BILLING UPDATES – NOVEMBER 2016

By Tammy Bartlett, Billing Manager

CENTERS FOR MEDICARE AND MEDICAID (CMS)

PQRS PAYMENT ADJUSTMENTS

We have received numerous letters from CMS for our clients that indicate PQRS criteria has not been met and  payment adjustments will occur, reducing Medicare payments by 2% for 2017 dates of service. The payment adjustments are based on services rendered in 2015. We will forward the letters to the applicable clients, as we receive them.

If you received a letter from CMS regarding reduction in payments and believe you have been incorrectly assessed, please review the payment adjustment resources located on the PQRS webpage at:

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Payment-Adjustment-Information.html

As mentioned in previous communications with our providers, Practicefirst recommended to report via a PQRS Qualified Registry.  By utilizing a registry, providers become eligible for measures group reporting, thus decreasing the required number of patients to report on.

As a reminder, due to the increasing requirements of PQRS reporting, Practicefirst no longer provides PQRS reporting services to providers at a reasonable cost.

MVP

MVP issued FASTFAX #50W on October 20, 2016 to the provider community regarding Preventive Visits and Modifier 25. Preventive visits (codes 99381-99397) are payable on the same date of service as a separately identifiable E&M service (i.e. 99213). The E&M would be submitted with modifier 25. The additional services for the E&M must be documented in the medical record and the claim should include both the preventive visit diagnosis code(s) and the relevant condition diagnosis code(s).

If the preventive code is not billed, the visit will not count for the preventive service quality measures (well child, adolescent and adult measures).

For additional information, please visit MVP’s website at http://www.mvphealthcare.com/provider/provider-resource-manual.html, select Section 15 for Payment Policies and then select the Modifier Policy from their bookmarks.

For Billing questions, please contact Tammy Bartlett at 716-348-3923 or tammyb@pracfirst.com

BILLING UPDATES – AUGUST 2016

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BILLING UPDATES – MARCH 2016

by Jackie Lucas, Medical billing Manager

Billing Updates

MEDICARE

Mandatory Payment Reduction of 2% Continues until Further Notice for the Medicare FFS Program – “Sequestration”

Medicare Fee-For-Service (FFS) claims will continue to incur a two percent reduction in Medicare payment until further notice. The claims payment adjustment will continue to be applied to all claims after determining coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments. Though beneficiary payments for deductibles and coinsurance are not subject to the two percent payment reduction, Medicare’s payment to beneficiaries for unassigned claims is subject to the two percent reduction. CMS encourages Medicare physicians, practitioners, and suppliers who bill claims on an unassigned basis to continue discussions with beneficiaries on the impact of sequestration on Medicare’s reimbursement. Questions about reimbursement should be directed to your Medicare Administrative Contractor (http://go.usa.gov/cymuF).

RAILROAD MEDICARE

Railroad Medicare’s (RMC) Medical Review (MR) unit will begin a service-specific review of Evaluation and Management (E/M) CPT code 99285, emergency department visit, requiring highly complex medical decision making. RMC selected this code based on internal data analysis. At the conclusion of this review, they will publish their findings on their website.

UNIVERA

On March 27, 2016 electronic prescribing of all controlled and non-controlled prescriptions (including syringes and medical devices), commonly referred to as e-prescribing will become mandatory for all prescribers in New York State. This regulation is one of the multiple sections of the Internet System for Over-Prescribing Act (I-STOP) program passed in 2012.  Most providers who use an electronic health record (EHR) can easily e-prescribe using the same software.  Those who do not have an EHR system in place will have to purchase an electronic prescribing computer application for one of the various software platforms based on their practice and e-prescribing needs.  For more information on electronic prescribing of controlled substances please visit

http://www.health.ny.gov/professionals/narcotic/electronic_prescribing/

BLUE CROSS

Changes to Performance and Quality Programs

Pay for performance (P4P) 2016—Focus will be on Primary Care Physicians (PCP’s)

  • Only PCP’s will be eligible to participate
  • P4P incentive payments will be contingent on PCP meeting threshold targets
  • The 2016 P4P program includes Medicaid members

The following measures have been added to the program:

  • HEDIS Medication Management for people with Asthma 75% Compliance
  • Measures replaced: HEDIS Appropriate Asthma Medications

The following measures have been eliminated from the program:

  • HEDIS Monitoring Persistent Meds ACE or ARB
  • HEDIS follow-up with 7 days after hospitalization for Mental Illness

For more information about Blue Cross’s 2016 P4P program, log onto bcbswny.com/provider and go to My Account>Reports>pay for performance>2016 P4P.

MEDICAID

In July 2015, we notified you that effective July 1, 2015 Medicaid would no longer reimburse partial Medicare Part B coinsurance amounts (20% of the Part B coinsurance). Medicaid did not implement this change until December 17, 2015. In February, Medicaid began making claim adjustments for dates of service 7/1/15 through their revision date of 12/17/15. Weekly Medicaid EFT’s/checks will be reduced until all of these claims are re-processed.

For Billing questions, please contact Jackie Lucas at 716-348-3923 or jackiel@pracfirst.com

CODING CORNER…FEBRUARY 2016

By Betsy Priest, Coding Manager

ADVANCED CARE PLANNING

Two new codes are available to help capture a patient’s advanced care planning.  These can be used in any setting, regardless of the specialty.

99497: Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.

99498: Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

These codes will be used to capture the time you spend in addition to what is already being done with the patient.  If you have a regular visit with the patient, code that visit with a modifier 25 and then the above codes. If you are only seeing the patient for Advanced Care Planning, you would only use these codes.

These are time based codes.  99497 is for the first 30 minutes of Face to Face time with the patient and the 99498 is for each additional 30 minutes. This is only face to face time with the patient.

The documentation needs to clearly state the total time, that it was face to face, and what was discussed.  (The providers do not need to re-write parts of their note if this information is elsewhere. We need to be able to clearly see what was discussed and that it was advanced care planning).

Reimbursement amounts have not been determined yet. CMS states that in 2016, they will reimburse these services, but no payment amount has been established. This was open for discussion through December 31, 2015 and no final decision regarding the reimbursement amount has been published as of yet.

These services can be performed by physicians as well as mid-levels

If you would like more information about how we can tailor our services to meet your needs, please contact Betsy Priest, Coding Manager at 716.348.3904 or Betsyp@pracfirst.com

CODING CORNER…FEBRUARY 2015

By Lisa Kropp, Coding and Credentialing Manager

2015 DELETED HCPCS CODES:

Below, you will find a listing of all the 2015 deleted HCPCS codes.  Please see your HCPCS books for revisions or additions.  This information will be available to you, upon request.

HCPCS Description Date Deleted
D6053 implant/abutment supported removable denture for completely edentulous arch

1/1/2015

G8552 All quality actions for the applicable measures in the ischemic vascular disease (IVD) measures group have been performed for this patient

1/1/2015

G8547 I intend to report the ischemic vascular disease (IVD) measures group

1/1/2015

G8502 All quality actions for the applicable measures in the back pain measures group have been performed for this patient

1/1/2015

G8501 All quality actions for the applicable measures in the perioperative care measures group have been performed for this patient

1/1/2015

G8492 I intend to report the perioperative care measures group

1/1/2015

G8406 Clinician documented that patient was not an eligible candidate for lower extremity neurological exam measure

1/1/2015

G8128 Clinician documented that patient was not an eligible candidate for antidepressant medication during the entire 12 week acute treatment phase measure

1/1/2015

G8126 Patient with a diagnosis of major depression documented as being treated with antidepressant medication during the entire 84 day (12 week) acute treatment phase

1/1/2015

G0922 No documentation of disease type, anatomic location, and activity, reason not given

1/1/2015

G0920 Type, anatomic location, and activity all documented

1/1/2015

G0919 Influenza immunization ordered or recommended (to be given at alternate location or alternate provider); vaccine not available at time of visit

1/1/2015

G0910 Most recent hemoglobin level <= 12.0 g/dl

1/1/2015

G0909 Hemoglobin level measurement not documented, reason not given

1/1/2015

G0908 Most recent hemoglobin (HgB) level > 12.0 g/dl

1/1/2015

G0461 Immunohistochemistry or immunocytochemistry, per specimen; first single or multiplex antibody stain

1/1/2015

G0457 Negative pressure wound therapy, (e.g. vacuum assisted drainage collection) using a mechanically-powered device, not durable medical equipment, including provision of cartridge and dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area greater than 50 sq cm

1/1/2015

G0456 Negative pressure wound therapy, (e.g. vacuum assisted drainage collection) using a mechanically-powered device, not durable medical equipment, including provision of cartridge and dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area less than or equal to 50 sq cm

1/1/2015

G0419 Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, >60 specimens

1/1/2015

G0418 Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, 41-60 specimens

1/1/2015

G0251 Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment

1/1/2015

G0173 Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session

1/1/2015

C9735 Anoscopy; with directed submucosal injection(s), any substance

1/1/2015

C9135 Factor IX (antihemophilic factor, recombinant), Alprolix, per IU

1/1/2015

C9134 Factor XIII (antihemophilic factor, recombinant), Tretten, per 10 IU

1/1/2015

C9023 Injection, testosterone undecanoate, 1 mg

1/1/2015

C9022 Injection, elosulfase alfa, 1 mg

1/1/2015

C9021 Injection, obinutuzumab, 10 mg

1/1/2015

C1300 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval

1/1/2015

A7042 Implanted pleural catheter, each

1/1/2015

J0150 Injection, adenosine for therapeutic use, 6 mg (not to be used to report any adenosine phosphate compounds, instead use A9270)

1/1/2015

G9272 LDL value >= 100

1/1/2015

G9271 LDL value < 100

1/1/2015

G9253 Adenoma(s) or other neoplasm not detected during screening colonoscopy

1/1/2015

G9252 Adenoma(s) or other neoplasm detected during screening colonoscopy

1/1/2015

G9193 Clinician documented that patient with a diagnosis of major depression was not an eligible candidate for antidepressant medication treatment or patient did not have a diagnosis of major depression

1/1/2015

G8957 Patient not receiving maintenance hemodialysis in an outpatient dialysis facility

1/1/2015

G8932 Suicide risk assessed at the initial evaluation

1/1/2015

G8931 Assessment of depression severity not documented, reason not given

1/1/2015

G8930 Assessment of depression severity at the initial evaluation

1/1/2015

G8780 Counseling for diet and physical activity performed

1/1/2015

G8779 Diabetes screening test not performed, reason not given

1/1/2015

G8464 Clinician documented that prostate cancer patient is not an eligible candidate for adjuvant hormonal therapy; low or intermediate risk of recurrence or risk of recurrence not determined

1/1/2015

G8127 Patient with a diagnosis of major depression not documented as being treated with antidepressant medication during the entire 84 day (12 week) acute treatment phase

1/1/2015

G9248 Patient did not have a medical visit in the last 6 months

1/1/2015

G8892 Documentation of medical reason(s) for not performing LDL-C test (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate)

1/1/2015

D6975 coping

1/1/2015

D6079 implant/abutment supported fixed denture for partially edentulous arch

1/1/2015

D6078 implant/abutment supported fixed denture for completely edentulous arch

1/1/2015

D6054 implant/abutment supported removable denture for partially edentulous arch

1/1/2015

G8579 Antiplatelet medication at discharge

1/1/2015

G8552 All quality actions for the applicable measures in the ischemic vascular disease (IVD) measures group have been performed for this patient

1/1/2015

G8547 I intend to report the ischemic vascular disease (IVD) measures group

1/1/2015

G8502 All quality actions for the applicable measures in the back pain measures group have been performed for this patient

1/1/2015

G8501 All quality actions for the applicable measures in the perioperative care measures group have been performed for this patient

1/1/2015

G8492 I intend to report the perioperative care measures group

1/1/2015

G8406 Clinician documented that patient was not an eligible candidate for lower extremity neurological exam measure

1/1/2015

G8128 Clinician documented that patient was not an eligible candidate for antidepressant medication during the entire 12 week acute treatment phase measure

1/1/2015

G8126 Patient with a diagnosis of major depression documented as being treated with antidepressant medication during the entire 84 day (12 week) acute treatment phase

1/1/2015

G0922 No documentation of disease type, anatomic location, and activity, reason not given

1/1/2015

G0920 Type, anatomic location, and activity all documented

1/1/2015

G0919 Influenza immunization ordered or recommended (to be given at alternate location or alternate provider); vaccine not available at time of visit

1/1/2015

G0910 Most recent hemoglobin level <= 12.0 g/dl

1/1/2015

G0909 Hemoglobin level measurement not documented, reason not given

1/1/2015

G0908 Most recent hemoglobin (HgB) level > 12.0 g/dl

1/1/2015

G0461 Immunohistochemistry or immunocytochemistry, per specimen; first single or multiplex antibody stain

1/1/2015

G0457 Negative pressure wound therapy, (e.g. vacuum assisted drainage collection) using a mechanically-powered device, not durable medical equipment, including provision of cartridge and dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area greater than 50 sq cm

1/1/2015

G0456 Negative pressure wound therapy, (e.g. vacuum assisted drainage collection) using a mechanically-powered device, not durable medical equipment, including provision of cartridge and dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area less than or equal to 50 sq cm

1/1/2015

G0419 Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, >60 specimens

1/1/2015

G0418 Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, 41-60 specimens

1/1/2015

G0251 Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment

1/1/2015

G0173 Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session

1/1/2015

C9735 Anoscopy; with directed submucosal injection(s), any substance

1/1/2015

C9135 Factor IX (antihemophilic factor, recombinant), Alprolix, per IU

1/1/2015

C9134 Factor XIII (antihemophilic factor, recombinant), Tretten, per 10 IU

1/1/2015

C9023 Injection, testosterone undecanoate, 1 mg

1/1/2015

C9022 Injection, elosulfase alfa, 1 mg

1/1/2015

C9021 Injection, obinutuzumab, 10 mg

1/1/2015

C1300 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval

1/1/2015

A7042 Implanted pleural catheter, each

1/1/2015

J0150 Injection, adenosine for therapeutic use, 6 mg (not to be used to report any adenosine phosphate compounds, instead use A9270)

1/1/2015

G9272 LDL value >= 100

1/1/2015

G9271 LDL value < 100

1/1/2015

G9253 Adenoma(s) or other neoplasm not detected during screening colonoscopy

1/1/2015

G9252 Adenoma(s) or other neoplasm detected during screening colonoscopy

1/1/2015

G9193 Clinician documented that patient with a diagnosis of major depression was not an eligible candidate for antidepressant medication treatment or patient did not have a diagnosis of major depression

1/1/2015

G8957 Patient not receiving maintenance hemodialysis in an outpatient dialysis facility

1/1/2015

G8932 Suicide risk assessed at the initial evaluation

1/1/2015

G8931 Assessment of depression severity not documented, reason not given

1/1/2015

G8930 Assessment of depression severity at the initial evaluation

1/1/2015

G8780 Counseling for diet and physical activity performed

1/1/2015

G8779 Diabetes screening test not performed, reason not given

1/1/2015

G8464 Clinician documented that prostate cancer patient is not an eligible candidate for adjuvant hormonal therapy; low or intermediate risk of recurrence or risk of recurrence not determined

1/1/2015

G8127 Patient with a diagnosis of major depression not documented as being treated with antidepressant medication during the entire 84 day (12 week) acute treatment phase

1/1/2015

G9248 Patient did not have a medical visit in the last 6 months

1/1/2015

G8892 Documentation of medical reason(s) for not performing LDL-C test (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate)

1/1/2015

D6975 coping

1/1/2015

D6079 implant/abutment supported fixed denture for partially edentulous arch

1/1/2015

D6078 implant/abutment supported fixed denture for completely edentulous arch

1/1/2015

D6054 implant/abutment supported removable denture for partially edentulous arch

1/1/2015

G8579 Antiplatelet medication at discharge

1/1/2015

G8552 All quality actions for the applicable measures in the ischemic vascular disease (IVD) measures group have been performed for this patient

1/1/2015

G8547 I intend to report the ischemic vascular disease (IVD) measures group

1/1/2015

G8502 All quality actions for the applicable measures in the back pain measures group have been performed for this patient

1/1/2015

G8501 All quality actions for the applicable measures in the perioperative care measures group have been performed for this patient

1/1/2015

G8492 I intend to report the perioperative care measures group

1/1/2015

G8406 Clinician documented that patient was not an eligible candidate for lower extremity neurological exam measure

1/1/2015

G8128 Clinician documented that patient was not an eligible candidate for antidepressant medication during the entire 12 week acute treatment phase measure

1/1/2015

G8126 Patient with a diagnosis of major depression documented as being treated with antidepressant medication during the entire 84 day (12 week) acute treatment phase

1/1/2015

G0922 No documentation of disease type, anatomic location, and activity, reason not given

1/1/2015

G0920 Type, anatomic location, and activity all documented

1/1/2015

G0919 Influenza immunization ordered or recommended (to be given at alternate location or alternate provider); vaccine not available at time of visit

1/1/2015

G0910 Most recent hemoglobin level <= 12.0 g/dl

1/1/2015

G0909 Hemoglobin level measurement not documented, reason not given

1/1/2015

G0908 Most recent hemoglobin (HgB) level > 12.0 g/dl

1/1/2015

G0461 Immunohistochemistry or immunocytochemistry, per specimen; first single or multiplex antibody stain

1/1/2015

G0457 Negative pressure wound therapy, (e.g. vacuum assisted drainage collection) using a mechanically-powered device, not durable medical equipment, including provision of cartridge and dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area greater than 50 sq cm

1/1/2015

G0456 Negative pressure wound therapy, (e.g. vacuum assisted drainage collection) using a mechanically-powered device, not durable medical equipment, including provision of cartridge and dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area less than or equal to 50 sq cm

1/1/2015

G0419 Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, >60 specimens

1/1/2015

G0418 Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, 41-60 specimens

1/1/2015

G0251 Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment

1/1/2015

G0173 Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session

1/1/2015

C9735 Anoscopy; with directed submucosal injection(s), any substance

1/1/2015

C9135 Factor IX (antihemophilic factor, recombinant), Alprolix, per IU

1/1/2015

C9134 Factor XIII (antihemophilic factor, recombinant), Tretten, per 10 IU

1/1/2015

C9023 Injection, testosterone undecanoate, 1 mg

1/1/2015

C9022 Injection, elosulfase alfa, 1 mg

1/1/2015

C9021 Injection, obinutuzumab, 10 mg

1/1/2015

C1300 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval

1/1/2015

A7042 Implanted pleural catheter, each

1/1/2015

J0150 Injection, adenosine for therapeutic use, 6 mg (not to be used to report any adenosine phosphate compounds, instead use A9270)

1/1/2015

G9272 LDL value >= 100

1/1/2015

G9271 LDL value < 100

1/1/2015

G9253 Adenoma(s) or other neoplasm not detected during screening colonoscopy

1/1/2015

G9252 Adenoma(s) or other neoplasm detected during screening colonoscopy

1/1/2015

G9193 Clinician documented that patient with a diagnosis of major depression was not an eligible candidate for antidepressant medication treatment or patient did not have a diagnosis of major depression

1/1/2015

G8957 Patient not receiving maintenance hemodialysis in an outpatient dialysis facility

1/1/2015

G8932 Suicide risk assessed at the initial evaluation

1/1/2015

G8931 Assessment of depression severity not documented, reason not given

1/1/2015

G8930 Assessment of depression severity at the initial evaluation

1/1/2015

G8780 Counseling for diet and physical activity performed

1/1/2015

G8779 Diabetes screening test not performed, reason not given

1/1/2015

G8464 Clinician documented that prostate cancer patient is not an eligible candidate for adjuvant hormonal therapy; low or intermediate risk of recurrence or risk of recurrence not determined

1/1/2015

G8127 Patient with a diagnosis of major depression not documented as being treated with antidepressant medication during the entire 84 day (12 week) acute treatment phase

1/1/2015

G9248 Patient did not have a medical visit in the last 6 months

1/1/2015

G8892 Documentation of medical reason(s) for not performing LDL-C test (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate)

1/1/2015

D6975 coping

1/1/2015

D6079 implant/abutment supported fixed denture for partially edentulous arch

1/1/2015

D6078 implant/abutment supported fixed denture for completely edentulous arch

1/1/2015

D6054 implant/abutment supported removable denture for partially edentulous arch

1/1/2015

G8932 Suicide risk assessed at the initial evaluation

1/1/2015

G8931 Assessment of depression severity not documented, reason not given

1/1/2015

G8930 Assessment of depression severity at the initial evaluation

1/1/2015

G8780 Counseling for diet and physical activity performed

1/1/2015

G8779 Diabetes screening test not performed, reason not given

1/1/2015

G8464 Clinician documented that prostate cancer patient is not an eligible candidate for adjuvant hormonal therapy; low or intermediate risk of recurrence or risk of recurrence not determined

1/1/2015

G8127 Patient with a diagnosis of major depression not documented as being treated with antidepressant medication during the entire 84 day (12 week) acute treatment phase

1/1/2015

G9248 Patient did not have a medical visit in the last 6 months

1/1/2015

G8892 Documentation of medical reason(s) for not performing LDL-C test (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate)

1/1/2015

D6975 coping

1/1/2015

D6079 implant/abutment supported fixed denture for partially edentulous arch

1/1/2015

D6078 implant/abutment supported fixed denture for completely edentulous arch

1/1/2015

D6054 implant/abutment supported removable denture for partially edentulous arch

1/1/2015

If you would like more information about how we can tailor our services to meet your needs, please contact Lisa Kropp; Coding & Credentialing Manager at 716.348.3904 or lisak@pracfirst.com

 

A SIMPLIFIED EXPLANATION OF A MSO – MANAGEMENT SERVICES ORGANIZATION

By Emilie J DiChristina, MBA for Practicefirst

In every practice, regardless of size, operational costs are increasing, capital expenditures (such as those for an EMR) are increasing, human resource costs are increasing, supply costs are increasing, utility costs are increasing, and the providers do not have the time to look for the best deals or negotiate with payers to offset these costs.

What to do? What to do?

One of the ways medical providers (including hospitals and physicians), and many other organizations such as schools, small businesses and not-for-profits are dealing with these challenges are through the development of a MSO – Management Services Organization.

While MSOs are often hospital driven, locally we are seeing a push  to develop MSO which bring together similar specialties, or specialties which will be supportive through a referral base and/or one-stop-shop model. The providers who join the MSO have some degree of financial buy-in either as part of the overall MSO umbrella, or through the purchasing of certain “menu” items such as billing, human resources, payroll, IT, purchasing, etc.

While very large practice may have their own Practice Administrator, their own in-house IT support, compliance personnel, Meaningful Use specialists and HR generalists, most practices do not have the size and scope to offer all those services internally, leaving practices at real risk, Likewise, even the largest practice does not have to bargaining power to achieve hospital sized discounts when purchasing, or negotiate higher rates from third-party payers.

Physician practices are suffering from rising costs and decreasing revenues, and individual practitioners are suffering from a decreased quality of life, particularly if they are trying to be the provider and “chief cook and bottle washer” for the practice.  Increased numbers of physicians are seeking out alliances in droves, looking for help and benefit without giving up their autonomy to practice as they see fit.

So whether seeking to work with other providers of the same specialty, or with a wider range of provider types, the goal is to become more collaborative and more integrated while avoiding any potential regulatory risks (price fixing, anti-trust, inurement, fraud and abuse) and the MSO is generally thought to be the most flexible option. MSOs bring together providers into beneficial alliances without requiring the provider to give up their autonomy.

The way a MSO is set-up (simply described) is to have a management team and an executive director run a business if which the customers (providers buying into the MSO) help define the services which will be provided, the most cost effective way to provide those services, and then to collect fees for those services from the client providers and insure that the services meet the needs of the clients.

For example the MSO usually offers a purchasing department. For a fee, providers who wish to use this centralized purchasing department will receive greater purchasing power when buying the everyday practice items including paper and pens, exam table paper, otoscope tips, and will also have greater power in negotiating for the high ticket items such as capital equipment. The goal is to standardize where possible, negotiate with the greater volume and decrease cost to the client practices.

The whole purpose of an MSO is to offer a specific menu of services made available to practices and structured in a cooperative fashion.  What we are seeing in WNY are MSOs which involve physician equity positions with a stated goal of assistance and guidance without interference.  The physicians are involved in an advisory policy-making capacity, to prioritize efforts and to pick services which will have universal appeal, are apolitical, and offer immediate payback.

The menu of services of an MSO frequently include overall management and consultative practice services, billing and collection, purchasing, equipment and personnel pooling, risk management and human resources/r

BILLING UPDATES – MARCH 2014

By Sarah Howarth, Billing Manager

Exchange Claim Processing

There are four levels of health insurance plans offered by each carrier through the Health Insurance Exchange.   Bronze plans hold the lowest cost with the highest out-of-pocket patient responsibility.  Platinum plans have the highest monthly premium with the lowest out-of-pocket responsibility.  Claim submission and payment processing will be handled the same way as all other insurance claims.  The carrier will follow their standard commercial fee schedule. 

If a patient fails to make their premium payment:

  • 90 day grace period for all carriers.
    • During the first 30 days, claims will be processed as normal.
    • 31-90 days of payment lapse, claims will be suspended (not denied) until premium payment is made.
      • Patients may not be billed for claim balances outside of copay amounts during this time.
    • After 90 days, if the premium payment has not been received, carriers may terminate the patient’s insurance policy and the patient will be held responsible for outstanding claim balances.

 Univera Exchange plans

New members enrolling in Child Health Plus as of January 1, 2014 must enroll through the NYS health plan marketplace.  Although enrollment is completed through the marketplace, the Affordable Care Act rules do not apply to Child Health Plus.  Members will be assigned one ID number per household, patient names will serve as a unique identifier. 

 Independent Health

Last month we notified you that Independent Health will no longer offer MediSource in Niagara County.  In February, IHA was able to obtain the funding to continue to offer MediSource in Niagara County.  Patients have been notified that there are no actions necessary to continue their insurance coverage. 

PQRS REMINDER

Medicare has released the 2014 requirements for PQRS reporting.  To avoid the 2016 payment adjustment, individual providers must report a minimum of 3 measures for at least 50% of eligible Medicare fee for service patients throughout the reporting period.  Providers interested in obtaining the 2014 PQRS payment incentive must report on 9 measures for at least 50% of Medicare fee for service patients throughout the reporting period. The reporting period begins January 1st and ends December 31, 2014.

  • Measure requirements are driven by diagnosis and procedure codes.
  • Providers may opt to report through a 3rd party registry, an EMR or by adding appropriate coding to their claims when billed.
  • Billing clients who select claim reporting must add the appropriate numerator quality-data code to the claim.
  • Providers must meet the requirements of the measure, add the appropriate numerator to the claim and ensure supportive documentation has been completed.

Medicare has a dedicated service line to answer questions specific to PQRS: 1-866-288-8912.

Additional information may be found at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html

Practicefirst will be happy to provide billing clients with the following upon request:

  • Summary of Medicare payments from 2013 to estimate the impact of the 1.5% payment reduction.
  • A report of ICD-9 and CPT codes billed in 2013 for cross-reference with the qualifying requirements of each measure.Additional assistance in determining appropriate measures and claims reporting is available.  Please contact Practicefirst for more information.

 For Billing questions, please contact Sarah Howarth at 716-348-3923 or sarahh@pracfirst.com<

BILLING UPDATES – FEBRUARY 2014

By Sarah Howarth, Billing Manager

IRS INSURANCE COMPANY PAYMENT SUMMARY

PF will aggregate your IRS Form 1099’s through February 15th.  These forms (1099-Misc) represent all of the payments made to you during calendar year 2013.  The IRS matches the aggregate of all 1099’s to the appropriate line of your entity’s tax return, to make sure recipients properly report their income.  In addition, any interest paid on claims is separately reportable on IRS Form 1099-Int.  This information is also matched and it is critical to properly report this income on the correct line of your tax return to avoid IRS scrutiny for under reporting income.

By law, insurance payers should mail them by January 31st.  However, our past experience indicates that they do not comply by the due date and therefore they are not all received until the third week in February.  At that time, we will send them to you by mail or through our courier service.

INDEPENDENT HEALTH

Effective February 28, 2014 Independent Health will no longer offer MediSource in Niagara County.  Patients will be notified of options to continue Medicaid managed care coverage through Fidelis Care New York and United Healthcare of New York.

If a provider does not participate with a patient’s new plan, the following circumstances will allow for reimbursement according to the fee schedule and policies of the new plan:

Patient is currently receiving ongoing care for a serious condition.  The new plan will reimburse you for services up to 60 days after enrollment in the new plan.

If the patient is three or more months’ pregnant as of February 28, 2104, the new plan will reimburse you for treatment of the patient until the baby is born and through post-partum care.

FLU VACCINES

Please notify Practicefirst of any changes to the type of flu vaccine administered at your office.  We will confirm the appropriate CPT code is applied based on the brand, dosage and source of the vaccine.

COLLECTION AGENCY CHANGE

Effective February 1, 2014 HoganWillig will no longer be providing collections services to clients of Practicefirst.  Unless you tell us otherwise, all collection accounts formally placed with HoganWillig will be transitioned to Tice Associates, Inc.  Should you have any questions or concerns regarding this transfer, please contact Practicefirst prior to February 15, 2014.

PQRS

Medicare has released the 2014 requirements for PQRS reporting.  To avoid the 2016 payment adjustment, individual providers must report a minimum of 3 measures for at least 50% of eligible Medicare fee for service patients throughout the reporting period.  Providers interested in obtaining the 2014 PQRS payment incentive must report on 9 measures for at least 50% of Medicare fee for service patients throughout the reporting period. The reporting period begins January 1 and ends December 31, 2014.

  • Measure requirements are driven by diagnosis and procedure codes.
  • Providers may opt to report through a 3rd party registry, an EMR or by adding appropriate coding to their claims when billed.
  • Billing clients who select claim reporting must add the appropriate numerator quality-data code to the claim.
  • Providers must meet the requirements of the measure, add the appropriate numerator to the claim and ensure supportive documentation has been completed.

Medicare has a dedicated service line to answer questions specific to PQRS: 1-866-288-8912.  Additional information may be found at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html

Practicefirst will be happy to provide billing clients with the following upon request:

  • Summary of Medicare payments from 2013 to estimate the impact of the 1.5% payment reduction.
  • A report of ICD-9 and CPT codes billed in 2013 for cross-reference with the qualifying requirements of each measure.

Additional assistance in determining appropriate measures and claims reporting is available.  Please contact Practicefirst for more information.

VERIFYING PATIENT COVERAGE IN A HEALTH INSURANCE MARKETPLACE PLAN

As mentioned in last month’s client memo, it is the beginning of the New Year and you’ll be verifying your patient’s insurance status when they come to your office. With the beginning of the Health Insurance Marketplace, also known as Health Insurance Exchange, over a million people will have a new insurance plan. In many cases, this will be the first time they have had insurance in years.   Many of these people will have signed up for their plan within the past few days. They may not have received their card yet or they may be unaware of the need to carry their insurance information. You may find your office needing to verify their coverage.

How do you verify their coverage?

If the marketplace in your state is run by the Federal government, it is best to call their plan’s customer service line, a list of all plans and their customer service numbers can be found at: https://data.healthcare.gov/dataset/QHP-Customer-Service-Phone-Numbers/vryg-tdzf

A fact sheet can be utilized for using the data base which is located:  http://marketplace.cms.gov/getofficialresources/publications-and-articles/contact-health-plan.pdf

If you can’t find the number, call the Marketplace Call Center (1-800-318-2596).

If your state has its own health insurance exchange, contact your state. To find the website for your state exchange, select the name of your state in the box at the left hand side of the health care website at: https://www.healthcare.gov/marketplace/individual/#state=alaska

How else can you help your patient?

Remind your patients to keep all of their paperwork and receipts from all of their doctor’s appointments and from the pharmacy as well. They may need them for their insurer. Remind them they should carry their card at all times. If they don’t have a card, they can contact their plan to get a card.

If the patient is uninsured, they have until March 31st to sign up for non-employer based coverage. They can go to HealthCare.gov to sign up for a plan and apply for financial assistance. The vast majority of uninsured will qualify for financial assistance to reduce their costs. You can also download copies of various fact sheets or educational material for your patients at: http://marketplace.cms.gov/getofficialresources/publications-and-articles/publications-and-articles.html

AETNA SETTLEMENT

We have received notification of a proposed settlement in a class action lawsuit: In re Aetna UCR Litigation. This lawsuit pertains to providers considered Out-of-Network who provided covered services to Aetna Plan Members and whose resulting claims for reimbursement included partially allowed claims.  Providers may be eligible to receive payment for improper reimbursement.  This settlement may apply to you if you were an Out-of-Network provider from June 3, 2003 through August 20, 2013.  Providers must complete and submit a claim form no later than March 28, 2014.  Providers may opt to make a claim from the General Settlement Fund or from the Provider Settlement Fund.  General Settlement Fund claims are anticipated to result in a payment of less than $40 per year for each year Out-of-Network covered services were provided.  Provider Settlement Fund claims are expected to make payment of up to 5% of the allowed amount for qualifying claims.  Please contact Sarah Howarth for additional information.

For Practicefirst to file a claim on your behalf, you must certify that you have provided Out-Of-Network services to Aetna Plan Member(s). Practicefirst will charge a flat fee of $25.00 for solo physicians and $50.00 for group practices. Please contact Sarah Howarth at Practicefirst by March 1, 2014 to file a claim form on your behalf. As always, you are free to file the claim on your own.  Additionally, if you have received a notice from Aetna, you may forward that to Sarah indicating you would or would not like to be included in this Class Action Lawsuit.

For Billing questions, please contact Sarah Howarth at 716-348-3923 or sarahh@pracfirst.com

BILLING UPDATES – JANUARY 2014

By Sarah Howarth, Billing Manager

CHART RETURNS

Charge slips / Encounters that cannot be submitted to the insurance carrier due to pertinent billing information that is lacking are returned to your office on a weekly basis, as a Chart Return. For PF’s non-PBS Medcode Corp. clients, examples of lacking information can pertain to missing CPT codes, diagnosis codes, modifiers, dates of service, etc. For PF’s PBS Medcode Corp. clients, examples of lacking information can pertain to size of laceration, final diagnosis missing, chart pages missing, etc.

At the end of each month, you will receive a summary of all outstanding Chart Returns. These claims have not been paid or submitted to the insurance carrier. Please keep in mind that any Chart Returns that you have recently addressed may not have been reviewed by our staff yet and subsequently still appear on the month-end Chart Return summary.  

If you do not have an understanding of why the Charge slip / Encounter has been returned to you, please contact us.

UNIVERA

Beginning January 1, 2014, you may begin to see some Univera Healthcare member identification cards bearing the TPA (Third Party Administrator) logo.  Referral and preauthorization requirements for this line of business will be indicated on the back of the ID card.  Please provide Practicefirst with copies of the new insurance cards to ensure claim processing runs smoothly for your practice. 

CENTERS FOR MEDICARE & MEDICAID (CMS)

REMINDERS – MEDICARE EHR INCENTIVE PROGRAM

If you are participating in the Medicare EHR Incentive Program, you must attest to demonstrating meaningful use of the data collected in 2013 by February 28, 2014. 

2014 is the last year to begin participation in the EHR Incentive Program. The first year of participation requires reporting for a continuous 90-day period.  Reporting for following years involves meeting the requirements for the entire calendar year.

PQRS

January 1, 2014 will mark a new reporting period for the Medicare Physician Quality Reporting System. To avoid a payment reduction of 1.5% in 2016, providers must fulfill the reporting requirements for PQRS.  Providers must report on 3 measures or 1-2 measures for at least 50% of Medicare Part B patients seen in 2014. Additional information regarding the requirements for 2014 will be posted on the CMS website by December 31, 2013. 

FINALIZATION TO PHYSICIAN PAYMENT RATES FOR 2014

One of the provisions included in the CY 2014 Physician Fee schedule final rule includes a separate payment for chronic care management services which will begin in 2015.

Primary Care and Chronic Care Management: As part of CMS’s ongoing efforts to appropriately value primary care services, Medicare will begin making a separate payment for chronic care management services beginning in 2015. In last year’s final rule, CMS established separate payment for transitional care management services for a beneficiary making the transition from a facility to the community setting. In this final rule, CMS further emphasized their support for advanced primary care through their establishment of policies to facilitate separate payment for non-face-to-face chronic care management services for Medicare beneficiaries who have multiple (two or more), significant chronic conditions.

Chronic care management services include the development, revision, and implementation of a plan of care; communication with the patient, caregivers, and other treating health professionals and medication management. Medicare beneficiaries with multiple chronic conditions who wish to receive these services can choose a physician or other eligible practitioner from a qualified practice to furnish these services over 30-day periods.

To review the final policy fact sheet, please access:

http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2013-Fact-Sheets-Items/2013-11-27-2.html

VERIFYING PATIENT COVERAGE IN A HEALTH INSURANCE MARKETPLACE PLAN

CMS has issued the following guidance for the Health Insurance Marketplace:

It is the beginning of the New Year and you’ll be verifying your patient’s insurance status when they show up in your office. With the beginning of the Health Insurance Marketplace, also known as Health Insurance Exchange, over a million people will have a new insurance plan. In many cases, this will be the first time they have had insurance in years.   Many of these people will have signed up for their plan within the past few days. They may not have received their card yet or they may be unaware of the need to carry their insurance information. You may find your office needing to verify their coverage.

 How do you verify their coverage?

If the marketplace in your state is run by the Federal government, it is best to call their plan’s customer service line, a list of all plans and their customer service numbers can be found at: https://data.healthcare.gov/dataset/QHP-Customer-Service-Phone-Numbers/vryg-tdzf

 A fact sheet can be utilized for using the data base which is located:  http://marketplace.cms.gov/getofficialresources/publications-and-articles/contact-health-plan.pdf

If you can’t find the number, call the Marketplace Call Center (1-800-318-2596).

If your state has its own health insurance exchange, contact your state. To find the website for your state exchange, select the name of your state in the box at the left hand side of the health care website at:

https://www.healthcare.gov/marketplace/individual/#state=alaska

How else can you help your patient?

Remind your patients to keep all of their paperwork and receipts from all of their doctor’s appointments and from the pharmacy as well. They may need them for their insurer. Remind them they should carry their card at all times. If they don’t have a card, they can contact their plan to get a card.

 If the patient is uninsured, they have until March 31st to sign up for non-employer based coverage. They can go to HealthCare.gov to sign up for a plan and apply for financial assistance. The vast majority of uninsured will qualify for financial assistance to reduce their costs. You can also download copies of various fact sheets or educational material for your patients at: http://marketplace.cms.gov/getofficialresources/publications-and-articles/publications-and-articles.html

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COMPLIANCE UPDATES MAY 2013

By Becky Amann, Compliance and Training Manager

COMPLIANCE WITH N.Y.S. DOH (Dept. of Health)

As a reminder, we notified you in April that Blue Cross issued a STAT Bulletin dated March 8, 2013, regarding Compliance to the NYSDOH Access and Availability requirements for their Medicaid Managed Care and Family Health Plus plans. NYSDOH indicated that many Blue Cross providers are not in compliance with the guidelines required by NYS Medicaid standards. If your practice does not comply, Blue Cross will be forced to apply monetary sanctions.

Please review the attached STAT regarding this compliance requirement. The bulletin can also be accessed via Blue Cross’s website at the link below. Please refer to Issue 3 – “Update your information for Access and Availability Standards”.

https://securews.bcbswny.com/web/content/BCBSWNY_provider/home/news—events/provider-bulletins/2013.html

 PHYSICIAN DELEGATION OF TASKS IN NURSING FACILITIES (NF’s)  AND SKILLED NURSING FACILITIES (SNF’s)

CMS published MLN article SE1308 to provide clarification of Federal guidance regarding the Affordable Care Act as it relates to physician delegation of certain tasks in SNF’s and NF’s to nurse practitioners, physician assistants or clinical nurse specialists referred to as NPP’s.

Requirements for long-term care facilities indicate that a physician may not delegate a task when the regulations specify that the physician must perform it personally. Regulations also indicate the delegation of tasks may be prohibited under State law or by the facility’s own policies.

If you employ an NPP who provides services at a SNF or NF, please review this article on CMS’s website to determine which tasks may be delegated. The article can be accessed at:

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1308.pdf

ELECTRONIC HEALTH RECORD (EHR) AUDITS

All eligible professionals attesting to receive an incentive payment for either the Medicare or Medicaid EHR Incentive Program may be subject to an audit. CMS performs pre- and post-payment audits on Medicare and dually-eligible (Medicare and Medicaid) providers who participate in the EHR Incentive Program. States perform audits on Medicaid providers participating in the Medicaid EHR Incentive Program.

For more information regarding these audits, please access CMS’s website below and scroll down to “What Providers Need to Know about EHR Audits”.

http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-04-11-Enews.pdf

MEDICARE QUARTERLY PROVIDER COMPLIANCE NEWSLETTER

The Medicare Quarterly Provider Compliance newsletter Volume 3, Issue 3 has been released. This educational tool is designed to provide education on how to avoid common billing errors and other erroneous activities when dealing with the Medicare Program. It includes information on corrective actions that health care professionals can use to address and avoid the top issues of the particular quarter.

This issue of the newsletter includes:  COMPREHENSIVE ERROR RATE TESTING (CERT) FINDINGS such as:

Split/Shared Evaluation & Management Services – Provider Types affected: Physicians and Non-Physician Practitioners

(A Split/Shared service is an encounter in which a physician and an NPP, such as a Nurse Practitioner (NP), Physician Assistant (PA), Clinical Nurse Specialist (CNS), or Certified Nurse-Midwife (CNM) each personally perform a portion of an E&M visit.)

  • The CERT Findings for Split/Shared services included insufficient documentation for CPT codes 99223 and 99211.
  • Recent CERT findings for insufficient documentation for 99223 included – The billing physician’s clinical documentation which supported the face-to-face evaluation and involvement in the E & M service billed was missing. Documentation from a follow-up call included a progress note written by the NPP and signed by the billing physician. The reviewer was unable to determine the physician’s involvement, other than signing the note.
  • Recent CERT findings for insufficient documentation for 99211  – An office visit note was not present to support that an evaluation and management service was performed. The documentation submitted for review included only laboratory results.
  • The two split/shared E & M CERT findings above, illustrate the importance of medical record documentation to support the proper E & M code.

To obtain guidance on how providers can avoid these problems, please review the newsletter at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN908625.pdf

For Compliance questions, please contact Becky Amann at 716-348-3902 or beckya@pracfirst.com