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:

1. Take action to ensure that otherwise acceptable claims are paid without delay or need for appeals;
2. 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;  
3. 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, 
4. 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]

You might be a coding and payment geek if . . .

The arrival of the new ICD-9 manual recently reminded me that there are certain things that distinguish coding and payment geeks from otherwise "normal" people.  So, for your consideration, I offer you the top 10 signs that you might be a coding and payment geek:

10.  The first thing you associate with December is the arrival of the new CPT book.

9.  You actually get excited when your new coding books arrive.

8.  You wonder why the toy doctors bag you bought your kid doesn't include a claim form.

7.  You worry your family physician is undercoding your visit.

6.  You consider the Federal Register light reading.

5.  You write to CMS more than to your own mom.

4.  You actually understand Medicare's Sustainable Growth Rate formula.

3.  You collect past issues of CPT Assistant on eBay.

2.  When your family physician tells you that you have conjunctivitis, you wonder what the ICD-9 code for that is.

 And the number one sign that you might be a coding and payment geek:

1.  You actually understood the humor in this blog post!

Posted at 01:10PM Oct 22, 2009 by Kent Moore  |  Comments[0]

Getting paid for H1N1-related services

Do you know where to obtain H1N1 vaccine for your patients and how to bill payers for its administration?

Free H1N1 vaccine kits are available through your state health agencies. The Centers for Disease Control has published a list of who to contact for information on obtaining the vaccine. If you do not wish to provide the vaccine in your practice, you can use this list to determine where to refer your patients.

Most privately insured patients will have benefits for the H1N1 vaccine administration even if their health plan does not typically cover preventive services; this is due to collaboration between the U.S. Department of Health and Human Services and payers. Medicare allows physicians to provide and bill for both H1N1 and seasonal influenza vaccines on the same date. Medicare created a new G code for administration of the H1N1 vaccine; submit code G9141 with diagnosis code V04.81. It is not necessary to report a separate code for the vaccine itself, but if you prefer to include it in your documentation, use code G9142. If billed, this code will be denied since the vaccine is provided at no cost. For the standard seasonal influenza vaccine and administration, use codes G0008 for the administration, V04.81 for diagnosis, and the appropriate CPT code for the vaccine itself (i.e., 90655, 90656, 90657, 90658 or 90660). Medicare will not pay for an office visit if the sole purpose of the visit is vaccine administration but will if a significant, separately identifiable E/M service is provided on the same date.

Your local private payers may still be deciding on the coverage and payment for the H1N1 vaccine, but most national payers have provided some guidance. The recent creation of CPT code 90470 for H1N1 vaccine administration may cause some plans to issue revised instructions. We have requested updated guidance from national health plans and will update the AAFP resources on H1N1 with this information as we receive it. As with all services, practices should check the individual patient’s benefits when scheduling the services.

Finally, it’s important to know how to code and bill for care provided to patients who are sick with the flu. New influenza diagnosis codes took effect Oct. 1, 2009. Code 488.1 is specific to influenza due to the H1N1 virus. Code 487.1 is still valid for patients with influenza not otherwise specified and other respiratory manifestations such as pharyngitis, laryngitis or URI. Code 487.0 for reporting influenza with pneumonia is also still valid. When providing in-office testing for influenza, code 87804QW represents CLIA-waived testing for influenza by immunoassay with direct optical observation. Most rapid tests do not differentiate between Influenza A and B. However, for those that do produce two separate results, payers may accept 87804QW on one claim line and 87804QW59 on a separate claim line. As always, you should check with your individual payers for specific coverage and billing guidelines.

Posted at 02:31PM Oct 02, 2009 by Cindy Hughes  |  Comments[0]

Records requests: Answer carefully

Your practice probably receives multiple requests for records each week. Unfortunately, more and more of these requests are related to your claims for payment. With ever-growing reports of waste and abuse in health care and profits to be made in recovering money paid to physicians and other providers, these requests are not going away. Whether from Medicare administrative contractors (MACs), recovery audit contractors (RACs), Comprehensive Error Rate Testing (CERT) program contractors, private payers or Medicaid plans, how your practice responds to these requests can make a big difference in your practice's financial future.

So the first question is, who responds to these requests in your practice? Do they understand the importance of sending the right records to support the services billed and doing this in the time period specified on the request? Many of you may be familiar with the CERT program that the Centers for Medicare & Medicaid Services (CMS) commissioned to review the accuracy of claims paid by their Medicare contractors. Some of the most common reasons for errors in the program are these:

1. Records not sent.
2. Records sent but not for dates or services billed.
3. Records illegible or unsigned.

If your practice doesn't provide the records to substantiate your charges, the claim is found to have been paid in error. Medicare contractors are obligated to recover money paid in error. Auditors working for private payers are incentivized to recover money paid in error.

The second question is whether you have a process for making sure that all documentation is provided to support the charges in question. If not, it is probably time to implement one. Here are some tips that might help:

• Identify a primary and back-up staff person to receive all records requests related to claims or payment.
• Create a log identifying the date the request was received, the type of records requested and the date the records were sent.
• If there is any question whether documents are legible or sufficient to support the services that were billed, the physician or other provider of services should review the records and provide a transcribed copy of the documentation in addition to a copy of the original documentation and/or a letter explaining any additional information that may have bearing on the outcome of the review. (Any addendum to the original documentation should be signed with the current date added.)
• Create a checklist to be used in confirming that copies are ready to be mailed.

Establishing a formal process for responding to requests for records may provide a framework for ensuring that all are appropriately and efficiently handled and help to identify recurring gaps in documentation. It may also protect money already paid to you as well money that you are due.

There are already too many opportunities for practices to lose money in the insurance billing process. Most practices can't afford to take lightly efforts by Medicare and others to recover money they have already been paid.

Posted at 05:34PM Sep 25, 2009 by Cindy Hughes  |  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]

Another urban myth about coding

Recently, I received a call from a physician who had heard from a consultant that he should code his levels of evaluation and management (E/M) services based solely on the medical decision making involved.  He asked me if this was true. 

As I have done with other callers asking the same question, I assured him that this was incorrect information.  Current Procedural Terminology (CPT) clearly states that all of the key components (i.e., history, examination, and medical decision making) play a role in selecting a level of E/M service (unless you’re coding on the basis of time because counseling and/or coordination of care dominated the encounter).  For some codes (e.g., new patient office visits), all three key components must meet or exceed the stated requirements to qualify for a particular level of E/M service.  For other codes (e.g., established patient office visits), two of the three key components must meet or exceed the stated requirements to qualify for a particular level of E/M service.  In no case does CPT state that medical decision making, by itself, determines the level of E/M service. 

Medicare policy supports this interpretation.  Section 30.6.1, “Selection of Level of Evaluation and Management Service,” of Chapter 12 of the Medicare Claims Processing Manual states, in part, “Instruct physicians to select the code for the service based upon the content of the service.”  That content includes the history and examination. 

This particular urban coding myth grows out of confusion between medical decision making and medical necessity.  As the same section of the Medicare Claims Processing Manual says, “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code.”  Using an extreme example, you can perform and document the history, examination and medical decision making necessary for a level-five office visit for a patient with a common cold, but there are not many people who would say that level of service was medically necessary in that circumstance.  In any case, medical necessity is not the same as medical decision making, and medical necessity governs payment, while medical decision making plays but one part in selecting the level of E/M service. 

So the next time someone tells you to code E/M services only on the basis of medical decision making, you might warn them about all the alligators living in the sewer system.

Posted at 04:47PM Apr 27, 2009 by Kent Moore  |  Comments[0]

For whom the bell curve tolls

As many family physicians, coders, and billers know, if your E/M coding pattern varies significantly from the norm of other physicians in your specialty, a Medicare audit can result. But what does the norm look like? According to national data from the Centers for Medicare & Medicaid Services for 2007 (the most recent data available), it looks like this for family physicians:

As one would expect, the norm is almost a bell-shaped curve.  If your coding pattern is to the right of this curve (i.e., you code a significantly greater percentage of your encounters at higher levels than the norm), you may want to review the documentation for a sample of encounters to ensure that (1) the documentation supports the level of service and (2) the level of service seems medically reasonable or appropriate.  

If your coding pattern is to the left of the curve (i.e., you code a significantly greater percentage of your encounters at lower levels than the norm), you may still want to review the documentation for a sample of encounters.  In this case, the rationale for doing so is to ensure that you are not routinely undercoding and leaving money on the exam table in the process. If you're not sure of your coding pattern, you can download an Excel spreadsheet from the FPM Toolbox that will help you calculate it.

In the end, it is not important that you conform to the norm.  Rather, it is important that you know where you stand relative to the norm and be able to explain and defend your position, if called upon to do so.

Posted at 04:43PM Mar 03, 2009 by Kent Moore  |  Comments[2]

The future of physician payment?

The start of a new year is often a time to look ahead and try to foresee the future. As I do that this January with respect to physician payment, I see “value-based purchasing” on the horizon.

What is “value-based purchasing?” Good question. I do not have a definitive answer, but I can tell you that the folks in the Centers for Medicare & Medicaid Services (CMS) view it as something that “aligns payment more directly to the quality and efficiency of care provided by rewarding providers for their measured performance across the dimensions of quality.”

And this is not just idle musing, either. By law, the Secretary of Health and Human Services is to develop a plan to transition to a value-based purchasing program for Medicare payment for covered professional services (including physician services) and submit a report to the Congress no later than May 1, 2010. To that end, CMS held a public listening session on this topic on Dec. 9, 2008, and has released an issues paper for review and comment.

What this all means for physician payment is not yet clear. However, I can imagine a day in the not-too-distant future when Medicare and other payers rely less on “fee-for-service” and more on what we have heretofore called “pay-for-performance.” In the meantime, it may be wise to keep an eye on CMS’s plans for transitioning to “value-based purchasing” as an indicator of things to come.

Posted at 04:57PM Jan 05, 2009 by Kent Moore  |  Comments[0]