Update to Medicare “Claims Hold”
for Services Paid Under the 2010 Medicare Physician Fee Schedule
CMS Revises Consultation
Policy and Issues New In-Patient & Nursing Home “Admissions”
Modifier to Mitigate Consultation Policy Change
Attention: Emblem Health
Participants – Policy Requests
CMS Announces Delay in Denial
Phase of Ordering/Referring Physician PECOS Requirement
Empire Blue Cross Blue Shield
Now Offering Free FWA Training
Important
Information about Accessing 2007 Re-Run and 2008 Physician
Quality Reporting Initiative (PQRI) Feedback Reports
Final Measure
Specifications for 2010 PQRI Released
CMS Releases Final Measure
Specifications for 2010 E-Prescribing Incentive
2010 Medicare Deductible and Premiums
United Healthcare
Announces Consultation Policy Update
Highmark Medicare Provides
New PC-ACE Pro32 Electronic Mailing List
Update to Medicare
“Claims Hold” for Services Paid Under the 2010 Medicare
Physician Fee Schedule
As we have previously reported, CMS has instructed all Medicare
Administrative Contractors (MACS) to hold Medicare claims for
the first 10 business days of January (January 1 through January
15) for 2010 dates of service. This should have minimum impact
on your cash flow because, under the payment floor rules, clean
electronic claims are not paid any sooner than 14 calendar days
(29 days for paper claims) after the date of receipt anyway.
Meanwhile, all claims for services delivered on or before
December 31, 2009, will be processed and paid under normal
procedures.
After 10 business days, contractors will begin releasing held
claims into processing under whatever fee schedule which
implements current law.
Current law is that the fees will be recalculated using the 2009
Conversion Factor, since the President signed the Medicare
freeze into law on December 21, 2009. Therefore, claims
released after January 15, 2010 will be paid using the 2009
Conversion Factor calculation methodology for dates of
service January 1, 2010 through February 28, 2010.
BUT—This does not mean that for January 1-February 28
claims, you should bill using the old 2009 fee schedule!
Here’s why: Only the conversion factor calculation was frozen.
There is no freeze on certain other changes, including the
consultation policy change and increases in the practice
expenses for certain services. Therefore, the “old” 2009 fee
schedules still have to be recalculated. The Medicare
Administrative Contractor (MAC) is expected to have the fee
schedules revised and posted to their web sites no later than
January 19, 2010.
We repeat: DO NOT bill using the old 2009 fee schedule.
That schedule does not reflect the updates in the practice
expenses for 2010. To the extent possible, it is recommended
that you hold claims until (1) the revised fee schedules are
posted, or (2) it becomes clearer whether or not any other
legislation is going to be enacted, or (3) until your cash flow
becomes problematic.
Note too that holding your claims allows the MAC time to receive
the new, updated payment files and perform necessary testing
before they start paying claims at the new rates. They really
need this time. As you know, Medicare pays the physicians the
lesser of the actual charge on the claim form or the fee
schedule amount—whichever is lower. So if the contractors are
NOT able to load the correct fees into their claims processing
system and you submit a claim with a date of service in January
2010, the following is likely to occur:
-
Physicians who
submit charges that are greater than the presently incorrect
2010 fee schedule amount will automatically have their
claims reprocessed.
-
Physicians who
submit charges that are equal to or less than the presently
incorrect 2010 fee schedule amount will need to request an
adjustment. (Submitted charges on claims cannot be altered
without a request from the physician/physician.)
Again, it is best to hold your claims!
As
more information becomes available, we will keep you posted.
Please understand that your patience has been very much
appreciated as this barrage of information continues. As in past
years, it will eventually settle down.
For guidance on this issue, contact us through the Third Party
Insurance Help Program.
CMS Revises Consultation
Policy and Issues New In-Patient & Nursing Home “Admissions”
Modifier to Mitigate Consultation Policy Change
Effective for services furnished on or after January 1, 2010,
instead of coding a consultation, physicians should code a
patient evaluation and management visit, using an E/M code that
represents where the visit occurs and identifies the complexity
or code level of the visit performed.
If a patient is referred to you for what would have been an
office consultation and this is the first time you have seen the
patient (a new patient), you may submit an Initial Visit.
Keep in mind, however, the parameters that classify a "new
patient" to mean a patient who has not received any professional
services from the physician within the previous 3 years. That is
if the patient has been seen in an Initial Visit setting within
the past 3 years, the visit must be coded as an established
patient visit depending on the documentation.
Please note these important points:
-
Documentation: You should continue to follow appropriate
documentation standards: (1) Physicians making a referral
and physicians accepting a referral should document the
request to provide an evaluation of the patient. (2) The
physician who has accepted the referral should communicate
the results of the evaluation to the requesting physician.
-
New
Modifier for Inpatient/nursing home admissions: As you
know, in the past, only the admitting physician has reported
initial hospital care codes (99221-99223) and specialists
who saw the patient separately often billed inpatient
consult codes. But now, as consult codes will no longer be
recognized, the following will apply. If you are the
“principal physician of record” (the physician who oversees
the patient’s care, as opposed to other physicians who
furnish specialty care), you should append modifier AI to
the E/M code. For example, you should append modifier AI to
the initial visit code when you first admit the patient to
the hospital or nursing home. If you are not the principal
physician of record—e.g., if you are just providing
specialty care once the patient has been admitted—do not use
modifier AI when you perform your own initial evaluation on
the patient. Just bill the E/M code for the complexity
level performed.
In summary, and
in the inpatient hospital setting and nursing facility setting,
any physician who performs an initial evaluation may bill an
initial hospital care visit code (CPT code 99221 – 99223) or
nursing facility care visit code (CPT 99304 – 99306), where
appropriate.
Please be aware that organized medicine is still actively
lobbying CMS to postpone this change; we will keep you apprised
as the situation develops. For guidance on this issue, contact
us through the Third Party Insurance Help program.
In
addition, there is a detailed MedLearn Matters article on the
CMS website at:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6740.pdf
Attention: Emblem Health
Participants – Policy Requests
Recent reports from the membership have indicated that requests
for policy documents from Emblem Health are going unanswered.
Please keep in mind that most of their policy is on their web
sites in the protected areas subject to User Name and Password
access. In addition, and in order to request these documents,
you must be a participant.
That being said, many members have indicated that this carrier
is reluctant to provide the appropriate material to ensure that
claims are coded correctly for proper payment.
It is recommended that if your office requires a policy document
that is not available via their web site that a letter be sent
to this carrier under Return Receipt Requested.
Insist that the policy be sent to you in writing as there
have been reports that the Provider Relations staff is calling
physicians and providing verbal policy clarifications ONLY. As
you can surmise, a verbal confirmation from any third party
insurer is not proof.
CMS Announces Delay in Denial
Phase of Ordering/Referring Physician PECOS Requirement
As
reported previously, Medicare was planning on implementing a
policy requiring physicians who order or refer services to be
enrolled in the Provider Enrollment, Chain and Ownership System
(PECOS) database.
If
they were not enrolled in PECOS, then the claims would deny
starting January 2010.
However, the Center for Medicare and Medicaid Services (CMS)
has announced that Phase 2 or the claim denial phase of this
mandate is delayed until April 5, 2010.
Physicians will continue to receive “educational reminders” on
this impending policy change until such time as it is fully
implemented in April 2010.
In
the meantime, physicians are still urged to check their status
as it relates to this impending policy based on the following
criteria.
-
If you are
already enrolled in Medicare, make sure you have a current
enrollment record. You can find out if you have an
enrollment record in PECOS by calling your designated A/B
Medicare Administrative Contractor (MAC) or by going
on-line, using Internet-based PECOS, to view your enrollment
record. PECOS is at the link here:
https://pecos.cms.hhs.gov/pecos/login.do
-
If you are not
enrolled in the Medicare program, or if you enrolled more
than 6 years ago and have not submitted any updates or
changes to your enrollment information in more than 6 years,
you do not have an enrollment record in PECOS!
In
order to continue to order or refer items or services for
Medicare beneficiaries, you will have to submit an initial
enrollment application.
You may do so either by (1) using Internet-based PECOS (which
transmits your enrollment application to the Medicare carrier or
A/B MAC via the Internet—be sure to mail the signed and dated
Certification Statement to the carrier or A/B MAC immediately
after submitting the application), or (2) filling out the
appropriate paper Medicare provider enrollment application(s)
(CMS-855I and CMS-855R, if appropriate) and mailing the
application, along with any required additional supplemental
documentation, to the local Medicare carrier or A/B MAC, who
will enter your information into PECOS and process your
enrollment application.
For guidance on this issue, contact us through the Third Party
Insurance Help Program.
Empire Blue Cross Blue
Shield Now Offering Free FWA Training
As reported previously, you may have received a letter from
Empire Blue Cross Blue Shield (EBCBS) stating that panel
physician’s “must” take a Fraud, Waste, and Abuse training (FWA)
class at their own expense and complete this training by
December 31, 2009 and annually thereafter.
By way of background, this is a CMS requirement that states that
FWA Training is mandatory for those healthcare providers who
have contracts with or participate with Medicare Advantage Plans
or MAOs. Note that Empire is not the only carrier you’ll hear
from on this issue; eventually you will probably receive similar
letters from other MAOs (carriers that market Medicare Advantage
Plans). This is a national effort, spurred by CMS.
The main concern with this mandate was the cost associated with
taking this training as it was another out of pocket expense
borne solely by the physician.
Empire Blue Cross Blue Shield is now offering this training
free of charge and physicians are urged to take advantage of
this by year end.
Go to the link here.
http://www.empireblue.com/home-providers.html
Then scroll down and under “Spotlight” click on the article
entitled “REQUIRED ANNUAL TRAINING: Medicare Advantage and Part
D Compliance Training for Providers”.
The download a copy of the Adobe file entitled “Downstate” or
“Upstate” under Region and see the last paragraph in this
document that shows you how to access the free training offered
by EBCBS.
With that said the EBCBS package is not New Jersey specific but
until such time as other MCOs in the state provide this
information, the information in the article here should be
sufficient for now.
United Healthcare (UHC) has a training package that is available
from their web site as well and impacts many New Jersey plans.
It can be accessed at the link here.
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools
and Resources/Training &
Education/Medicare_FraudWasteAbuse_Training.pdf
But, however you get the training, note that the plans that
contact you must receive confirmation that training was
completed by December 31, 2009.
For guidance on this issue, contact us through the Third Party
Insurance Help Program.
Important
Information about Accessing 2007 Re-Run and 2008 Physician
Quality Reporting Initiative (PQRI) Feedback Reports
The Centers for Medicare & Medicaid Services (CMS) would like to
remind Physician Quality Reporting Initiative (PQRI)
participants that there is a “Verify Report Portlet” look-up
tool available on the PQRI Portal for Eligible Professionals
(EPs) to verify if a 2007 re-run and/or 2008 PQRI feedback
report exists for your organization's Tax Identification Number
(TIN) or National Provider Identifier (NPI).
For more information, go to the link here.
Highmark Medicare Services
https://www.qualitynet.org/portal/server.pt
Final Measure
Specifications for 2010 PQRI Released
The Center for Medicare & Medicaid Services (CMS) has released
information relative to a number of changes to the 2010
Physician Quality Reporting Initiative (PQRI). Physicians should
be aware that:
-
Consultation
codes are no longer applicable numerator codes, due to the
fact that they will no longer be recognized by Medicare in
2010.
-
There are also
two reporting options in 2010. Physicians can either report
for the full year (Jan. 1 to Dec. 31) or a half year (July 1
to Dec. 31). If you report the half year, your incentive
will only be calculated from revenues in that reporting
timeframe.
To
review the 2010 Quality Measures, go to the link here and then
click on Measures/Codes on the left hand side menu:
CMS PQRI Page
CMS Releases Final Measure
Specifications for 2010 E-Prescribing Incentive
Physicians will only have to report the measure 25 times for
applicable patient encounters (E&M or eye visit codes) during
the 12-month reporting period (Jan. 1 to Dec. 31).
There is also only one G-code to report that a physician is
e-prescribing.
In 2010, use only G8553: At least one prescription created
during the encounter was generated and transmitted
electronically using a qualified eRx system.
AMA
http://www.ama-assn.org/ama/pub/eprescribing/home.shtml
2010 Medicare Deductible and
Premiums
The Medicare Part B deductible increases from $135 to $155 on
January 1, 2010.
In
addition, the 2010 Part B premium remains unchanged for most
(approximately 73%) Medicare beneficiaries and will continue to
be $96.40 a month. Approximately twenty seven percent (27%) of
Medicare beneficiaries will see an increase to their
premiums. They include:
1.
New enrollees during the year
2. Beneficiaries subject to the income-related additional
premium
3. Beneficiaries who do not have their Part B premiums withheld
from social security benefit payments, including dual-eligible
Medicare/ Medicaid beneficiaries
The increased premium for those who do not qualify for the
“hold-harmless” provision will increase to $110.50, or greater
for those with higher incomes.
Medicare beneficiaries with taxable income greater than $85,000
for an individual or $170,000 for a couple will pay higher
Medicare Part B premiums between $110.50 monthly to $353.60
monthly depending on income reported on their tax returns.
United Healthcare
Announces Consultation Policy Update
As reported previously, and effective January 1, 2010, the
Centers for Medicare and Medicaid
Services (CMS) is eliminating the use of Evaluation and
Management (E&M)
Consultation CPT Codes (99241-99255) for its Medicare providers
and requiring them to bill the most appropriate office visit or
hospital inpatient CPT codes (99201- 99215 and/or
99221-99239).
Many physicians were concerned that the managed care community
would enact the same inequitable policies as the federal
government.
However, United Healthcare has announced that there will be no
change in reimbursement for
CPT codes 99241-99245 and 99251-99255 for their commercial plans
at this time.
Physicians may continue to submit claims for these services, and
will be reimbursed according to United Healthcare payment
policies.
For United Healthcare Medicare Solutions, including Secure
Horizons, AARP, Medicare Complete, Evercare, and AmeriChoice
Medicare Advantage benefit plans, these plans will follow CMS
regulations and implement the change, effective January 1, 2010.
The change also includes the revalued relative-value units (RVUs)
for E&M CPT codes and a new coding edit, consistent with CMS, to
deny the CPT consult code as a non-covered service.
For AmeriChoice Medicaid plans that follow Medicare rules for
their fee schedules, AmeriChoice will be aligning with CMS rules
and implement the change effective January 1, 2010.
For all other Medicaid states, AmeriChoice will follow the
United Healthcare commercial position and continue to pay for
the consult codes, until directed otherwise by a state to pursue
other strategies.
Highmark Medicare Provides
New PC-ACE Pro32 Electronic Mailing List
Highmark Medicare Services (HMS) has announced that all PC-ACE
Pro32 upgrade notifications are going paperless!
All future PC-ACE Pro32 upgrade notifications will only be sent
via e-mail and posted on the Highmark Medicare Services Web
site:
www.highmarkmedicareservices.com
The e-mail notifications will go to all customers on the new
PC-ACE Pro32 electronic mailing list.
Beginning with the January 2010 upgrade, you will no longer
receive upgrade notification letters. You must be signed up for
the PC-ACE Pro32 electronic mailing list to receive the upgrade
information via e-mail notification.
This is a new
electronic mailing list. Signing up is necessary even if you are
currently receiving some e-mail notifications from Highmark
Medicare Services.
To
subscribe, go to Highmark Medicare Services’ E-mail Lists at:
https://www.highmarkmedicareservices.com/mailinglists.html
Click the “Part A & B PC-ACE Pro32 Users” box, type your e-mail
address in the required field and click “Subscribe.”
It
is a CMS requirement that you to use the most current version of
the software program and to eliminate the use of prior versions
within 90 days of receipt of the upgrade notification.
Therefore, it is very important that you subscribe to the PC-ACE
Pro32 mailing list as soon as possible.
To
save time and resources, the Internet download is the
recommended method of installing and upgrading the PC-ACE Pro32
software program. In order to reduce costs, HMS has asked that
you contact them at 1-866-488-0546 if you are no longer using
the PC-ACE Pro32 CD-ROM. Please sign up to join this new
electronic mailing list today.
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