5010 compliance delayed

CMS announced today that although they are not moving the deadline for the new 5010 claims format which was mandatory on Jan 1, 2012, they will not enforce compliance until March 31, 2012. Essentially delaying it for three months. There has been a lot of chatter in the industry from covered business entities that they have not firmed up testing to allow for only the 5010 format on Jan 1, 2012 so if either your clearinghouse or payor are not ready yet, you may still be able to transmit claims in the old 4010 legacy format. And if you haven't had time yet to update your provider and facility zip codes, you still have time.

CMS news release can be found here: http://www.cms.gov/ICD10/Downloads/CMSStatement5010EnforcementDiscretion111711.pdf

Top Medicare Denials

Noridian Medicare just released last week the top five denials for October through December.

The top five are:

Non covered because the service is not deemed medically necessary
The procedure code or modifier was invalid for that service date
Claim denied as patient can not be identified
Claim lacks the NPI of the referring or ordering physician
or NPI is invalid
Maximum benefits for time period have been exceeded

The Part B newsletter can be found at the link below:

https://www.noridianmedicare.com/provider/updates/docs/top_claim_submission_errors_Oct-Dec.pdf

What is more shocking, is that all of these reasons are easily preventable. By simply checking benefits and eligibility four of them can be eliminated and there are NPI look ups through NPPES.

We'll go more in depth on how to solve these denials in future posts or for tips on how to eliminate these denials in your office, give us a call, we'd love to help!

The A-Z revenue cycle, why it doesn't work.

I remember years ago there was a commercial, I think for an investment banking firm that claimed they “make money the old fashioned way, they earned it”. Well if you are following up on outstanding a/r balances the old fashioned way, you could be losing it. It used to be that offices would print out an a/r report and then start calling on balances from A-Z. It was quickly apparent that no one ever gets to “Z”. I have even had a coworker whose last name starts with “Z” exclaim how fun he thought it was to berate offices when they would call him about a balance months after the fact. They’d be so embarrassed at their inefficiency they’d write it off. Offices thought they got smart when they would work the report in reverse every other month to make sure that "Z" got 'worked' at least every 60 days. You can imagine how happy this would make the people with last names staring with “L”. In todays world an efficient office should have a turnaround time of less than 60 days, many offices have turnaround times of 45 days or less. Often this is referred to as “days in a/r”, and is a measurement of the average time it takes from the date of service to receive payment. Anything over 60 days and you should be identifying workflow issues in your office and implementing solutions to resolve them. If you need help with your revenue cycle, give us a call, we love this stuff.

New Vaccine Admin codes

Last week I had a family practice office ask about the new vaccine admin codes that went into effect on Jan 1, 2011. They were confused on when and how you would use them.

The new codes: 90460 and 90461 have replaced the code range 90465-90468 for use when the physician provides counseling to the patients along with the vaccination. You would still use the new codes along with the code identfying the medication administered such as the code 90633 - 90634 for Heb, and 90645 for Hib, and 90680 for rotovirus.

The first new code, 90460 is used to identify the first vaccine component and 90461 is used for each for all additional components in which the physician provided administration AND counseling. 90461 is also noted as an add on code and can not be billed without 90460. Also important to note in the description is that both of the new codes are for administration and counseling in children 18 or younger as opposed to the codes they replaced that had an age limit of 8 years of age.

So what this means is if a nine year old child came in for MMR shot, and the physician provided counseling they would bill out administration for three components: measles, mumps, and rubella, which would be 90460, 90461 x 2

The American Acadmey of Pediatrics has recommended that the code 90461 is billed on one line item with the number of units rather than two sepearte line items of 90461. For more information and some FAQ's, please see their website at:

http://practice.aap.org/content.aspx?aid=2980

You would use still use 90471 and 90472 if there is NO counseling such as flu clinics where patients just walk in, get a shot, and walk out or for patients over the age of 18.

AMA clarifies modifier -25 usage for wellness visits

During their symposium in Chicago in Nov the AMA clarified that in 2011 you will no longer need to append a modifier-25 to wellness visits billed with covered screening tests, however you will still need to use the modifier if you are billing the wellness exam with a separately identifiable E/M service.

They also clarified that the new subsequent observation codes (99224-99226) are designed to be reported by both the physician who initiates observation care and any other doctor who evaluates the patient. For the non-initiating doctors, the AMA states you should report consult codes for non-Medicare payers and the subsequent observation codes for Medicare

Medicare Physician Fee Schedule changes for 2011

The Centers for Medicare & Medicaid Services (CMS) issued a 2011 Medicare Physician Fee Schedule (MPFS) Final Rule Correction Notice to revise some physician work, practice expense (PE) and malpractice (MP) relative value units (RVUs) set forth in the 2011 MPFS Final Rule, published in the Nov. 29, 2010 Federal Register.

Subsequent legislative changes occurring after the publishing of the correction notice have made additional revisions affecting Medicare payments to physicians necessary. Of particular importance is the Medicare and Medicaid Extenders Act of 2011, which President Obama signed into law Dec. 15, 2010. This Act averts the negative update to the fee schedule that would have otherwise taken effect Jan. 1 and provides a zero percent update to the MPFS for claims with dates of service Jan. 1, 2011 through Dec. 31, 2011.

While the PFS update is zero percent, there was an adjustment to the conversion factor (CF) to make the changes budget neutral. The revised CF that will go into effect on Jan. 1, 2011 is $33.9764.

For more information you can view the transmittal here:

http://www.cms.gov/transmittals/downloads/R828OTN.pdf

EHR Incentive Registration

The Medicare and Medicaid EHR Incentive Program Registration and Attestation System portal went live today, although not all states are ready for Medicaid registration.

The portal allows eligible hospitals and professionals to register and participate in meeting Stage 1 meaningful use criteria. Participants are being urged to register even if do not have an enrollment record in the Provider Enrollment, Chain and Ownership System (PECOS). They are also urged to register even if their EHR has not yet been certified. A link to the portal can be found at the bottom of this page.

To use the portal, Eligible Professionals (EPs) participants must have an active National Provider Identifier (NPI) and a National Plan and Provider Enumeration System (NPPES) Web user account. EPs will use their NPPES user ID and password to log into the registration system. Eligible Hospitals registering on the system an active NPI is also required. Users working on behalf of an Eligible Hospital must have an Identity and Access Management system Web user account and be associated to an organization NPI to register.

From the portal there is also a link to the CMS website where provides can access user guides for registration and attestation with information about completing modules, a list of EHR technology that is certified for the program, specification sheets with additional information on each meaningful use objective, and other general resources.

https://ehrincentives.cms.gov/hitech/login.action

New Medicare Coverage for Annual Wellness Visits

Starting January 2011, Medicare will add coverage for annual well visits (AWV), not just the Welcome to Medicare visit.

There are two new HCPCS Level II codes: G0438 and G0439. G0438 is an initial visit for annual wellness. G0439 is a subsequent annual wellness visit. Both include a personalized prevention plan of service.

According to CMS, these codes can be billed as incident-to and will be paid using the same relative value units (RVUs) as 99204 (office/outpatient visit, new, $155.23) for the initial AWV and 99214 (office/outpatient visit, est., $99.93) for subsequent AWVs.

2011 HCPCS Level II Released

The Centers for Medicare & Medicaid Services (CMS) posted the 2011 HCPCS Level II files . There are 147 new codes and modifiers and more than 286 codes have been deleted. A new Table of Drugs and Index has also been released.

A quick overview of changes include a large number of G codes and injectables. Additional changes are in the Q temporary section with new flu tracking codes and the addition of pass-through codes. Most of the deleted codes come from the G section.

New Flu codes

There are five new temporary HCPCS codes that became effective Oct 1, 2010 for flu vaccines in persons over three years of age but they will not be recognized by Medicare processing systems until Jan 1 2011, when the code 90658 will no longer be recognized.

Four of the five new temporary influenza vaccine codes identify a specific name brand of vaccine and should be reported accordingly. They are Q2035 (Afluria), Q2036 (Flulaval), Q2037 (Fluvirin), and Q2038 (Fluzone). The fifth code, Q2039 (NOS), is for all other influenza vaccines that do not fall under one of the name brands listed above.

These should be billed in addition to the administration code for the vaccine.

Medicare cuts postponed.

The Senate approved by unanimous consent a bill that will provide a 31-day payment patch to the Medicare sustainable growth rate (SGR) formula. The bill will freeze current rates for services provided through Dec. 31, and temporarily avert a 23 percent cut to physician payments that was slated to take effect on Dec. 1.

While the 31-day fix, if approved, is a step in the right direction, it is only a temporary patch. Physicians still face a 25 percent cut on January 1, 2011.

PECOS

PECOS stands for Medicare’s Internet based Provider Enrollment, Chain and Ownership System. It replaces the paper CMS-855I and 855R forms. The online process has a quicker turn around time for processing. Usually 45 days rather than 60 for the paper applications. PECOS can be used for initial enrollment or to view or change enrollment information. You can now also track your enrollment application through the submission process, which could not be done previously with the paper form. In addition to enrolling and tracking the application, providers can now change, add or reassign benefits and even withdraw from the program through the system. Just like the paper application process, PECOS needs to be updated whenever there is a Reportable Event that affects information on the enrollment record such as ownership, change in address of practice location, licensure, etc. Changes must be reported within 30 days of a reportable event. A full list of Reportable Events can be found at: www.cms.gov/MedicareProviderSupEnroll.

All providers (Individual Physicians and Non-Physician Practioners) need to complete an online application even if they are currently enrolled with Medicare, with the exception of DMEPOS (durable medical equipment, prosthetics, orthotics, and supplies CMS-855S) which will be available later this year.

PECOS uses the same ID’s and passwords that are established when providers apply online to the National Plan and Provider Enumeration System (NPPES) for their NPI’s. Once the application process is completed online, the system generates a two page Certification Statement. Providers will need to sign the original statement (blue ink is recommended) and mail it to their Medicare contractor within seven days.

If providers do not have established User IDs and passwords they can do so at https://nppes.com.hhs.gov/NPPES. If they have forgotten their passwords or User IDs they can retrieve them by contacting the NPI Enumerator at 800.465.3202 or emailing customerservice@npienumerator.com.

CMS had indicated in addition on enrollment requirements for physicians that claims may automatically start rejecting on July 6th, 2010 if the referring or ordering provider was not enrolled. Many providers and provider organizations have voiced their concerns that their revenue may be interrupted by no fault of their own. Additionally many providers have reported issues with using the online system creating delays in their application approval, which prompted CMS announced in June that it was launching a review of PECOS and has moved back the date that providers need to be enrolled to Jan 3, 2011.

Healthcare Reform

House approves 2 bills addressing final healthcare reform bills; legislation returns to Senate
Late Sunday night, the House of Representatives passed two bills, culminating their effort to approve final healthcare reform legislation. Initially, the House passed H.R. 3590, the Patient Protection and Affordable Care Act, the bill approved by the Senate last December. This bill passed by a vote of 219 to 212. The president is expected sign H.R. 3590 into law shortly. Following that vote, the House then passed H.R. 4872, the Health Care and Education Affordability Reconciliation Act of 2010, by a vote of 220 to 211. This legislation modifies the Senate bill (H.R. 3590), and H.R. 4872 serves as the foundation of changes made by Congress to the current healthcare delivery, payment and insurance system. The bills fail to address the pending 21.3 percent cut to Medicare physician payment and the repeal of the sustainable growth rate (SGR) formula. Senate Republicans have stated their intention to offer numerous amendments and raise multiple points of order to the legislation. If the bill is changed in any way prior to Senate approval, it must return to the House for an additional vote before the president can sign it.

President Signs extension of payment freeze

The president signed H.R. 4691, the Temporary Extension Act of 2010 into law. This legislation includes a provision that freezes Medicare physician payments at their current level until March 31, 2010. The bill passed the Senate by a vote of 78 – 19. The House of Representatives had unanimously approved a companion bill by voice vote on Feb. 25.

The Senate is also currently debating H.R. 4213 the American Workers, State, and Business Relief Act of 2010. This legislation extends the freeze on Medicare physician payments until Sept. 30, 2010. It also provides an extension of the geographic practice cost index floor through Dec. 31, 2010. If approved by the Senate, the bill would have to be approved by the House before transmittal to the president.

2010 Medicare Physician Fee Schedule Announcement

Congress was unable to pass legislation that would repeal the 21% paycut going into effect on March 1, 2010. However, CMS believes Congress is working to avoid the negative update. Consequently, they have instructed its contactors to hold claims containing services paid under the MPFS for the first 10 business days of March. The holding of MPFS claims will only affect claims with dates of service March 1, 2010, and forward. This hold should have a minimum impact on provider cash flow because, under current law, clean electronic claims are not paid any sooner than 14 calendar days (29 for paper claims) after the date of receipt. Be on the alert for more information about the 2010 Medicare Physician Fee Schedule Update

Welcome to Medicare

I get asked frequently the requirements to bill a routine physical to Medicare.

Here is the rule: Medicare does not pay for routine physicals. You would not send a claim and you would not have the patient sign an ABN form. Just let the patient know that it is not covered and they need to pay for the services at the time of the visit. If you need a denial to send to a secondary, then you would submit the claim with the modifier GY to indicate that you are sending the claim only to receive the denial.

Now for rule there is an exception. Medicare will cover a "Welcome to Medicare" physical. It is one time only and MUST be within the first six months of becoming eligible for Part B. There are seven components that need to be meet. The reimbursement does not include any clinical labs.

1. A review of the patients medical and social history with attention to modifiable risk factors
2. A review of the patients potential risk for depression
3. A review of the patients functional ability and safety level
4. An exam that includes their height, weight, blood pressure, and visual acuity
5. Performance and interpretation of an EKG
6. Education and or counseling based on the results of the previous five components
7. education, counseling and referral with brief written plan for obtaining the appropriate screenings and/or other Part B preventive services.

The provider (physician, qualified NPP, or hospital) may also provide and bill separately for the screenings. The patient will have a %20 coinsurance and may have to meet a portion if not all of the deductible.

Don't forget to check the LCD and NCD for your specific Medicare carrier.

Welcome

Welcome to PM Billing and Consulting. We are a physician billing and revenue cycle management firm located in Utah. We are members of both the Professional Association of Health Care Office Management (PAHCOM) and the Utah Medical Group Management Association (UMGMA). We are certified professional coders (CPC) through the American Academy of Professional Coders (AAPC) and Certified Endocrine Coders (CEC) through the American Association of Clinical Endocrinologists (AACE).

We currently bill for endocrinology, pediatrics, opthalmology, and family practice.

If you are looking for a full service billing company or just need some advice in a few areas such as charge slip creation or setting fees, we can help.

Check out our full list of services at our website: www.pmmedicalbilling.com

You can email or call us with questions. info@pmmedicalbilling.com or 801.649.6325

We look forward to working with you!