Medicare shoots first and asks questions later
On Oct. 5, 2009, the Centers for Medicare and Medicaid Services (CMS) quietly began implementing system edits intended to assure that Medicare Part B providers and suppliers bill for ordered or referred items or services only when those items or services are ordered or referred by physician and non-physician practitioners who are eligible to order/refer such services. The edits are an expansion of existing claims edits intended to meet the Social Security Act requirements for ordering and referring providers. Essentially, the law requires that a provider or supplier who bills Medicare for an item or service that was ordered or referred must show the name and unique identifier of the ordering/referring provider on the claim.
That is all well and good, but CMS has interpreted that to mean that claims that are the result of an order or a referral must contain the National Provider Identifier (NPI) and the name of the ordering/referring provider and the ordering/referring provider must be in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) or in the Medicare contractor's claims processing system with the appropriate type of provider. During Phase 1 of the implementation (Oct. 5, 2009 to Jan. 3, 2010), if the ordering/referring provider is not in PECOS and is not in the claims system, the claim will continue to process and the Part B provider or supplier will receive a warning message on the Remittance Advice. During Phase 2 (Jan. 4, 2010 and thereafter), if the ordering/referring provider is not in PECOS and is not in the claims system, the claim will not be paid. It will be rejected (but not denied), which means it can be resubmitted at some point, but it cannot be appealed. For more information, you can read MedLearn Matters article 6417 on the CMS web site.
Like seemingly all Medicare policies, this one is fraught with problems. For instance, despite being enrolled in Medicare, if physicians and other health care practitioners are not in the PECOS database or in contractor files, those physicians, suppliers, and other health care practitioners to whom they refer and order services will not be paid. A physician or health care practitioner who enrolled in Medicare prior to 2003 when CMS began using PECOS will be required to re-enroll if they want to continue referring and ordering. As of July 2008, there were 793,346 physicians and other health care practitioners enrolled in Medicare. According to data from an October 2009 Office of Inspector General report, there were 559,235 physicians and other health are practitioners in PECOS. Therefore, as many as 200,000 or 30 percent of all Medicare physicians and other health care practitioners are not in PECOS and will need to re-enroll, and we all know how glacial the pace of Medicare enrollment is.
Another flaw is that some providers who commonly refer Medicare patients or order services for them do not typically enroll in Medicare. For instance, some residents may not be enrolled in Medicare but will certainly be ordering or referring providers for Medicare purposes. Likewise, dentists may be ordering/referring providers but otherwise have no reason to enroll in Medicare. CMS staff indicate that they will soon be issuing instructions to deal with the dentist issue, but one wonders why CMS didn't think to do that before it started implementing the edits in question.
Finally, physicians have no practical or convenient way to check whether the physicians or other health care practitioners who send them patients with orders or referrals are included in PECOS or other contractor enrollment records. CMS has promised to address this particular concern by making publicly available a list of eligible referral providers before January 2010, but again, one is left to wonder why they did not do so before implementing the edits. I can only conclude that CMS staff favors the "shoot first and ask questions later" approach.
In the meantime, downstream providers and suppliers of referred/ordered services/items are at risk of nonpayment, even though they are not responsible for the enrollment/reenrollment of physicians and other health care practitioners who legally order and refer patients to them for items or services. That is why the AAFP, the AMA, and 54 other organizations are advocating with CMS to:
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Take action to ensure that otherwise acceptable claims are paid without delay or need for appeals;
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Indefinitely suspend the plan to deny these claims and instead wait at least until all practicing Medicare physicians, other health care practitioners, and residents can be revalidated and reenrolled or enrolled for the first time;
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Focus its efforts on ensuring a smooth and efficient revalidation process, which will require physicians and other health care practitioners to re-enroll in Medicare if they have not done so since 2003; and,
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Convene a high-level meeting with stakeholders to discuss concerns about ordering and referring physicians and other health care practitioners, and collaboratively develop a feasible and appropriate plan and timetable for addressing these concerns.
It remains to be seen how CMS will respond to this advocacy. In the meantime, please be aware of the issue and how it may affect your Medicare claims beginning in January.
Posted at 01:43PM Nov 19, 2009 by Kent Moore | Comments[0]
Sunny with a chance of gloom
There is potential good news on the Medicare horizon as far as family physicians are concerned. However, the silver lining is attached to a big, black cloud that could rain on everyone's parade unless Congress intervenes by the end of the year.
On Friday, Oct. 30, the Centers for Medicare and Medicaid Services (CMS) put the final rule on the 2010 Medicare physician fee schedule on display for review and comment by all interested stakeholders. CMS plans to publish the final rule in the Federal Register on Nov. 25, 2009. CMS will accept comments until Dec. 29, 2009.
In the final rule, CMS finalized many of the proposals that it made in its proposed rule earlier this year. For those of you keeping score at home, that's good news for family physicians. In fact, in the final rule, CMS estimates that family physicians will experience a 4 percent increase in their Medicare allowed charges in 2010 as a result of the rule, all other things being equal. That is second only to ophthalmologists and optometrists, who are projected to reap a 5 percent increase, and much better than physicians in many other specialties, who are expected to see a decrease in their 2010 Medicare allowed charges as a result of the rule.
Of course, with Medicare, there's always a catch, and the final rule on the 2010 physician fee schedule is no exception. Under current law, the Medicare conversion factor, which translates Medicare's relative value units into payment allowances, is scheduled to decrease 21.2 percent on Jan. 1, 2010, which would more than wipe out the potential gains for family medicine noted above. That means Congress has until Dec. 31, 2009, to intervene, as it has the last several years, to avoid this cut. Forecasters inside the Beltway are optimistic, but as they say on Wall Street, past performance is no indication of future returns.
So, as we approach the new year, the outlook is sunny, but you might want to keep your umbrella handy, just in case.
Posted at 02:17PM Nov 05, 2009 by Kent Moore | Comments[0]
The trouble with consultations
In a rather surprising move, the Centers for Medicare and Medicaid Services (CMS) included in the proposed rule on the 2010 Medicare physician fee schedule a proposal to remove codes for consultations from the Medicare fee schedule. Physicians instead would report the office/outpatient, hospital, or nursing facility evaluation and management (E/M) visit codes as appropriate, and these codes would be awarded higher relative value units (RVUs) in the fee schedule, resulting in potentially higher payment. Whether these increased payments would make up for the elimination of the higher-paying consultation codes likely depends on each individual physician’s mix of consults and office/hospital visits and the percentage of established patients versus new patients.
Some physicians won't like this, as it redistributes payment for E/M services among all physicians. These physicians state that their work is always worth more money because of the additional education and training they have related to specific medical problems. What they may be missing is that Medicare is offering a carrot, an increase in RVUs for non-consult E/M codes and fewer of the coding and documentation burdens that were associated with consultation codes.
At the same time, the Medicare auditors are bringing out the sticks in the form of pre-payment and post-payment audits. Medicare's Comprehensive Error Rate Testing (CERT) Report for May 2008 specified a high "paid claims error rate" of 16.6 percent for consultation services, with a projected improper payment of $516,912,824. Incorrect coding accounted for 86.4 percent of the consultation coding errors. WPS, Medicare contractor for Iowa, Kansas, Nebraska and western Missouri is performing a widespread probe of all consultation claims submitted and requiring pre-payment submission of medical records to substantiate charges. Other Medicare contractors have also chosen consultations for review. Given the state of Medicare funding, can the administrators ignore these results and not attempt to collect (with interest) the money paid out for these consultation services? Will Medicare's Recovery Audit Contractors, who receive a percentage of all money returned to Medicare, ignore these findings? If it were me, I'd accept the carrot and hope the stick is eventually aimed elsewhere.
The proposed removal of consultation codes from the Medicare fee schedule is mostly positive for family physicians, since you seldom get the benefit of the higher payment associated with consultation codes despite doing extensive work-ups before referring patients to subspecialists for specific procedures. However, there could be a drawback in that the higher payment was an incentive for the subspecialists you refer to to promptly report back to you, as the consultation codes require. There is some danger that removal of the incentive will cause greater delays or failure of communication, making it more important than ever that your staff keep logs (automated or manual) to be sure that you are aware of all physicians caring for your patients and follow-up as needed to receive records or reports. If you don't have systems in place to help track referrals, lab tests, etc., consider downloading the AAFP's Road to Recognition guide. Though created to help physicians document the elements necessary for recognition under the National Committee for Quality Assurance's Physician Practice Connections - Patient-Centered Medical Home (PPC-PCMH), the simple tracking tools it includes may be useful in many practices. If you feel certain that you always receive timely written follow-up from consultants, using these tools will provide you with evidence of whether your feelings are matched by your results.
Posted at 04:52PM Aug 20, 2009 by Cindy Hughes | Comments[0]
Potentially good news on the Medicare horizon
I don't normally recommend reading the Federal Register unless you're a masochist or have trouble sleeping. However, last month, the Centers for Medicare and Medicaid Services (CMS) published its proposed rule on the 2010 Medicare physician fee schedule in the Federal Register, and there is actually some good news for family physicians in what CMS is proposing.
Among the proposals that CMS estimates will have a positive impact on family physicians, two are most significant. One is that CMS proposes to use more current physician practice cost data in its calculation of practice expense relative value units. The other is that CMS proposes to increase the relative values of office visits and initial hospital visits in conjunction with a proposal to no longer recognize and pay consultation codes. CMS estimates that the impact of these changes would result in approximately an 8 percent increase in Medicare allowed charges for family physicians in 2010. Not surprisingly, the AAFP has commented in support of both proposals.
Of course, every silver lining is attached to a cloud. In this case, the cloud is a 21.5 percent decrease in the Medicare conversion factor for 2010 if Congress does not intervene between now and Jan. 1. Here's hoping the folks on Capitol Hill get around to that, whether or not they get around to health care reform in general.
CMS is accepting comments on the proposed rule until Aug. 31. You can submit comments online or by other means specified in the proposed rule.
Posted at 03:32PM Aug 12, 2009 by Kent Moore | Comments[0]
The check may yet be in the mail
I know it's 2009, but Medicare's 2007 Physician Quality Reporting Initiative (PQRI) continues to make news.
Those of you who have been following this saga may recall that a lot of physicians who thought that they should have received a bonus check for participating in the 2007 version of PQRI never did. It turns out that some of them probably should have, after all.
In a set of new PQRI frequently asked questions posted on the Centers for Medicare and Medicaid Services (CMS) web site, CMS confirmed that it is re-running the 2007 PQRI feedback reports and incentive payments. According to CMS, it investigated reported issues following delivery of the 2007 PQRI feedback reports and incentive payments and determined that several unanticipated technical issues could be corrected by conducting back-end system analytics and re-running the data. New reports are anticipated to be available in the fall of 2009.
These new reports will be available only for those eligible professionals who have qualified due to the back-end system analysis and re-running the data. That means if you already received an incentive for 2007, the re-run will not apply to you, and you will not receive an additional feedback report. For those that do qualify, feedback reports will be available via the PQRI Reports Delivery System, for which an Individuals Authorized Access to the CMS Computer Services (IACS) user name and password will be required to access.
Interestingly, there will also be a 2007 PQRI re-run for Medicare Advantage participants. Thus, those Medicare Advantage eligible professionals who previously did not receive a bonus but are bonus eligible following the back-end system analysis and re-run of the 2007 PQRI data will potentially receive the 2007 re-run incentive.
So, if you thought you were owed a 2007 PQRI bonus check, you may still be right. Unfortunately, you won't find out for sure until this fall. Think of it as Christmas in October ... from the U.S. Department of Better Late Than Never.
Posted at 03:53PM Jun 15, 2009 by Kent Moore | Comments[0]
Mental health parity to come to Medicare
By law, Medicare payment for outpatient mental health services is limited to 62.5 percent of covered expenses incurred in any calendar year in connection with the treatment of a mental, psychoneurotic or personality disorder for an individual who is not a hospital inpatient at the time the expenses are incurred. The limitation is typically triggered by the primary diagnosis on the claim, and the limitation essentially changes the usual 80/20 Medicare/beneficiary payment responsibility to a 50/50 split. The physician is essentially held harmless.
For a more thorough explanation of the limitation and its implications, please see the article "Understanding Medicare's Mental Health Treatment Limitation," which appeared in the November/December 2000 issue of Family Practice Management.
Thanks to the Medicare Improvements for Patients and Providers Act (MIPPA), this limitation will be phased out over the next few years. Specifically, Section 102 of MIPPA provides that, beginning in 2010, for expenses reflecting the Medicare approved amount that are incurred in a calendar year in connection with the treatment of outpatient psychiatric services, Medicare will begin to increase the percentage (currently 50 percent) that it will cover as follows: 55 percent of expenses incurred in 2010 or 2011; 60 percent in 2012; 65 percent in 2013; 80 percent in 2014 or in any subsequent calendar year. Thus, MIPPA will gradually phase beneficiary coinsurance rates for outpatient mental health services down to 20 percent by 2014.
Look for the Centers for Medicare and Medicaid Services to address its implementation of this provision this summer in the proposed rule on the 2010 Medicare physician fee schedule.
Posted at 04:28PM May 13, 2009 by Kent Moore | Comments[0]
The future of diagnosis coding
The Centers for Medicare & Medicaid Services (CMS) announced the future of diagnosis coding for physicians last week. Specifically, on Jan. 16, CMS published a final rule specifying that by
The good news is that you have almost five years to get ready, which is two years longer than CMS originally proposed. The bad news is that you will still have to make systems changes and train yourself and your staff to use the new codes.
In the meantime, you and your practice will also have to comply with an updated X12 standard, Version 5010, for certain electronic health care transactions, including claims, remittance advice, eligibility inquiries, referral authorization, and other administrative transactions. Version 5010 accommodates the use of the ICD-10 code sets, which are not supported by Version 4010/4010A1, the current X12 standard. The compliance deadline is
They say that “forewarned is forearmed.” Please consider yourself “forewarned” and anticipate that Family Practice Management, the
Posted at 05:15PM Jan 21, 2009 by Kent Moore | Comments[0]
