COMMUNITY CORNER….

By Caitlyn Foley

This past month, Practicefirst began raising money for “Pennies for Paws”. Practicefirst employees put their spare change into a jar, and once it’s filled, we will donate the funds to a local non-profit animal rescue shelter. There are many animal shelters that work strictly off of public donations, which are critical in providing medical/other care to these animals. Practicefirst is always searching for new opportunities to give back to our community to the best of our ability!

If you would like more information about how we are involved in our community, please contact Caitlin Foley at 716-348-3977 or caitlinf@pracfirst.com

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COMPLIANCE UPDATES JULY 2015

By Becky Amann, Compliance Manager

Medicare – Exclusions From Coverage

National Government Services (NGS) recently published an article regarding: Charges Imposed by Immediate Relatives of the Patient or Members of Household. NGS has recently identified claims submitted by providers who furnished services to their immediate relatives or to members of their household. Medicare does not pay for these services, since they are ordinarily furnished gratuitously because of the relationship between the Medicare beneficiary and the provider. Immediate relatives are defined as:

  • Husband or wife
  • Natural or adoptive parent, child and sibling
  • Stepparent, stepchild, stepbrother or stepsister
  • Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law or sister-in-law
  • Grandparent or grandchild
  • Spouse

A step-relationship and an in-law relationship continue to exist even if the marriage upon which the relationship is based terminates through divorce or death of one of the parties.

Members of Household are defined as:

Persons sharing a common abode with the patient as part of a single family unit, including those related by blood, marriage or adoption, domestic employees and others who live together as part of a single family unit. A mere roomer or boarder is not included.

This Medicare exclusion applies whether the provider is a sole proprietor who has a relationship (as identified above) to the patient, or a partnership in which one of the partners is related to the patient.

Please refer to the Medicare Benefit Policy Manual, Chapter 16, Section 130 for further information regarding these exclusions from coverage. The Medicare manuals are located on CMS’s website under their Guidance section at:

http://www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance.html

*** Please note: These exclusions also pertain to Medicare Advantage Plans ***

Univera – Risk Adjustment Review of Medical Records

Univera has contracted with Verisk Health to retrieve medical record documentation from providers. The record retrieval is a necessary part of their Risk Adjustment Program that is designed to capture the medical complexity of their Medicare Advantage members. CMS requires Medicare Advantage plans to confirm that the diagnosis codes submitted via claims are supported in the medical records. The record review also ensures the documentation properly reflects the clinical conditions of the patient.

Verisk Health will begin contacting selected providers in July to schedule the retrieval of medical records reflecting services rendered from January 1, 2014 to present.

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

BILLING UPDATES JULY 2015

By Sarah Howarth, Billing Manager

Univera News

Univera & Excellus ID Cards

Members enrolling in the Univera Medicare or Excellus Medicare coverage on or after June 30, 2015 will be issued identification cards with subscriber ID numbers that begin with the letter “M”.  There will be no change to ID numbers for existing Medicare members.

Univera Community Health

On or after July 1, 2015, Univera Community Health will be changing its name and launching a new website.  No other information is available at this time.  Practicefirst will keep you updated as information is released.

 

DXA Scan Screening:

 

Effective July 1, 2015, Univera Community Health will adopt the New York State Department of Health policy regarding DXA scan reimbursement limitations for members who have Plus Med Coverage.

 

Reimbursement for medically necessary DXA scans will be limited to once every two years for:

  • Women ages 64 and older and men ages 70 and older
  • Women and men ages 50 and older who have significant risk factors for osteoporosis (e.g. post-menopause; family history of osteoporosis; use of certain medications, including some steroids and chemotherapy agents, etc.)
  • Individuals regardless of age, preparing to or currently taking Depo-Proveraa

Copay Update Reminder For Ultrasounds Rendered to Medicare Advantage Members

Univera has updated its claims processing system to apply an X-Ray copay to ultrasounds rendered to Medicare Advantage members. This service was previously applying a Diagnostic Radiology copay, which was inaccurate. Diagnostic radiology copays should only apply to higher-cost tests such as CT, MRI and PET Scans.

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

CODING CORNER JULY 2015….FOCUS ON ICD-10

By Lisa Kropp, Coding and Credentialing Manager

Practicefirst’s Implementation Assistance Plan

  • On or around June 1, 2015, your practice should have received a report containing the 20+ most commonly billed ICD-9’s by your practice in 2014.  We included the ICD-10 mappings that may be applicable.  The purpose of this is to assist you in identifying the impact to your practice.  In many cases, there are direct mappings (ICD-9 to ICD-10).  In other cases, where more complex conditions & manifestations are present, there are NOT direct mappings and you will have to investigate these further.
  • If you did not receive a report, please contact Lisa Kropp 716.348.3904 or lisak@pracfirst.com

What to Expect This Month:

  • Direct contact by Practicefirst to gain more information regarding your implementation readiness.
  • More ICD-10 fun facts!
  • ICD-10 resources

Need ICD-10 Practice?

CMS has launched the following site to provide interactive case studies with questions & answers (e.g. how to assign an ICD-10 for a patient with strep pharyngitis & tonsillitis).

Cases are updated weekly!

Visit: http://www.roadto10.org/ics/

ICD-10 Differences:

  • Injuries are grouped by anatomical site rather than by type of injury
  • Category restructuring and code reorganization occur in a number of ICD-10 chapters, resulting in the classification of certain diseases and disorders that are different from ICD-9
  • Certain diseases are reclassified to different chapters or sections to reflect current medical knowledge
  • New code definitions (for example, definition of AMI is now 4 weeks rather than 8 weeks)
  • The codes corresponding to ICD-9 “V” codes (Factors influencing health status & contact w/health services) and E codes (External causes of injury and poisoning) are incorporated into the main classification (in ICD-9, they were separated into supplementary classifications

ICD-10 Resource List

  1. http://www.cms.gov/Medicare/Coding/ICD10/
    1. Contains videos for small practices, resource flyers as well as a clinical documentation video.
    2. https://www.aapc.com/icd-10/
      1. Robust resources for practices of all sizes including options to purchase physician training, ICD-10 manuals
      2. https://www.aapc.com/icd-10/crosswalks/
        1. Laminated ICD-10 crosswalk cards available for purchase ($24.95-specialty specific)

Below are suggested links you should begin using now as ICD-10 nears:

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@pracfir