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

Monday Mar 31, 2014

SGR delay puts brakes on Medicare physician fee schedule claims

While physicians wait to see if Congress passes legislation today that avoids a 24 percent cut to Medicare payments, the continuing debate over the Sustainable Growth Rate (SGR) is already affecting claims.

The House of Representatives passed HR 4302 by voice vote on March 27. The bill would delay the SGR's mandated cuts for another 12 months. The Senate was scheduled today to take up the bill, or introduce its own version, ahead of the April 1 SGR deadline.

To give Congress more time, the Centers for Medicare & Medicaid Services (CMS) has instructed the Medicare Administrative Contractors (MACs) to hold claims containing services paid under the Medicare physician fee schedule (MPFS) for the first 10 business days of April (i.e., through April 14, 2014). This hold would affect only MPFS claims with dates of service on or after April 1. The hold should have minimal impact on physician cash flow because MACs under current law do not pay clean electronic claims any sooner than 14 calendar days (29 days for paper claims) after the date of receipt.

MACs will process and pay all claims for services delivered under normal procedures on or before March 31, regardless of any Congressional action – or inaction, as the case may be.

– 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 Mar 04, 2014

Medicare plans additional testing for ICD-10

If you're not participating in this week's test of the ICD-10 coding change, you'll get a second chance soon.

Last week, the Centers for Medicare & Medicaid Services (CMS) announced that it would add a second week of acknowledgement testing for physicians and others who submit Medicare claims. It also provided more details about end-to-end testing with Medicare.

The announcement came in the form of an article revision on the Medicare Learning Network (MLN). According to the revision, CMS plans to offer a second week of acknowledgement testing in early May 2014.

The revised article also states that CMS will offer end-to-end ICD-10 testing in late July 2014 to a small sample group of providers. End-to-end testing tracks a claim from initial connectivity and claim submittal all the way through remittance advice (RA), denials, and refund requests. CMS’s goals for this test are to demonstrate that:

• Providers or submitters are able to successfully submit claims containing ICD-10 codes to the Medicare fee-for-service claims systems;

• CMS software changes made to support ICD-10 result in appropriately adjudicated claims (based on the pricing data used for testing purposes); and

• Accurate RAs are produced.

CMS will select more than 500 volunteer submitters for the project, choosing a broad cross-section of providers, suppliers, and other submitters and claims types. CMS will provide information on volunteering later this month and disseminate additional details about the test in a separate MLN Matters article.

– 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 18, 2013

Penalty for unsuccessful e-prescribers coming in 2014

Were you a successful electronic prescriber under either the 2012 or 2013 Medicare Electronic Prescribing (eRx) Incentive Program? If so, congratulations! If not, expect slightly smaller Medicare payments in 2014.

Eligible professionals and group practices (who self-nominated for the 2012 and/or 2013 eRx group practice reporting option) who didn't successfully complete the incentive programs will receive a 2 percent penalty next year. That means they'll receive only 98 percent of the Medicare Part B physician fee schedule allowed charges they would otherwise have received for services provided from Jan. 1–Dec. 31, 2014.

If you do get notified by the Centers for Medicare & Medicaid Services (CMS) that your payments are being cut, you can get a second opinion by requesting an informal review. Complete instructions on how to request an informal review are available in the 2014 eRx Payment Adjustment Informal Review Made Simple educational document on the CMS web site. You should email your eRx informal review request to no later than February 28, 2014.  

For all other questions related to the eRx Incentive Program, CMS asks that you contact the QualityNet Help Desk at 1-866-288-8912 (TTY 1-877-715-6222) or via They are available Monday through Friday from 7 a.m.–7 p.m. CST.

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

Tuesday Dec 10, 2013

Medicare sets dates for ICD-10 testing

If you remember "mid-terms" in school, they were tests administered to gauge your level of knowledge and understanding of a course ahead of the big exam at the end of semester.

When it comes to implementing ICD-10-CM next October 1, the Centers for Medicare & Medicaid Services (CMS) has scheduled its own version of mid-terms. The agency has instructed all of the Medicare administrative contractors (MACs) to  conduct ICD-10 tests with trading partners, including physicians, during the week of March 3-7, 2014.

The MACs plan to validate whether trading partners can meet technical compliance and performance processing standards necessary for implementing ICD-10 on schedule. The tests will also give the MACs and CMS itself a chance to show they're ready to implement ICD-10 as well.

The event will be conducted virtually and will be posted on each MAC's website as well as the CMS website. Each MAC will announce and promote the testing week through listserv messages and on its website and publicize how to register for the testing week at least four weeks before it begins.

Physicians and other trading partners will have access to real-time electronic data interchange help desk support, which will be available at least from 9 a.m. to 4 p.m. local contractor time. They will also have enough support to handle any increased call volume. Participating providers and suppliers will receive electronic acknowledgement confirming that submitted test claims were accepted or rejected.

Following the tests and by March 18, the MACs will report to CMS the number and percentage of trading partners who participated in the testing, what percentage of test claims were accepted, and any significant problems found during testing.

Note that this is not full cycle end-to-end simulated claims submission testing, which would track a claim from initial connectivity and claim submittal all the way through remittance advice, denials, and refund requests. CMS officials have previously said they would not provide end-to-end testing, but there has been some indication lately that they may be reconsidering that position.

Stay tuned.

– 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

Monday Nov 04, 2013

Medicare adds flexibility to E/M documentation guidelines

The Centers for Medicare & Medicaid Services (CMS) recently added a small measure of flexibility to the documentation guidelines for evaluation and management services.

Historically, CMS has required physicians to choose either the 1995 or 1997 version of the guidelines when documenting a given encounter. That has sometimes left family physicians in a quandary. Many prefer the simplicity of the exam portion of the 1995 guidelines over the “bullet points” in the exam portion of the 1997 guidelines. But they also like the history portion of the 1997 guidelines, which reference “the status of at least three chronic or inactive conditions” in the definition of an extended History of Present Illness – something missing from the 1995 guidelines.

CMS has acknowledged the problem, recently adding the following to its frequently asked questions on the documentation guidelines:

Q. Can a provider use both the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services to document their choice of evaluation and management HCPCS code?

A. For billing Medicare, a provider may choose either version of the documentation guidelines, not a combination of the two, to document a patient encounter. However, beginning for services performed on or after September 10, 2013 physicians may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document an evaluation and management service [emphasis added].

It is a small change on the part of CMS, but hopefully, it is one that will allow family physicians and others to enjoy the best of both sets of documentation guidelines.

– 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

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

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