American Academy of Family Physicians
Friday Aug 29, 2014

CMS providing Meaningful Use exemption for slow Internet

Physicians working to comply with stage 2 of the Centers for Medicare & Medicaid Services' (CMS) Meaningful Use program know that not all of the requirements are under their control.

Specifically, more than 5 percent of patients must send a secure message to their physician that is received using the electronic messaging function of the electronic health record (EHR), and more than 5 percent must view, download, or transmit their health information to a third party.

But both of those require the patient having access to broadband Internet service.

Enough physicians in Internet-poor locales have asked CMS how they can be required to meet those guidelines that the agency has finalized an exemption.

Under the rule, an eligible professional will not have to meet either of the above Meaningful Use measures if at least 50 percent of his or her patient encounters are in a county where more than 50 percent of the housing units lack access to broadband download speeds of at least 3 megabits per second (Mbps), as measured by the Federal Communications Commission (FCC) on the first day of the EHR reporting period.

Physicians can check the broadband download speed in their county through the FCC's National Broadband Map. Click "Analyze the data" and then "Rank your geography." Under step one, pick "Rank within a State," click "County," and then select your state. Under step two, click "Speed" (which defaults to a download speed of > 3Mbps). On the next screen select "Manage metrics" and then click "% housing units." As an example, here's the breakdown for FPM's home state of Kansas.

It must be noted, however, that the FCC map is based on advertised broadband speeds not typical ones, so the vast majority of counties in the United States are considered to have access to broadband speeds of 3 Mbps or more.

That means unless you practice in some truly remote areas of the country, slow broadband may not be an adequate defense against Meaningful Use stage 2.

Tuesday Jun 24, 2014

Medicare to expand its use of prior authorization

The Centers for Medicare & Medicaid Services (CMS) is looking to expand its requirements that it provide prior authorization before Medicare beneficiaries can receive certain medical devices or supplies.

In a May release, CMS said it plans to more than double the number of states where it has prior approval power over power mobility devices, launch new prior authorization trials for two types of non-emergency services, and get public comment on establishing prior authorization rules for a number of other devices and supplies it says are frequently prescribed to patients who don't need them.

Since 2012, CMS has operated the Medicare Prior Authorization of Power Mobility Device Demonstration in seven states:  California, Florida, Illinois, Michigan, New York, North Carolina, and Texas. CMS believes the demonstration project has been sufficiently successful and plans to extend it to an additional 12 states. These states include Arizona, Georgia, Indiana, Kentucky, Louisiana, Maryland, Missouri, New Jersey, Ohio, Pennsylvania, Tennessee, and Washington.

CMS will also launch two new payment model demonstrations to test prior authorization for certain non-emergent services under Medicare. These services include hyperbaric oxygen therapy and repetitive scheduled non-emergent ambulance transport. CMS hopes that information from these models, each being held in three states, will let officials fine-tune future policy decisions on the use of prior authorization in Medicare.

Finally, CMS has proposed to establish a prior authorization process for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) that it believes are frequently prescribed but unnecessary. Through a proposed rule, CMS is soliciting public comments on the process and criteria for selecting durable medical items subject to the new rules. The deadline to submit comments is July 28, 2014.

You can find additional information on CMS's prior authorizations initiatives on the CMS web site.

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

Friday May 30, 2014

Potential pitfall in Medicare billing: psychotherapy in conjunction with an evaluation and management service

Four times a year, the Centers for Medicare & Medicaid Services (CMS) publishes its Medicare Quarterly Provider Compliance Newsletter, which seeks to help physicians avoid common Medicare billing errors. The latest issue highlights at least four errors that may be relevant to family physicians. This week, we’ll cover one related to psychotherapy provided in conjunction with an evaluation and management (E/M) service.

Family physicians are often the first point of contact for patients with mental health issues and sometimes provide psychotherapy to such patients in addition to an E/M service at the same encounter. Since January 2013, these services provided by the same provider on the same day are separately reportable and payable as long as they are significant, separately identifiable, and billed using the correct codes. In this situation, designated add-on codes are used to report psychotherapeutic services performed in addition to E/M codes.

Those CPT codes are:

•    +90833: Psychotherapy, 30 minutes with patient and/ or family member when performed with an E/M service
•    +90836: Psychotherapy, 45 minutes with patient and/ or family member when performed with an E/M service
•    +90838: Psychotherapy, 60 minutes with patient and/or family member when performed with an E/M service

CPT provides flexibility by identifying time ranges that may be associated with each of the timed codes:

•    90833: 16 to 37 minutes
•    90836: 38 to 52 minutes
•    90838: 53 minutes or longer

Psychotherapy sessions lasting less than 16 minutes are not separately reportable.

Documentation is crucial here. Time spent for the E/M service must be recorded separately from the time spent providing psychotherapy, and time spent providing psychotherapy cannot be used to meet criteria for the E/M service. Physicians can't enter one time period that includes both the E/M service and the psychotherapy.

CMS identified this blending of time periods as a common billing error in its quarterly newsletter. For example, a physician billed for a level 3 E/M service (99213) and 45 minutes of psychotherapy (90836). However, an authenticated printed visit note from the physician's electronic health record indicated total face-to-face time with the patient of 45 minutes and did not separately indicate the time spent providing psychotherapy services. The Medicare contractor, after an unsuccessful request for additional information, counted the claim as an overpayment due to insufficient documentation and recouped the payment from the physician.

Next week:  pitfalls associated with preventive services

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

Friday May 23, 2014

Opportunity to review Open Payments data is approaching

The release in April of Medicare payments made to individual physicians caused its share of headaches and hand-wringing among practitioners who claimed that some of the information was incorrect or could be interpreted poorly by the public without the proper context.

Later this summer, another round of public filings could make life difficult. The Centers for Medicare & Medicaid Services (CMS) will begin releasing data from pharmaceutical and medical device manufacturers and group purchasing organizations on all financial interactions they've had with individual physicians and teaching hospitals.

Open Payments (you may remember it when it was called the Sunshine Act) is scheduled to release data for the final five months of 2013 by the end of September this year. Described as a way to provide more transparency to the financial relationships between physicians and their suppliers, the program tracks any payment or transfer of value of more than $10 from an applicable vendor to a physician. Beginning next year and thereafter, the Open Payments releases will cover an entire year.

Unlike the Medicare payments release, physicians will have a shot at reviewing the information submitted by manufacturers and attempting to correct any errors before publication.

Beginning June 1, eligible practitioners will be able to register for the CMS Enterprise Portal. This is considered the first step and must be completed before physicians, beginning in July, can register in the Open Payments system itself. That registration will gain the physician access to any manufacturer information reported about him or her, as well as allow the physician to dispute any payments he or she believes are inaccurate.

For more information on the Open Payments program, the CMS has a web site, complete with a downloadable user's guide.

Tuesday Apr 22, 2014

Dealing with the opportunities and threats of the new Medicare data release

This month's release by the Centers for Medicare & Medicaid Services (CMS) of a public use file on Medicare physician utilization and payment data creates both opportunities and threats for family physicians. We're going to consider both.

On the plus side, the release of the Medicare data provides a great opportunity for the family medicine community to highlight the complexity of care that family physicians provide. Also, the data show wide variation in total payments made among various medical specialties, which reinforces the point that primary care physicians are underpaid relative to other specialists and sub-specialists. When that data set is further studied, it may make the case that family physicians, who provide comprehensive and time-intensive health care to their patients, are undervalued from a payer perspective.

On the other hand, the Medicare data set has lots of limitations. For example, physicians weren't given an opportunity to review the data for potential errors; the data don't measure the quality of care provided; there's no allowance for residents or nurse practitioners filing claims under a physician's national provider identifier, meaning the payment numbers could be inflated; Medicare payments may not always cover the costs of treatment, which makes the numbers an inaccurate portrayal of physician compensation; the data are not risk-adjusted, don't account for patient mix or include care for private insurance patients or Medicaid beneficiaries; the numbers don't reflect the often higher reimbursements provided in facility settings versus a physician's office; and they don't consider changes in Medicare's coding and billing rules that may different over time and across regions of the country.

Those weaknesses presents several threats:

•    Insurers, hospitals, and accountable care organizations could use the data to assess physicians’ charges and potentially drop those individuals deemed to be high-cost physicians.
•    Public and private insurers might use the data as a reason to impose additional prior authorization requests for expensive Part B drugs.
•    The data set has the potential to paint a negative picture of some physicians with patients, and it also has the potential to further enhance the perception that physicians are overpaid relative to the average U.S. worker.

Finally, the data may generate some difficult questions from patients or local media. Here are some points to emphasize if you find yourself in such a conversation:

•    Greater transparency in the health care system is a laudable goal, and there is potential value in the release of Medicare payment data for ensuring the quality of care for patients and efficient use of resources in the delivery of health care services.
•    Release of this data shines a light on the need to reform physician payment away from fee-for-service and toward payment for quality of care.
•    Data should include context and background on physician payments so that policy makers, patients, and the public understand the overall quality of care their physicians provide.
•    The data release still needs safeguards to ensure that neither false nor misleading conclusions are derived from this information, which has its limitations.
•    Medicare payment information by itself does not describe a physician’s practice.
•    Hopefully, researchers will use this data to understand and improve how health care dollars are spent, so that we can also improve the health of patients, families, and communities.

Whether the potential opportunities outweigh the potential threats remains to be seen. However, knowing what they are provides a starting point for trying to maximize the former while minimizing the latter. For more information on this subject, check out the AAFP's "Physician Payment Transparency" web page and read the frequently asked questions on the CMS website.

– Kent Moore, Senior Strategist for Physician Payment for the 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

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