Medicare Fees for January –
February 2010 Posted to Highmark Medicare Services Web Site
Medicare Announces New
Non-Covered Modifiers for ABN Usage
Physicians Get Direction on
Earning EHR-Adoption Bonus
Reminder on Ordering/Referring Physician
PECOS Mandate
Medicare Fees for
January – February 2010 Posted to Highmark Medicare Services
Web Site
The fees that are now posted on the Highmark Medicare Services
(HMS) web site are the correct fees to use during January and
February 2010.
These fees were 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 by HMS will be
paid using these fees for dates of service January 1, 2010
through February 28, 2010.
They reflect the consultation policy change and other increases
in the practice expenses for certain other services. In
addition, this temporary calculation is based on the 2009
Conversion Factor and will be in play until February 28, 2010 or
until Congress makes any additional changes.
To download a copy in PDF, Excel, or Text format, go to the link
below and click on the appropriate links under “2010 January 1 -
February 28 - New Jersey Fee Schedule”.
https://www.highmarkmedicareservices.com/partb/reimbursement/feedb-2010.html
Medicare Announces New
Non-Covered Modifiers for ABN Usage
CMS has announced plans to update the ABN modifiers effective
April 1, 2010.
Modifier GA should be used for items or services that may be
denied as not reasonable or necessary and has been revised to
read, “Waiver of liability statement issued as required by payer
policy.” You’ll use this when a required ABN was issued as
dictated by instructions in an LCD.
The Advanced Beneficiary Notice (ABN) and the GA modifier must
be used each time a procedure or service is provided. An example
would be when a test is performed more often than the Local
Coverage Determination (LCD) policy allows or a diagnosis is not
on a Covered Indications list for a given procedure.
Modifier GX — GX is a new modifier and has been created with the
definition “Notice of Liability Issued, Voluntary under Payer
Policy” which should be used to report when a voluntary
ABN was issued for a service.
Modifier GX should be used when you expect that the item or
service will be denied because it is program exclusion or does
not meet the definition of any Medicare benefit such as
refraction, cosmetic surgery, or a personal comfort item.
No Medicare ABN is needed. You add the GX modifier when
submitting a claim at the patient’s request, since the patient
needs the Medicare denial before submitting a claim to a
secondary insurance.
You may use the –GX modifier to provide beneficiaries with
voluntary notice of liability regarding services excluded from
Medicare coverage by statute, and in these cases, you may report
it on the same line as certain other liability-related
modifiers. Please note that the –GX modifier must be submitted
with non-covered charges only, and your FI or A/B MAC will deny
the claim as a beneficiary liability.
Please note that you don’t have to issue an ABN and submit the
claim to your carrier with a modifier appended for services that
are statutorily non-covered or program exclusions such as
refraction and routine exams under Medicare.
To read more, see the MLN Matters article at:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6563.pdf
Physicians Get Direction
on Earning EHR-Adoption Bonus
The Department of Health and Human Services (HHS) recently
released an interim and proposed rule on its electronic health
record (EHR) incentive program, and the initial set of EHR
technology standards and certification criteria. Beginning in
2011, physicians can earn up to $44,000 in incentives for
demonstrating “meaningful use” of certified EHR systems as
outlined at the link here.
See Table 1 – Page 12 -
http://edocket.access.gpo.gov/2010/pdf/E9-31217.pdf
In order to receive the incentive, a provider has to
demonstrate meaningful use of a certified EHR:
Meaningful use will be defined in three stages through
rulemaking: stage 1 starts in 2011, stage 2 in 2013 and stage 3
in 2015. Stages 2 and 3 will be defined in future CMS
rulemaking. In order to qualify for the incentive during
stage 1 (see link below), a provider’s certified EHR must
See Table 2 – Page 25 -
http://edocket.access.gpo.gov/2010/pdf/E9-31217.pdf
Providers will have to attest that they use certified EHR
technology to report on a core set of measures and a subset of
clinical measures most appropriate to their specialty.
Those who do not adopt and become “meaningful users” by 2015
face financial penalties in 2016.
Reminder on Ordering/Referring
Physician PECOS Mandate
Physicians are reminded that effective April 2010, the
Ordering/Referring Physician PECOS mandate goes into effect and
claims will begin to be denied as per the following scenarios.
-
During
Phase 2, (April 5, 2010 and thereafter): If the billed
item or service requires an ordering/referring provider and
the ordering/referring provider is not in the claim, the
claim will not be paid. It will be rejected. If the
ordering/referring provider is on the claim, Medicare will
verify that the ordering/referring provider is in PECOS and
eligible to order and refer. If the ordering/referring
provider is not in PECOS, the carrier or Part B MAC will
search its claims system for the ordering/referring
provider. 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. If the ordering/referring provider is
in PECOS or the claims system but is not of the specialty to
order or refer, the claim will not be paid. It will be
rejected.
-
In both
phases, Medicare will verify the NPI and the name of the
ordering/referring provider reported in the claim against
PECOS or, if the ordering/referring provider is not in
PECOS, against the claims system. In paper claims, be sure
not to use periods or commas within the name of the
ordering/referring provider. Hyphenated names are
permissible.
-
Providers who
order or refer may want to verify their enrollment in
PECOS as Medicare may already have entered your enrollment
information into PECOS if you made any changes to your
enrollment information over the last 6 years. They may do so
by accessing the Internet-based PECOS web site at:
https://pecos.cms.hhs.gov/pecos/login.do
If
you have made NO changes to your enrollment information
over the last 6 years, you may not be in the PECOS system but
may want to set up a record on a going forward basis as any
future changes can then be done on-line instead of through the
cumbersome paper application process.
Before using Internet-based PECOS, providers should read the
educational material about Internet-based PECOS that is
available at the link here:
http://www.cms.hhs.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS.asp
Once at that site, scroll to the downloads section of that page
and click on the materials that apply to you and your practice.
For guidance on this issue, contact us through the Third Party
Insurance Help Program.
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