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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.

Wednesday Aug 27, 2014

Medicare plans new coding modifiers for 2015

The Centers for Medicare & Medicaid Services (CMS) recently announced that it is creating four new Healthcare Common Procedure Coding System (HCPCS) modifiers that will further refine the popular -59 modifier.

Adding a modifier -59 indicates that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled. Family physicians and others often use it to override edits found in Medicare’s National Correct Coding Initiative (NCCI). In fact, according to CMS, -59 is the most widely used modifier in the HCPCS.

That popularity is partly because, as currently defined, the -59 modifier can be used in a wide variety of circumstances, such as identifying different encounters, different anatomic sites, or distinct services. But physicians aren't always clear on why they're using the modifier, and, from CMS’s perspective, that usage is not always correct. CMS believes it can reduce the incorrect use of modifier -59 – and the subsequent Medicare overpayments – with a combination of more precise coding options, increased education, and selective editing.

As noted in the latest Medicare Learning Network Matters article, CMS on Jan. 1, 2015, will establish four new HCPCS modifiers to define specific subsets of the -59 modifier. They are referred to collectively as -X{EPSU} modifiers:

•    XE - Separate Encounter, a service that is distinct because it occurred during a separate encounter,
•    XS - Separate Structure, a service that is distinct because it was performed on a separate organ/structure,
•    XP - Separate Practitioner, a service that is distinct because it was performed by a different practitioner, and
•    XU - Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service.

For the time being, CMS will continue to accept the -59 modifier. But don't expect that to last indefinitely as the agency notes that, under CPT, physicians should not use the -59 modifier when a more descriptive modifier is available. That means CMS may decide to require a more specific - X{EPSU} modifier for billing certain codes it believes are more likely to generate billing errors. For example, CMS may designate a particular NCCI code pair as payable only with the –XE (Separate Encounter) modifier and not the -59 or other -X{EPSU} modifiers. So be prepared to be more selective in your use of modifiers with Medicare in the near future.

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

Wednesday Aug 20, 2014

How much is care management worth?

The Centers for Medicare & Medicaid Services' (CMS) proposal to begin paying for chronic care management in 2015 has led some to ask how much care management is worth. The CMS's proposal values it at approximately $42 for 30 days.

However, CMS’s Comprehensive Primary Care Initiative says it is reportedly worth between $8 and $40 per beneficiary per month (PBPM), averaging $20 PBPM during the first two years and $15 PBPM during the third and fourth years. Meanwhile, a Robert Graham Center presentation found that care management fees across public and private programs varied greatly, ranging from 60 cents to $444 per member per month (PMPM).

The fees are highly variable partly because no two fees are covering the same group of services. It is a matter of comparing not only apples and oranges but also pineapples and bananas.

One way to try to make sense of this fruit salad is to attempt to define what a care management fee should include. The AAFP recently took a stab at this by creating a policy on "Care Management Fees." The new policy lists seven elements it considers are core activities covered by a PMPM care management fee within the context of a patient-centered medical home:

1.    Nonphysician staff time dedicated to care management
2.    Patient education
3.    Use of advanced technology to support care management
4.    Physician time dedicated to care management
5.    Medication management
6.    Population risk stratification and management
7.    Integrated, coordinated care across the health care system

The policy does not address how much the AAFP thinks these activities are worth, either individually or as a group. However, it does provide a starting place for trying to value care management in a systematic way.

So, how much do you think care management is worth?

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

Friday Aug 15, 2014

Open Payments program reopens after two-week glitch

The online database for a new federal program designed to track financial relationships between physicians and medical suppliers has reopened after a technical glitch forced officials to close it down almost two weeks ago.

Physicians will also have more time to check the database for errors.

The Centers for Medicare & Medicaid Services (CMS) announced Friday that physicians and teaching hospitals were again allowed to access the Open Payments system (formerly called the Sunshine Act). The initiative will eventually disclose financial payments or other transfers of value that pharmaceutical or medical device manufacturers and group purchasing organizations have made to individual physicians.

CMS shut down the system on Aug. 3 after discovering that some manufacturers and group purchasing organizations had mixed up records for physicians who have similar names, which allowed the physicians to see information that was not their own. The agency said it has worked to fix the problem, including making sure that all payment records are connected to a single physician and that the erroneous information is not published.

Despite the delay, and lingering concerns from some medical societies about releasing the data, CMS said it will still release the financial information to the public as scheduled on Sept. 30.

However, CMS has extended the 45-day period during which physicians who have registered with CMS can review and dispute data attributed to them. Originally scheduled to end on Aug. 27, the review and dispute period will now end on Sept. 8.

CMS asked physicians to make sure the National Plan and Provider Enumeration System (NPPES) and the Provider Enrollment, Chain, and Ownership System (PECOS) have their correct first name, last name, National Provider Identifier (NPI), and license information. CMS uses these programs to verify payments. The agency also said physicians should provide complete and accurate information when registering for Open Payments so that CMS can accurately match records reported about them by manufacturers and group purchasing organizations.

Thursday Aug 14, 2014

Medicare offers ICD-10 testing opportunities

Now that the Centers for Medicare & Medicaid Services (CMS) has declared Oct. 1, 2015, as the new compliance date for switching to the ICD-10 coding system, the agency can again turn its eyes toward making sure Medicare providers are ready. The CMS has announced its approach to preparing the Medicare fee-for-service (FFS) community, focusing on four areas:

• CMS internal testing of its claims processing systems
• CMS Beta testing tools available for download
• Acknowledgement testing
• End-to-end testing

The first two areas are largely in CMS's control. But as for acknowledgement testing, physicians are welcome to submit acknowledgement test claims anytime up to Oct. 1, 2015. In addition, CMS is planning special week-long acknowledgement tests in November 2014, March 2015, and June 2015 to give submitters access to real-time help desk support and allow CMS to analyze testing data. Registration is not required for these virtual events, and physicians should contact their Medicare Administrative Contractor (MAC) for more information about acknowledgment testing.

CMS plans to offer Medicare claims submitters the opportunity to participate in end-to-end testing with MACs and the Common Electronic Data Interchange contractor in January, April, and July 2015. As planned, approximately 2,550 volunteer submitters can participate over the course of the three testing periods. CMS says that additional details about end-to-end testing will be available soon.

In the meantime, for more information, see Medicare Learning Network Matters Special Edition Article #SE1409 , “Medicare FFS ICD-10 Testing Approach.”

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

Tuesday Aug 05, 2014

It's official: You have another year to prepare for ICD-10

Last week, the secretary of Health and Human Services (HHS) issued a final rule designating Oct. 1, 2015, as the new compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10.

That means that you and your practice have another year to prepare, and the Centers for Medicare & Medicaid Services (CMS) seems committed to doing what it can to help. CMS has implemented a comprehensive testing approach, including end-to-end testing in 2015, to help ensure providers are ready. Also, CMS has an extensive array of ICD-10 resources on its web site, including the Road to 10, a free online tool that enables small provider practices to create an ICD-10 action plan and jumpstart their transition. The AAFP also has ICD-10 resources on its web site, including a timeline to assist physicians in preparing the transition to ICD-10 and a tool to calculate how much it will cost to implement ICD-10 in your practice.

Not to be outdone, Family Practice Management has amassed a collection of articles on the topic.

Whether you seek resources from CMS, AAFP, FPM, or someone else, it is not too late and certainly not too early to get started in the transition process.

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

Wednesday Jul 16, 2014

CMS looks to add new code to track care provided off hospital grounds

If you're in a family medicine practice owned by a hospital or other health system, the recently proposed 2015 Medicare physician fee schedule offers some new reporting requirements.

The Centers for Medicare & Medicaid Services (CMS) wants to require hospitals and physicians to report a coding modifier for those services furnished in an off-campus, provider-based department.  

The modifier would be reported on both the claim form for physicians’ services and on hospital outpatient claims. CMS defines a hospital campus to be the physical area immediately adjacent to the provider's main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis by the CMS regional office. The new rule would apply to everything outside of that.

CMS said the information collected will help it improve its practice expense data and methodology under the physician fee schedule and more appropriately account for the different resource costs among traditional office, facility, and off-campus, provider-based settings.

The AAFP has prepared a summary of these and other changes proposed by CMS. You can access the full proposed rule  through the CMS web site.

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

Friday Jul 11, 2014

Medicare proposes paying for chronic care management

The Centers for Medicare & Medicaid Services (CMS) wants to begin reimbursing physicians for some of the unpaid care management services they provide patients with several chronic conditions.

Contained in CMS's proposed 2015 Medicare physician fee schedule, the provision would pay approximately $42 for the chronic care management (CCM) code no more than once per month per qualified patient. The payment is intended to compensate physician practices for non-face-to-face CCM services for Medicare beneficiaries who have two or more significant chronic conditions.

Under the proposal, CCM services include regular development and revision of a plan of care, communication with other treating health professionals, and medication management. Other requirements to bill Medicare for CCM services include:

• Access to care management services 24 hours a day, seven days a week, which means providing beneficiaries with a way to make timely contact with health care providers in the practice to address the patient’s urgent chronic care needs regardless of the time of day or day of the week.

• Continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments.

• Care management for chronic conditions, including systematic assessment of patient’s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of patient self-management of medications.

• Creation of a patient-centered care plan document to assure that care is provided in a way that is congruent with patient choices and values. A plan of care is based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment and an inventory of resources and supports. It is a comprehensive plan of care for all health issues.

• Management of care transitions between and among health care providers and settings, including referrals to other clinicians; follow-up after a beneficiary visit to an emergency department; and follow-up after discharges from hospitals, skilled nursing facilities, or other health care facilities.

CMS proposes that practices use an electronic health record (EHR) or other health information technology or information exchange platform to furnish the CCM services. It also says that technology solution should include an electronic care plan that is accessible to all providers within the practice, regardless of the hour of day, as well as being accessible to care team members outside of the practice. Physicians and other qualified health care professionals furnishing CCM services beginning in 2015 would be required to use an EHR certified to at least 2014 Edition certification criteria.

The AAFP has prepared a summary of this and other changes proposed by CMS.

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

Tuesday Jul 08, 2014

CMS looks to tweak Open Payments reporting for CME events

The Centers for Medicare & Medicaid Services (CMS) Open Payment initiative hasn't truly gone into effect yet and its framers already want to change it.

The Open Payment program, which tracks and discloses financial relationships between physicians and drug and device manufacturers, will begin releasing that information by the end of September. Physicians will be able later this month to review the information reported about them and report any errors.

But in the 2015 Physician Fee Schedule proposed rule announced on July 3, CMS proposed some changes to the program based on feedback from stakeholders since the original rules were introduced last year.

Chief among those changes is a proposal requiring that applicable manufacturers disclose any payments or other transfers of value made to speakers at continuing education programs.

These types of payments had been excluded under the current rules, assuming they met three criteria:

• The speaker is appearing at a program accredited or certified by the ACCME, AAFP, ADA, AMA, or AOA,
• The manufacturer does not pay the speaker directly,
• The manufacturer does not choose the speaker or provide the third-party organizer with a list of preferred speakers.

CMS said commenters have argued that limiting the exemption to speakers at events tied to just those five organizations made the reporting requirements inconsistent and appeared to give continuing education events held by those five organizations CMS's "endorsement or support."

The agency said this was an "unintended consequence" and proposed removing the exemption language in its entirety.

Open Payments already has a general exemption for indirect payments or transfers of value where the manufacturer does not know the identity of the recipient, so payments and transfers of value to speakers would remain exempt under that rule, provided the manufacturer doesn't directly pay the speaker or provide the third-party organizers with a list of preferred speakers.

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

Tuesday Jun 03, 2014

Potential pitfall in Medicare billing: preventive services

Last week, we began looking at some of the common Medicare billing errors identified by the Centers for Medicare & Medicaid Services (CMS) in its most recent Medicare Quarterly Provider Compliance Newsletter. This week, we’ll focus on another of those pitfalls, this one associated with Medicare-covered preventive services.

In recent years, the CMS has expanded Medicare coverage of preventive services to include many recommended with a grade of A or B by the United States Preventive Services Task Force. These services (and their corresponding Medicare billing codes) include:

•    Annual alcohol misuse screening, 15 minutes (G0442)
•    Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes (G0443)
•    Annual depression screening, 15 minutes (G0444)
•    Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes (G0446)

Unfortunately, Medicare contractors have determined that insufficient documentation is causing many improper payments for these services. “Insufficient documentation” in this context means that something was missing from the medical records, such as:

•    No record of the amount of time spent providing a timed service
•    No record of the billed service itself
•    No physician’s signature on the medical record

To avoid these potential problems, CMS advises physicians to:

•    Record start and stop times, or the total time spent, when providing a timed service
•    Sign entries in medical records at the time of service
•    Learn about the non-covered indications and frequency limits for preventive services under Medicare

To the last point, you should know that:

•    Screening for depression is not covered when performed more than once in a 12-month period
•    Alcohol screening is not covered when performed more than once in a 12-month period
•    Brief face-to-face behavioral counseling interventions are not covered when performed more than once a day
•    Brief face-to-face behavioral counseling interventions are not covered when performed more than four times in a 12-month period.

You can find additional information and links to other relevant resources in the newsletter. Next week, we’ll look at the pitfalls associated with misuse of a common coding modifier.

– 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.

Thursday May 22, 2014

One-stop shopping Medicare quality reporting programs

One of the downsides to participating in multiple Medicare quality reporting programs, such as the Physician Quality Reporting System (PQRS) or Meaningful Use, is that you often have had to report the same data separately for each.

The Centers for Medicare & Medicaid Services (CMS) has heard your woes, however, and created a new interactive tool that will help you submit your quality data one time only and earn credit for multiple programs.

The “Reporting Once for 2014 Medicare Quality Reporting Programs” tool provides guidance based on how you plan to participate in PQRS in 2014:

•    As an individual eligible professional
•    As part of a group practice
•    As part of a Medicare Shared Savings Program Accountable Care Organization (ACO)
•    As part of a Pioneer ACO

Using the interactive tool, you will learn whether you will be eligible for PQRS incentives in 2014, will avoid PQRS Medicare penalties in 2016, and can satisfy the clinical quality measure component of the Medicare Electronic Health Record (EHR) Incentive Program. If you are part of a group practice with 10 or more eligible professionals, the tool will also help you assess the impact of your participation in PQRS on the Value-Based Payment Modifier.

You can use these streamlining options only if you have participated in the Medicare EHR Incentive Program for more than a year, and you are still required to report your core and menu objectives through the CMS Registration & Attestation System.

To use the interactive tool, simply click on the green “Start” button on page two of the tool. You can also use the “How to Report Once for 2014 Medicare Quality Reporting Programs” fact sheet  for an overview of the quality programs and reporting once in 2014.

For step-by step instructions for 2014 PQRS participation, view the PQRS How to Get Started web page on the CMS web site. If you have additional questions, contact the QualityNet Help Desk at 866-288-8912 or via qnetsupport@hcqis.org. The Help Desk is available Monday through Friday from 7:00 a.m. to 7:00 p.m. (Central Time).

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

Tuesday May 06, 2014

Update on ICD-10 delay

A previous post noted that the Protecting Access to Medicare Act of 2014, which was enacted on April 1, 2014, said that the Secretary of Health and Human Services (HHS) may not adopt ICD-10 before Oct. 1, 2015. The law, however, did not limit when the Secretary could adopt ICD-10 beyond that date.

Accordingly, the Centers for Medicare & Medicaid Services (CMS) announced last week that the Secretary of HHS expects to release an interim final rule in the near future that will include a new compliance date that would require the use of ICD-10 beginning Oct. 1, 2015. The rule will also require Health Insurance Portability and Accountability Act covered entities to continue to use ICD-9 through Sept. 30, 2015.

CMS also announced that it has canceled the ICD-10 end-to-end testing that it otherwise planned to conduct during the week of July 21. CMS canceled the July testing due to the ICD-10 implementation delay and said additional opportunities for end-to-end testing will be available in 2015.

Meanwhile, the acknowledgment testing that occurred in March was apparently a success. CMS previously reported that from March 3 to March 7 they received approximately 127,000 ICD-10 acknowledgment test claims, representing about 5 percent of those who submit claims to Medicare. CMS and its contractors encountered no systems problems associated with those test claims. CMS had originally planned to offer another week of acknowledgment testing this month; there is no word yet on whether it will still do so or postpone that to 2015 as well.

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

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