CODING CORNER… NOVEMBER 2014

As a reminder…..CMS has established four new HCPCS modifiers to define subsets of the -59 modifier 

CPT Definition of -59 Modifier: Distinct Procedural Service

Purpose of Subsets:

  • Prevent Fraud & Abuse
  • Reduce number of reviews & appeals
  • Help providers assign this code properly

New Modifiers & Meanings:

  1. XE Modifier: Separate encounter i.e. a service that is distinct because it occurred during a separate encounter.
  2. XS Modifier: Separate structure i.e. a service that is distinct because it was performed on a separate organ/structure.
  3. XP Modifier: Separate Practitioner i.e. a service that is distinct because it was performed by a different practitioner.
  4. XU Modifier: Unusual Non-Overlapping Service i.e. the use of a service that is distinct because it does not overlap usual components of the main service

Takeaways:

  1. Implementation date is January 5, 2015
  2. CMS will continue to recognize the -59 modifier, but it should NOT be used in addition to these new modifiers because they are more descriptive.
  3. CMS may make the use of these modifiers mandatory when used to bill certain codes that are considered at high risk for incorrect billing.
  4. These modifiers are valid even before national edits are in place.  Providers are encouraged to use the more selective modifiers. MAC’s are not prohibited from requiring the use of selective modifiers in lieu of the general -59 modifier. 

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

BILLING UPDATES – NOVEMBER 2014

By Sarah Howarth, Billing Manager 

INDEPENDENT HEALTH NEWS

DUAL DIFFERENCE MEDICARE ADVANTAGE

Independent Health previously notified providers of changes to their claim payment process for full dual eligible Dual Difference Medicare Advantage members. Since this notice, Independent Health has decided not to make the billing change that was scheduled for October 1, 2014. Claims will continue to process according to the Medicare contracted allowable amount and providers will not need to bill NYS Medicaid.

Instead, the following changes will be implemented beginning January 2015.

The Dual Difference plan will include a member cost share for most services. This will only affect Dual Difference members who are partially dual eligible (those who receive a subsidy for their Medicare Part B premiums only and not Medicaid medical benefits).

Generally, the partial dual eligibles’ member cost share will be a 20% coinsurance of Independent Health’s Medicare contracted allowed amount. The appropriate amount will be reflected on the Explanation of Payment.

Fully dual eligible members will continue to have zero cost shares. Providers will not be required to bill NYS Medicaid. Reimbursement will be made by Independent Health.

CHILD HEALTH PLUS

Effective October 1, 2014 Independent Health began offering Child Health Plus to residents of Niagara County.

BLUE CROSS

Beginning January 1, 2015 Blue Cross will be offering two new Medicare Advantage products in the eight counties of Western New York.

Senior Blue HMO Select – Members must visit an in-network facility for services to be covered. Emergency room visits are covered anywhere. This plan will replace Senior Blue HMO-POS 650.

Forever Blue Medicare PPO Value – Services are covered nationwide, at any doctor or hospital that accepts Medicare. The member will pay a higher cost-share for services outside of the Western New York Service area.  Emergency room visits are covered anywhere at an in-network copay.

MEDICARE EHR INCENTIVE PROGRAM

The submission period for hardship exception applications for eligible professionals to avoid the 2015 Medicare payment adjustments for not demonstrating meaningful use of Certified Electronic Health Record Technology (CEHRT) has been extended. The new deadline will be November 30, 2014.  

The reopened submission period is for eligible professionals who have been unable to fully implement 2014 Edition CEHRT due to delays in 2014 Edition CEHRT availability and were unable to attest by October 1, 2014. These are the only circumstances that will be considered for this reopened hardship exception application submission period.

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