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

Thursday Mar 27, 2014

CMS institutes a reprieve in RAC operations

The Centers for Medicare & Medicaid Services (CMS) is in the middle of processing the next round of Recovery Audit Program contracts. To make sure the current Recovery Audit Contractors (RACs) complete their work before the current contracts expire, CMS has announced that it will wind down some of the RACs' operations.

Specifically, CMS says the RACs were to cease sending pre- and post-payment additional documentation requests (ADRs) by the beginning of March and review the ones they already have. RACs have until June 1, 2014, to send improper payment files to Medicare administrative contractors for adjustment.

As a reminder, if you have received an ADR from a RAC, you have 45 days to respond to it. The RACs, in turn, have up to 60 days to make a determination on the claim.

Besides giving the RACs time to complete their work, the CMS said the pause in RAC operations will allow it to continue refining and improving the Medicare Recovery Audit Program. For example, CMS is reviewing the ADR limits, timeframes for review, and communications between RACs and physicians. CMS has already announced a number of changes it plans to make to the RAC program with the next round of contractor awards. CMS invites physicians with additional questions to send them to for answers.

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

Wednesday Mar 12, 2014

Medicare clarifies expectations for certifying home health eligibility

If you certify your patients' eligibility for the Medicare home health benefit, the Centers for Medicare & Medicaid Services (CMS) has released clarified guidance on how to properly document the required face-to-face visit.

In a January Special Edition Article of Medicare Learning Network Matters, the CMS included helpful examples of correct and incorrect documentation. It also addresses the proper form and substance of the required documentation.

First, CMS emphasized that physicians must draft the encounter documentation in a narrative form that is dated, signed by the physician, and titled "Home Health Face to Face Encounter.” Simply listing the beneficiary’s diagnoses, recent injuries, or procedures is insufficient.  

CMS also said that the substance of the documentation must address the two qualifying elements of the Medicare benefit: that the beneficiary is homebound and requires intermittent skilled nursing services, physical therapy, or speech language pathology services. The narrative documentation should explain why the patient is homebound and what skilled care the beneficiary will need in his or her home.

Obviously, this documentation will be more germane to the home health agency getting paid than to your office. However, because following these documentation requirements may determine if that home health agency remains willing to work with you, following the directions may ultimately help you and your patients.

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

Tuesday Feb 11, 2014

Medicare turns deaf ear to CPT changes on cerumen removal

Medicare payment policy doesn't always match the American Medical Association's Current Procedural Terminology (CPT).

The Centers for Medicare & Medicaid Services (CMS) provided another example of that recently in the final rule on the 2014 Medicare physician fee schedule.

For 2014, CPT revised its description of code 69210 to read, “Removal impacted cerumen requiring instrumentation, unilateral.” Previously, the code description read, “Removal impacted cerumen (separate procedure), 1 or both ears.” To account for situations in which the procedure is provided on both ears at the same encounter, CPT 2014 states, “For bilateral procedure, report 69210 with modifier 50.”

Unfortunately, CMS sees things differently. In the new 2014 fee schedule, CMS stated its opinion that the procedure will typically be done on both ears at the same encounter, because “the physiologic processes that create cerumen impaction likely would affect both ears.” CMS did not provide any evidence or citations to support this opinion.

CMS went on to say, “Given this, we will continue to allow only one unit of CPT 69210 to be billed when furnished bilaterally.” Consequently, CMS elected to maintain the 2013 work value of 0.61 for CPT code 69210 when the service is furnished.

The bottom line is that Medicare will pay you the same amount for 69210 whether you do one ear or two, even though the CPT descriptor now says it is for one ear only.

If only CMS could hear how ridiculous that sounds.

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

Friday Jan 24, 2014

Medicare clarifies coverage for incarcerated beneficiaries, issues refunds

Medicare is cleaning up the mess it made last summer when it denied claims and initiated recovery of previously paid claims based on faulty data from the Social Security Administration about supposedly "incarcerated" beneficiaries.

The Centers for Medicare & Medicaid Services (CMS) has announced that it is “actively addressing” the issue and produced a fact sheet to clarify the matter.

According to CMS, it has restored the original data on its Medicare Enrollment Data Base, and is basing any new claim denials for incarcerated beneficiaries based on that information. In the meantime, it said it had identified all of the claims that were incorrectly demanded or collected and completed the bulk of refunds to providers. It also changed its claims processing system.

The fact sheet clarifies when CMS considers patients to be “in custody” or “incarcerated,” making them ineligible for benefits, and that CMS is making its denial forms and notices more explicit in justifying a repayment. The fact sheet also explains how physicians can ensure a patient’s eligibility either through the electronic transaction for eligibility verification, the Medicare administrative contractor’s (MAC’s) online portal, or by calling the MAC’s hotline. Finally, the fact sheet outlines exceptions to the Medicare policy and instructs physicians how to submit claims for these exceptions. It also provides additional guidance and resources for affected physicians.  

For additional information about this issue, including a link to frequently asked questions, please refer to the dedicated page on the CMS website.

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

Wednesday Dec 04, 2013

As the year winds down, two new payment rules to contemplate

Just in time for Thanksgiving last week, the Centers for Medicare & Medicaid Services (CMS) released two final rules that could influence physician reimbursements in coming years.

In terms of the actual 2014 Medicare physician fee schedule, CMS estimates that changes to the relative value units (RVUs) in the final rule will have no impact on family physicians’ Medicare allowed charges in 2014. In some sense, that’s the good news because, barring last-minute Congressional action, the Medicare conversion factor is scheduled to fall 20 percent next year. Anxiety over the Medicare Sustainable Growth Rate issue has become an annual occurrence.

But CMS also said it was developing "a series of initiatives" in the final rule that supports primary care and recognizes that care management should be increasingly rewarded because of its ability to improve patient health and limit the growth of future health costs.

One of those initiatives, beginning in 2015, establishes a separate payment for chronic care management (CCM) services provided to patients with multiple chronic conditions. The payment would be made through a “G” code and cover at least 20 minutes of CCM services provided every 30 days. Patients will be required, at least every 12 months, to provide advance consent to the practice for the code to be used and can revoke consent at any time. Final details on practice standards for the code and payments rates are currently unknown and await future notice-and-comment rule making.

The other final rule concerns the outpatient prospective payment system, which pays hospitals for their outpatient Medicare services. Specifically, CMS plans to replace the current five levels of hospital clinic visit codes for both new and established patients with a single code describing all outpatient clinic visits. CMS believes a single code and payment for clinic visits is more administratively simple for hospitals and better reflects the cost of resources hospitals expend supporting an outpatient visit. The current five levels of outpatient visit codes are designed to distinguish differences in physician work.

While this doesn't directly affect physician payments, physicians should keep an eye on it because it does not take a lot of creativity to imagine CMS doing something similar under the physician fee schedule somewhere down the road.

It is something to think about as we wait to see if Congress rescues the physician fee schedule again this year.

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

Tuesday Nov 19, 2013

Getting a second opinion on your 2012 PQRS participation

Did you fail to earn a 2012 Physician Quality Reporting System (PQRS) incentive payment when you believe you should have? Or was your PQRS incentive payment less than you thought it should be?

You can get a second opinion by requesting an informal review of your 2012 PQRS reporting performance. The informal review is available for all 2012 reporting methods, including:

    •    Claims,
    •    Qualified registry,
    •    Qualified electronic health record,
    •    Group Practice Reporting Option (GPRO) Web Interface (for groups of 100 or more eligible professionals).

To request an informal review of your 2012 PQRS performance, you must send the Centers for Medicare & Medicaid Services (CMS) a valid request via CMS’s Quality Reporting Communications Support Page between now and February 28, 2014. Make sure to fill in all of the mandatory fields so CMS can process your request. CMS or its contractor, the QualityNet Help Desk, may contact you for additional information, if necessary.

Eligible professionals or designated support staff will need to submit an informal review request for each individual rendering National Provider Identifier and Tax Identification Number under which the requestor submitted 2012 PQRS quality-data codes (QDCs) or data. Groups that participated in the GPRO will need to have their main point of contact request an informal review for the TIN under which the GPRO submitted 2012 PQRS QDCs or data.

For more information about the informal review, see the 2012 PQRS Informal Review Made Simple fact sheet  or visit the PQRS website.

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

Friday Oct 18, 2013

New Medicare enrollment revalidation phase begins this month

This month, the Centers for Medicare & Medicaid Services (CMS) will begin the next phase of Medicare revalidation, which will last until the spring of 2015.

This phase will affect physicians at group practices of 200 or more members who reassign their Medicare billing rights to the group and who enrolled or revalidated before March 25, 2011. Medicare Administrative Contractors (MACs) will mail a notification letter to these organizations to alert them that the MAC will send revalidation requests for specific physicians within 60 days. The letter will be mailed to the group’s correspondence address and will contain a spreadsheet with the affected physicians’ names, national provider identifiers, and specialties. This initial letter is an alert, and practices should wait to receive the formal request to revalidate the enrollment for a particular physician. A sample of the letter is available online through MGMA.

If you receive notification from your MAC to revalidate:

•    Update your enrollment through Internet-based Provider Enrollment, Chain, and Ownership System or complete the appropriate 855 application form;
•    Sign the certification statement on the application;
•    If applicable, pay your fee online, and
•    Mail your supporting documents and certification statement to your MAC.

Failure to submit the enrollment forms as requested may result in your Medicare billing privileges being deactivated.

Note that the Medicare provider enrollment revalidation effort does not change other aspects of the Medicare enrollment process. You should continue to submit routine changes – address updates, reassignments, additions to practices, changes in authorized officials, information updates, etc. – as you always have. If you also receive a request for revalidation from the MAC as an individual, respond separately to that request.

For more information, please see Medicare Learning Network Matters article SE1126 on the CMS web site.

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

Wednesday Oct 09, 2013

Next deadline on the Physician Quality Reporting System timeline is close

October 15 is the next significant deadline for individuals and groups looking to participate in the Physician Quality Reporting System (PQRS) and avoid reimbursement penalties in the future.

Firstly, October 15 is the last day for groups to register for the group practice reporting option (GPRO) for the 2013 PQRS program year, which they can do either through Web Interface or registry reporting. Either is required to qualify for the 2013 PQRS payment incentive. More information is available in the Centers for Medicare & Medicaid Services (CMS) Quick Reference Guide for Group Practices.

It is also the last day for individuals and groups participating in the GPRO – and wanting to avoid a PQRS payment "adjustment" in 2015 – to choose to participate in the administrative claims-based reporting mechanism. Under this option, CMS calculates quality data from administrative claims. While this option avoids a penalty, it cannot be used to earn a 2013 PQRS incentive payment. Individual health care professionals should consult CMS's Quick Reference Guide for Individual Eligible Professionals.

Finally, October 15 is the last day for groups of 100 or more eligible professionals to self-nominate/elect quality-tiering for the Value Modifier that CMS will implement beginning in 2015. The Value Modifier will not apply to groups of less than 100 eligible professionals in 2015.

To qualify for either the GPRO's administrative claims-based reporting mechanism or quality-tiering to calculate the Value Modifier for 2015, individuals and groups must use the Physician Value-Physician Quality Reporting System (PV-PQRS) Registration System. It can be accessed at using a valid Individuals Authorized Access to the CMS Computer Services (IACS) User ID and password. For additional information regarding registration and obtaining or modifying an IACS account, please see the CMS Self Nomination/Registration webpage.

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

Tuesday Oct 01, 2013

Medicare payments unaffected by government shutdown ... for now

Tuesday’s partial shutdown of the federal government may have you wondering if your Medicare payments will be delayed. The short answer is, “not immediately.”

According to a Department of Health and Human Services contingency plan, “In the short term, the Medicare Program will continue largely without disruption during a lapse in appropriations.” The Centers for Medicare & Medicaid Services has also reassured providers by email, “During the time that the partial government shutdown is in effect, Medicare Administrative Contractors will continue to perform all functions related to Medicare fee-for-service claims processing and payment.”

So, for now, Medicare payments will continue to flow to physicians even as other parts of the federal government grind to a halt.

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

Monday Sep 30, 2013

Medicare updates influenza vaccine payment allowances

Fall is typically the season for administering influenza vaccine. Accordingly, the Centers for Medicare & Medicaid Services (CMS) recently published its annual update of influenza vaccine payment allowances.

The allowances printed in the update are for dates of services beginning Aug. 1, 2013, and ending July 31, 2014. Medicare administrative contractors have until Oct. 25, 2013, to implement the new payment allowances in their claims processing systems. The payment allowances apply when Medicare payment is based on 95 percent of the average wholesale price, except when furnished in a hospital outpatient department, a Rural Health Clinic, or a Federally Qualified Health Center for which payment is based on reasonable cost.

The update covers a variety of Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes used to report influenza vaccine. These include some CPT codes that are new for 2014 and at least one, 90687 (Influenza virus vaccine, quadrivalent, split virus, when administered to children 6-35 months of age, for intramuscular use), for which Food and Drug Administration approval is still pending. You can find a list of the new CPT vaccine codes on the American Medical Association’s web site. As the information becomes available, CMS will post payment limits for influenza vaccines that are approved after the update’s release date, including CPT codes 90687 and 90688 (Influenza virus vaccine, quadrivalent, split virus, when administered to individuals 3 years of age and older, for intramuscular use), on the CMS Seasonal Influenza Vaccines Pricing webpage.

When billing for an influenza vaccine administered to a Medicare patient, don’t forget to also report the HCPCS administration code, G0008 (Administration of influenza virus vaccine).

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

Thursday Sep 19, 2013

Further delay in Medicare's face-to-face requirement for durable medical equipment

Two months ago, we noted that the Centers for Medicare & Medicaid Services (CMS) had extended until Oct. 1 the deadline for physicians to comply with requirements that they perform face-to-face encounters with patients before prescribing certain durable medical equipment (DME). As with other federal rules this year, physicians are getting more time.

On Sept. 9, CMS announced that due to continued concerns that some physicians, other health care providers, and suppliers may need additional time to establish operational protocols necessary to comply with the rules it would not begin enforcing the DME face-to-face requirements at this time. Instead, the agency pointed to an unannounced date in 2014. The rules originally were to go into effect July 1, 2013.

CMS said it expects suppliers and physicians who order certain DME items to continue to collaborate and work toward compliance during the next several months. Those suppliers and physicians who are currently implementing the face-to-face requirement should continue to do so, the agency said.

CMS will continue to address industry questions concerning the new requirement and update information on its web site at

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

Tuesday Sep 10, 2013

Medicare offers some relief on transitional care management claims

Another month, another set of Medicare fixes aimed at helping physicians submit and receive reimbursement for transitional care management (TCM) claims.

During an Aug. 27 conference call with physicians, nurses, and allied health professionals, Centers for Medicare & Medicaid Services (CMS) staff said that the agency is aware that physicians are continuing to have trouble getting paid for TCM claims and Medicare contractors have made adjustments to their claims edits to address the issue.

CMS has put that acknowledgement in writing in the form of a new question and answer added to its frequently asked questions about TCM.

In response to the question, “What should practitioners do if claims for appropriately furnished Transitional Care Management (TCM) have been rejected or denied by Medicare,” CMS said that many physicians make mistakes on their claims and repeated the main requirements for these types of claims:

    •    the discharge that initiated TCM occurred on or after Jan. 1, 2013
    •    the TCM service began with a qualified discharge from a facility
    •    the date of service on the claim is the 30th day of the TCM service period (i.e. the 29th day after the date of discharge)

The agency then added, "We also have made some adjustments to our claims processing systems to better accommodate the unique billing requirements of this new, 30-day service. We believe that with the adjustments that we have made and extra care with billing on behalf of practitioners, that the problems that have been encountered will be alleviated."
If you verify that all requirements for furnishing the service have been met and the claim is still unpaid, CMS is encouraging you to re-submit it. For more resources about billing TCM services, see the Getting Paid blog post from July 31, 2013, detailing the last batch of TCM assistance.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday Sep 06, 2013

Can you see the Sunshine Act clearly?

Beginning this past Aug. 1, applicable manufacturers and group purchasing organizations began documenting many of the lunches, dinners, and other "freebies" they provide to physicians and teaching hospitals.

Under the Physician Payment Sunshine Act, the Centers for Medicare & Medicaid Services plans next year to begin posting all payments and transfers of value of $10 or more on a public website that patients and others can access to see the financial connections between physicians and their suppliers.

A breakdown of how the new law affects physicians will be published in the September/October issue of Family Practice Management but is already available online.

You can also go to the CMS website for more information on the Sunshine Act, sometimes called the Open Payments program, as well as for a list of frequently asked questions and two continuing medical education activities to teach physicians more about the the new law.

If you would like to track such payments and other transfers of value in real time yourself, CMS has developed a mobile application, which will be available for free in both the iOS Apple Store and Google Play Store.

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

Friday Aug 16, 2013

Medicare makes an "Oops!" on denial of incarcerated claims

If you recently had a Medicare claim denied because the patient was supposedly "incarcerated," the Centers for Medicare & Medicaid Services (CMS) wants you to know it may have made a mistake.

The CMS earlier this summer began denying claims and initiating recoveries on previously paid claims from physicians and others based on Social Security Administration data that indicated that the Medicare beneficiaries cared for had been incarcerated on the date of service. Medicare will generally not pay for medical items and services furnished to a beneficiary who is incarcerated, which the CMS defines as being confined within a penal facility, on a supervised release, on medical furlough, residing in a halfway house, or other similar situations.

CMS has since learned that the information related to these periods of incarcerations was, in some cases, wrong – or “incomplete for CMS purposes," as the government puts it. That has led CMS to review the data and begin changing how it determines whether a recipient is incarcerated. In the meantime, however, CMS is also working to quickly identify and correct any inappropriate overpayment recovery proceedings against providers.

According to a related set of frequently asked questions on the CMS web site, fixing these mistakes will take a lot of work, including restoring the original Medicare Enrollment Data Base, identifying overpayments that need to be abated or refunded, and creating a claims processing system. CMS does not yet have a firm target date and anticipates that it won't complete the process before October.

Physicians will not have to resubmit claims that may have been denied or considered an overpayment. If you have received a related overpayment demand letter, you will either need to repay the debt or appeal while CMS is working out the corrections. Considering that many of these overpayments will likely be overturned, it's a good idea to preserve your rights by filing an appeal.

CMS will continue to issue messages about this topic, including timeframes for resolution, to keep the physician community informed. Information will also be posted on the All-Fee-For-Service-Providers page on the CMS website.

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

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