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.