By Emilie J DiChristina, MBA for Practicefirst

To many the requirement for quality measures adds just one more layer to the complex nature of providing health care.

The question is…Why? I mean do any health care providers wake up in the morning planning to provide sub-standard care? Of course not!

It is just seems to be a bit too much, particularly for older physicians and those facing higher costs and decreased revenues.

If we look at it from perspective of health care costs and the cost to the insurance carrier, the requirement to tie some financial conditions to  quality seems to be late in coming.  In 2009 the estimated waste in health care spending was somewhere between $600 – $850 Billion dollars as published by Thomas Reuters, Analytics in Healthcare.

By far, the majority of the waste was tied to unnecessary care, uncoordinated care, and avoidable care. IF an increased focus on quality can reduce the waste, it is surely worth putting a financial incentive on the effort. The key is to find out how to meet the quality incentives without breaking the bank (or the provider’s back) to do so.

If we examine the statistics propagated by the CMS, Office of the Actuary, National Health Statistics Group, we can see why the emphasis for saving money through quality initiatives lands pretty squarely on the shoulders of the provider. Of the more than $2.3 TRILLION spent for health care, hospital, nursing home and medical provider payments account for 58% of the expenditures – further illustrating the role of the provider in providing quality and efficiency for overall lower costs.

Why the provider? It is the provider who has the “power of the pen”, and whether the quality issues arise in the hospitals (31% of health care expenditures), the provider’s office ( 21% of expenditures) or the nursing home (6% of expenditures)– it is the physician who writes the referrals, the prescriptions, the orders, and provides the information to the clients as to why and how their health can improve.

When physicians and health care providers look to the quality indicators being offered by CMS, as well as those being promulgated by the private insurance carriers, it can make the job of meeting the incentives seem even more daunting particularly for those in primary care. Are you going to choose to focus on smoking cessation, asthma management, diabetic care, something else?

Where will you get the biggest bang for your buck and help the most patients at the same time? You have to know your practice health demographics, and like I said in primary care this leads to a lot of choices. If you are a Radiologist, the choices for quality measures are less, and less onerous to achieve.

Step # one should be to first evaluate diseases or conditions result in the majority of the visits to your practice, or of those conditions for which you most often provide care in a hospital or nursing facility.

The following list is an estimate of the 10 most expensive diseases as calculated by Charles Roehrig, health economist at the Altarum Institute in Ann Arbor, Michigan, based on 2005 data

  • # 1 Mental Health Disorders @ $142.2 Billion and an annual growth rate of 6%
  • # 2 Heart Disease @ $123.1 Billion and an annual growth rate of 5%
  • # 3 Trauma @ $100.2 Billion and an annual growth rate of 6%
  • # 4 Cancer @ $99.4 Billion and an annual growth rate of 7%
  • # 5 Pulmonary Problems @ $64.6 Billion and an annual growth rate of 6%
  • # 6 Hypertension @ $ 50.2 Billion and an annual growth rate of 9%
  • # 7 Osteoarthritis @ $48 Billion and an annual growth rate of 9%
  • # 8 Back Problems @ $40.1 Billion and an annual growth rate of 9%
  • # 9 Kidney Disease @ $35.9 Billion and an annual growth rate of 13%
  • #10 Diabetes @ $35.8 Billion and an annual growth rate of 8%

Using these diseases, look at the rates in which they occur or are seen in your population – those are of course the conditions which you should choose for your PQRI/PQRS quality measures, and for which you should be willing to work with your affiliated hospitals and nursing homes.

Not surprisingly, the diseases listed above are where the private payors have placed their emphasis, so the next step is to find ways to address the quality measures without adding extra expenses to your practice and without introducing inefficiencies such as tying up FTE’s to perform cumbersome data mining.

In Part Two (see April 2012 Edition), we will look at ways to meet indicators and possibly even lower costs and introduce efficiencies while doing so. If you have an immediate need, please contact Practicefirst at tomm@pracfirst.com to request a con


 By: Lisa Kropp, Practicefirst Coding and Credentialing Manager

 What’s an LCD (Local Coverage Determination)?

An LCD is a document published by Medicare Contractors (NGS); that details which conditions or DIAGNOSIS codes support medical necessity for a service or procedure.

They specify under what clinical circumstances a service is considered to be reasonable and necessary.

What’s an NCD (National Coverage Determination)?

NCD’s are developed by CMS to describe the circumstances for which Medicare will cover specific services, procedures, or technologies on a national basis. Often, NCD’s are clarified by the creation of an LCD (at the local contractor level).

How to Use LCD’s and NCD’s

  • Always use the LCD first, if there is one published.
  • In absence of an LCD, you must use the NCD.
  • If neither an LCD nor an NCD have been published relating to specific procedure or service; medical necessity remains the overarching criterion; but there is no determination you have to check prior to claim submission.

What happens when an LCD is Retired?

  • LCD’s are retired as of a specific date.
  • Claims submitted for dates of service after the retirement date will no longer be adjudicated according to the LCD requirements on a pre-pay basis.
  • Claims can still be subject to a post-pay review.
  • If an LCD is retired, and an NCD is active, follow the NCD.
  • You MAY refer to retired LCD’s for guidance, but it’s important to note that diagnosis lists won’t be updated or expanded.

Where can I find LCD’s & NCD’s?


By Becky Amann, Practicefirst Compliance and Training Manager


The E-Prescribing Medicaid incentive payment for fourth quarter 2010 was issued by eMedNY on the Medicaid remittance cycle 1807, dated April 9, 2012. This payment will appear as a lump-sum payment on the remittance, with Financial Control Number LSE. eMedNY will notify the provider community when the incentive payments will be issued for calendar year 2011. Once that payment has been processed, the incentive will be issued quarterly.


Beginning in September 2012, NYS Medicaid will require all billing providers to register for EFT, but providers are urged to act now with this new requirement. Questions about this process can be directed to the eMedNY call center at 800-343-9000. You can also contact our Credentialing Manager, Lisa Kropp at 716-348-3904 or lisak@pracfirst.com to take advantage of our Credentialing service.


The Affordable Care Act provides coverage for annual wellness visits for Medicare beneficiaries. Three HCPCS codes have been established as follows:

G0402 – Initial Preventive Physical Examination (IPPE). This annual visit is covered within the first twelve months of a beneficiary’s enrollment for Part B services and identified as their Welcome to Medicare physical. This service is paid only once in a patient’s lifetime.

G0438 – Initial Annual Wellness Visit (AWV). This initial annual visit is payable for individuals who are no longer within 12 months of their effective date of their Medicare Part B coverage. This service is paid only once in a patient’s lifetime. The claim will deny if the patient is still eligible for their Welcome to Medicare physical.

G0439 – Subsequent Annual Wellness Visit (AWV). This subsequent wellness visit is payable for Medicare beneficiaries on a yearly basis.  The claim will deny if the patient is still eligible for their Welcome to Medicare physical.

Please Note: A separately identifiable medically necessary E & M service may be reported in addition to the IPPE or AWV. The E & M service would be reported with CPT codes 99201 – 99215 with modifier 25 appended.

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

Medicare Mail…Is it a Revalidation Reminder?

By: Lisa Kropp, Practicefirst Coding and Credentialing Manager

All providers and suppliers who enrolled in the Medicare Program prior to Friday, March 25, 2011 will have their enrollment re-validated under new risk screening criteria required by the Affordable Care Act (section 6401a). Do not send in re-validated enrollment forms until you are notified to do so by your Medicare Administrative Contractor. You will receive a notice to re-validate between now and March 2013. This notice MAY be in the form of a post-card so please alert your staff NOT to discard any mailings from Medicare until they have been examined.

National Government Services asks providers NOT to respond until they receive a letter. However, if you do receive a letter, it is imperative that you respond immediately, with the necessary actions, as there is a 60 day time frame in which you have to respond.

What are my Options?

  • Paper Enrollment – Fill out a CMS-855 (enrollment form), CMS-588 (EFT Form), and attach the required documents listed on the letter.  Note that as per existing regulations, providers and suppliers that expect to receive payment from Medicare for services provided must also agree to receive Medicare payments through electronic funds transfer (EFT).
  • Electronic Enrollment thru PECOS Online.
  • Contact Practicefirst’s Credentialing department to assist you in complying with this initiative.

As always, our current and potential clients can rely on Practicefirst’s highly qualified staff to provide assistance to your practice or organization.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

Amanda Isch, Credentialing Coordinator at 716.348.3927 or amandai@pracfirst.com<

CMS Press Release Monday, April 9, 2012 (ICD-10 Delay)

New health care law provisions cut red tape, save up to $4.6 billion.

Department of Health and Human Services (HHS) Secretary Kathleen Sebelius today announced a proposed rule that would establish a unique health plan identifier under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The proposed rule would implement several administrative simplification provisions of the Affordable Care Act.

The proposed changes would save health care providers and health plans up to $4.6 billion over the next ten years, according to estimates released by the HHS today. The estimates were included in a proposed rule that cuts red tape and simplifies administrative processes for doctors, hospitals and health insurance plans.

“The new health care law is cutting red tape, making our health care system more efficient and saving money,” Secretary Sebelius said. “These important simplifications will mean doctors can spend less time filling out forms and more time seeing patients.”

Currently, when health plans and entities like third party administrators bill providers, they are identified using a wide range of different identifiers that do not have a standard length or format. As a result, health care providers run into a number of time-consuming problems, such as misrouting [sic] of transactions, rejection of transactions due to insurance identification errors, and difficulty determining patient eligibility.

The rule simplifies the administrative process for providers by proposing that health plans have a unique identifier of a standard length and format to facilitate routine use in computer systems.  This will allow provider offices to automate and simplify their processes, particularly when processing bills and other transactions.

The proposed rule also delays required compliance by one year- from Oct. 1, 2013, to Oct. 1, 2014- for new codes used to classify diseases and health problems. These codes, known as the International Classification of Diseases, 10th Edition diagnosis and procedure codes, or ICD-10, will include new procedures and diagnoses and improve the quality of information available for quality improvement and payment purposes.

Many provider groups have expressed serious concerns about their ability to meet the Oct. 1, 2013, compliance date. The proposed change in the compliance date for ICD-10 would give providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition to these new code sets.

The proposed rule announced today is the third in a series of administrative simplification rules in the new health care law. HHS released the first in July of 2011 and the second in January of 2012, and plans to announce more in the coming months.

More information on the proposed rule is available on fact sheets (4/9/12) athttp://www.cms.gov/apps/media/fact_sheets.asp. The proposed rule may be viewed at www.ofr.gov/inspection.aspx. Comments are due 30 days after publication in the Federal Register.