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

Tuesday Apr 08, 2014

Another patch and more time to prepare for ICD-10

Following up last week's post, the Senate approved and the president signed a House bill that prevents steep cuts to Medicare physician payments from going into effect for one year. The bill (now law) also delays the conversion to ICD-10 diagnostic and procedure codes for at least one year.

The measure calls for a 0.5 percent increase in physician payments through Dec. 31, 2014, and no change from Jan. 1 through March 31, 2015. That means is that it will be another year before you have to worry about a potential cut in the Medicare physician payment rate. It also means that Congress has additional time to pass a permanent repeal of the Sustainable Growth Rate that has led to the current predicament. Such action in advance of the mid-term elections seems unlikely, however, given the current lack of agreement on how to pay for repeal.

On the plus side, the delay in ICD-10 does give physicians more time to prepare for that change, which will now occur on Oct. 1, 2015 (or later). Until then, everyone will continue to use ICD-9 codes. That said, you shouldn't use the delay in implementation as an excuse to delay preparation. Physicians, payers, and other users of ICD-10 should continue to move forward with preparation wherever they are in the process, and AAFP has resources to help its members do just that.

– 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

Tuesday Feb 04, 2014

Survey: Average family physician wait times are more than two weeks

The average wait time for a patient wanting to get an appointment with his or her family physician has dipped slightly from two years ago, a new study says. But patients are still having to wait two weeks or longer.

Health care consulting firm Merritt Hawkins, in a new report, says its survey of family physician offices in 15 U.S. metropolitan areas found an average appointment wait time of 19.5 days in 2013. By comparison, average appointment wait time was 20.3 days in 2009.

However, the researchers noted that average wait times equaled or exceeded 14 days in 10 of the 15 markets last year. In 2009, only eight markets equaled or exceeded the two-week mark.

The company surveyed almost 1,400 offices across the 15 metro areas in family medicine and four other specialties. Researchers considered family medicine essentially flat. Cardiologists (16.8 days) and dermatologists (28.8 days) saw their wait times increase while obstetricians/gynecologists (17.3 days) and orthopedists (9.9 days) saw a decrease.

Overall, the average wait time to see a physician across all specialties and markets decreased from 20.4 days in 2009 to 18.5 days in 2013.

Despite the decline, Merritt Hawkins warned that physicians unable to see patients within 14 days are likely busy and need the help of other physicians or advanced practitioners to handle the overflow.

The survey also found that the overall average acceptance of Medicaid patients has declined in the 15 markets over the past four years, falling to 45.7 percent in 2013, compared with 55.4 percent in 2009. An average of 76 percent of practices in the 15 markets accepted Medicare in 2013. Merritt Hawkins didn't survey for Medicare in its 2009 survey.

If you're looking for ways to get more patients into your practice faster, you can check out articles in Family Practice Management's Access to Care topic collection.

Tuesday Jan 28, 2014

Medicare offers two-for-one deal, of sorts

Are you an eligible professional trying to earn a 2013 incentive payment through Medicare’s Physician Quality Reporting System (PQRS)? Do you also hope to achieve an electronic health record (EHR) incentive from Medicare? If so, the Centers for Medicare & Medicaid Services (CMS) is offering you the chance to do both through its PQRS Medicare EHR Incentive Pilot.

The pilot program allows eligible professionals to meet the clinical quality measure (CQM) reporting requirement for the EHR program through electronic submission while also reporting for the PQRS program.

If you would like to participate in the pilot you must submit 12 months of CQM data by 11:59 p.m. (EST) on February 28, 2014, by taking the following steps:

1.    Register for an Individuals Authorized Access to the CMS Computer Services (IACS) account (for EHR submission only), if you do not have one already.
2.    Indicate in EHR Registration & Attestation System your intent to report CQMs using the pilot.
3.    Generate required reporting files.
4.    Test data submission.
5.    Submit quality data.

If you cannot submit your CQM data for 12 months electronically through PQRS, you must return to the EHR Attestation System and deselect the electronic reporting option. Please note: if you do not submit your 2013 quality data or deselect the electronic reporting option in the EHR Attestation System, you will not receive an EHR incentive payment.

For further guidance on the 2013 PQRS-Medicare EHR Incentive Pilot, please read the participation guide and quick-reference guide. If you have questions, please contact the QualityNet Help Desk at 1-866-288-8912 or via The Help Desk is available Monday through Friday from 7:00 a.m.-7:00 p.m. (CST).

– 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 Jan 22, 2014

Survey shows Stage 2 meaningful use compliance still low

If physicians were required today to comply with the Stage 2 requirements of the federal "meaningful use" program, instead of later this fall, relatively few would be able to do so, according to a new Centers for Disease Control and Prevention (CDC) survey.

The National Ambulatory Medical Care Survey, released this month, found that only about 13 percent of office-based physicians said they both intended to participate in the Medicare and Medicaid EHR incentive programs and that their EHR was capable of supporting 14 of the meaningful-use program's 17 "core" objectives.

To comply with Stage 2, physicians will have to show that their EHRs can support all 17 core objectives and three of six "menu" objectives. For that reason, the CDC added that its 13 percent estimate may be too high.

About 56 percent of physicians who intended to participate in meaningful use said their EHRs were not capable of supporting 14 core objectives. Nineteen percent were uncertain if they would apply for the incentive program, and almost 12 percent said they were not.

Not complying with at least Stage 1 meaningful-use requirements by the end of the year will result in Medicare reimbursement cuts for those physicians, beginning in 2015.

Physicians who have already complied with Stage 1 of meaningful use for at least two years will have until October 2014 to begin complying with Stage 2. Those who didn't start Stage 1 until more recently will have later deadlines.

The CDC did say that for the seven Stage 2 meaningful-use capabilities for which statistics are available – including the ability of an EHR to record patient information and demographics, order prescriptions, send prescriptions to a pharmacy electronically, warn of drug interactions or contraindications, order lab tests, issue reminders for guideline-based interventions, and report immunization information to online registries – all saw an increase between 2010 and 2013 of the percentage of physicians able to comply.

The survey also found that more than 78 percent of office-based physicians had some form of EHR system last year, compared with a little more than 17 percent in 2003 and 51 percent in 2010.

For more information on Stage 2 meaningful use and how to comply with the new regulations, see this article in the January/February issue of Family Practice Management.

Thursday Jan 16, 2014

Recovery auditors focus on Annual Wellness Visits

Do you provide Annual Wellness Visits (AWV) to your Medicare patients? Are you aware of the different codes to report the visit, depending on whether the patient has had one before? Medicare’s recovery audit contractors (RACs) are apparently finding that some physicians aren't, and that's leading to Medicare overpayments.

The Centers for Medicare and Medicaid Services (CMS) highlights this issue in the January 2014 edition of its Medicare Quarterly Provider Compliance Newsletter. In the newsletter, CMS notes that Medicare pays for an "initial" AWV for each beneficiary once in their lifetime. All successive AWVs must be billed as "subsequent" AWVs. The corresponding billing codes are:

    •    G0438 – Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit
    •    G0439 - Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit

Unfortunately, the RACs have reported finding multiple instances of physicians billing G0438 more than once for the same beneficiary.

For more information on Medicare’s rules related to the AWV, check out section in Chapter 12 of the Medicare Claims Processing Manual as well as Medicare’s quick reference guide and booklet on the AWV. You can also find information on the AAFP’s web site through Family Practice Management's article collection on this topic.

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

Friday Jan 03, 2014

Medicare to begin new restrictions on durable medical equipment and other supplies

Medicare is finally implementing new rules that will target physicians who order or refer items and services for their Medicare patients but who lack proper identification.

Effective Jan. 6, 2014, Medicare contractors will implement specific edits that will restrict suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) from receiving payment from Medicare for items that physicians have prescribed if they do not have a current enrollment in the Medicare Provider Enrollment, Chain and Ownership System (PECOS).

The second phase of denial edits was originally supposed to go into effect last May, but they were delayed by technical issues and the new date announced in December.

For any DMEPOS item to qualify for Medicare coverage, it must be ordered by a physician or a practitioner who:
•    is enrolled in PECOS,
•    is registered in the system, and
•    has a specialty that is eligible to order DMEPOS items for Medicare beneficiaries.

The provider specialties who can order DMEPOS items include:
•    Doctor of Medicine or Osteopathy
•    Doctor of Dental Medicine or Dental Surgery
•    Doctor of Podiatric Medicine
•    Physician Assistant
•    Certified Clinical Nurse Specialist
•    Nurse Practitioner
•    Doctor of Optometry

Physicians can help the DMEPOS suppliers with whom they work by promptly enrolling in PECOS, or by updating their existing Medicare enrollment information. To continue to order DMEPOS for Medicare beneficiaries, physicians will have to enroll in the Medicare program or “revalidate” their Medicare enrollment information. To do so, either use the Internet-based PECOS, or fill out the appropriate Medicare provider enrollment application(s) and mail it, along with any required information, to the local Medicare carrier or A/B Medicare Administrative Contractor (MAC) for processing.

You can confirm if you are currently enrolled in Medicare by contacting your designated enrollment contractor or by viewing your enrollment record online on PECOS. If you have a PECOS record, make sure it includes your National Provider Identifier (NPI) and update your record if it doesn't. You can also download the Medicare Ordering and Referring file and see if your NPI is listed.

For additional information, contact your local A/B MAC.

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

Monday Dec 23, 2013

A short reprieve from Medicare cuts and a little something extra, too

President Obama is expected to sign into law legislation that would grant physicians a reprieve from drastic cuts in their Medicare payments beginning on Jan. 1. The new law, adopted by the Congress last week, provides a 0.5 percent update to Medicare payments for the first three months of 2014 and avoids a 24 percent cut otherwise required under current law.

That action gives Congress three more months to complete its work on legislation that would repeal the Sustainable Growth Rate (SGR) without further disruption to the Medicare program. Both the Senate Finance Committee and the House Ways and Means Committee (amending a bill produced by the House Energy and Commerce Committee) have overwhelmingly approved similar but not identical bills – the SGR Repeal and Medicare Beneficiary Access Act (S 1871) and the Medicare Patient Access and Quality Improvement Act (HR 2810). The three-month extension of the Medicare physician fee schedule (with a 0.5-percent increase) means that the two committees have until March 31 to work out the differences in the bills.

In the meantime, physicians must make decisions about their Medicare participation status for 2014. Physicians wishing to change their Medicare participation or non-participation status for 2014 are required to do so by Jan. 31, 2014. Participation decisions are effective Jan. 1, 2014, even if made between then and Jan. 31, 2014, and are binding for the entire year. More information on physicians’ Medicare participation options is available on the AAFP web site.

– 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

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