CODING CORNER… JANUARY 2016

By Betsy Priest, Coding Manager

2016 NEW, DELETED, AND REVISED CPT AND HCPCS CODES:

Revisions, addition and deletions to the CPT and HCPCS code set are effective January 1, 2016. Use of deleted codes will delay payment, as we will need to “Chart Return” the charge slips to your office for the correct code.

To determine which clients will be impacted by the 2016 changes, we have compared these changes to each client’s procedures performed in 2015.

We will be faxing, mailing or delivering customized reports to our Clients that are impacted by the 2016 CPT changes.

If you would like a complete listing of all the Deleted, New, and Revised Codes, we can provide that upon request.

DOCUMENTING TIME FOR E&M LEVELING:

During some visits you may spend a lot of time with a patient counseling them or coordinating their care.  If this happens, and you have the correct documentation in your note, leveling of your Evaluation and Management codes can be captured by time in lieu of the 3 main components.

It is a good tool for those patients that use a lot of your time, knowledge and resources and wind up with a very straight forward problem.

A good example of documentation needs for coding by time is: “This encounter was 30 minutes long and over half of that time was spent on counseling and coordination of care”.  You can also give a brief overview of what was discussed, if you would like.  But it will not be needed in this statement if the rest of your note supports that.

Your visit can be coded by time if the statement above is listed in the body of the note.  “This was a 45 minute visit” or “I spent 45 minutes with the patient” is not considered to be acceptable by the payers.

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@pracfir

BILLING UPDATES JANUARY 2016

By Jacqueline Lucas, Medical Billing Director

NATIONAL GOVERNMENT SERVICES (NGS)

In order to implement corrections to technical errors discovered after publication of the Medicare Physician Fee Schedule, Medicare Administrative Contractors will hold claims containing 2016 dates of services for up to 14 calendar days. The hold should have minimal impact on provider cash flow as clean electronic claims are held for 14 calendar days, under current law.

The holding of claims does not impact 2015 dates of services.

INDEPENDENT HEALTH  – PREVENTIVE VISITS – CPT CODES 99381-99397

Effective January 1, 2016, IHA will no longer offer coverage for routine physicals (CPT codes 99381-99397) for their Medicare Advantage plans. Claims with dates of service January 1, 2016 and after will be denied as service code not reimbursable.

They will continue to offer coverage for the Annual Wellness Visit as well as the Enhanced Annual Visit in the primary care setting for their Medicare Advantage plans.

MEDICAID ELECTRONIC PRESCRIBING

Effective March 27, 2016, electronic prescribing for both controlled and non-controlled substances will be required in New York State. In order to process Electronic Prescriptions for Controlled Substances (EPCS), a prescriber must select and use a certified electronic prescribing computer application that meets all federal requirements. This application must first be registered by the practitioner with the NYS Dept. of Health, Bureau of Narcotic Enforcement (BNE).

Per the Dept. of Health, the implementation timelines for EPCS software vary and may be lengthy. If you have not already begun this process, it is recommended that you begin immediately.

Information related to electronic prescribing, including frequently asked questions and information regarding the EPCS registration process, can be found on the BNE’s website at: http://www.health.ny.gov/professionals/narcotic/electronic_prescribing/

For Billing questions, please contact Jacqueline Lucas, our Medical Billing Director. Jackie can be reached at 716-348-3923 or jackiel@pracfirst.com.<

BILLING UPDATES DECEMBER 2015

By Tom Mahar, President and CEO

NEW YEAR, NEW INSURANCE

As the New Year approaches please keep in mind patient insurance coverage and benefits may change.  Please review each patient’s insurance card for updated subscriber information and forward any pertinent changes to Practicefirst to ensure claims are submitted correctly.

CENTERS FOR MEDICARE AND MEDICAID (CMS)

PQRS INFORMAL REVIEW PROCESS

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 2016 dates of service. We have forwarded the letters to the applicable clients.

If you received a letter from CMS regarding reduction in payments and believe you have been incorrectly assessed, you have until the end of the day on December 16, 2015 to submit an informal review. Requests must be submitted via the Quality Reporting Communication Support Page at: https://www.qualitynet.org/portal/server.pt/community/pqri_home/212

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.

MEDICARE PART B DEDUCTIBLE / CO-INSURANCE

The Medicare Part B annual deductible for 2016 has increased to $166.00. Co-insurance remains at 20%.

COLORECTAL CANCER SCREENING  – CLAIMS PROCESSING ISSUE

Due to an increase in inappropriate denials, CMS has expedited an update to National Coverage Determination (NCD) 210.3, Colorectal Cancer Screening Tests. CMS is taking action to have Medicare Administrative Contractors correct inappropriate denials of HCPCS code G0105 with ICD-10 code Z86.010 where they exist. Appropriate payment will be made for these procedures within 45 days. No action is needed by providers.

NATIONAL GOVERNMENT SERVICES (NGS)

CHANGE IN PROCESSING CLAIMS FOR NON-COVERED ICD-10 DIAGNOSIS CODES

Effective for claims received January 1, 2016, with dates of service 10/1/2015 and after, claims submitted with a combination of non-covered routine diagnosis codes and payable diagnosis codes will be considered for payment. Providers that submit claims with the intent of denial for supplemental insurance will no longer be able to submit a routine diagnosis for denial unless all of the reported diagnosis codes are routinely non-covered. A combination of the routine diagnosis and the use of “GY” modifier will be required for denial.

PRE-OPERATIVE TESTS DENIED IN ERROR

NGS announced on November 13th, that some claims for pre-operative tests, (e.g., EKGs, chest X-rays), denied in error due to an editing issue. These pre-operative services are covered, if there is medical necessity as reflected by a clinical diagnosis on the claim and they are not simply being performed as routine pre-operative tests. The claims which denied for these tests incorrectly, will be reprocessed by NGS. No provider action is required.

RAILROAD MEDICARE

Railroad Medicare will be conducting a service-specific review of E&M CPT code 99223. Railroad Medicare selected this code based on internal data analysis. Please be aware that medical documentation may be requested to review these particular services. At the conclusion of their review, they will publish their findings on their website.

HEALTH REPUBLIC INSURANCE

It was previously announced that Health Republic would be closing as of December 31, 2015. However, the NYS Dept. of Financial Services and CMS have announced Health Republic is closed effective November 30, 2015.

The sudden closure of Health Republic meant their 200,000 members had to find another plan for the remainder of 2015 before November 15th. The NYS Departments of Health and Financial Services announced agreements with three health insurers (Excellus, Fidelis and MVP) to enroll Health Republic members who did not voluntarily pick a new plan by November 15th.

NYS indicated that claims processing payments would cease on or around November 5, 2015 and are hopeful that “modest payments” on outstanding claims may be made in the future.

The Greater New York Hospital Association indicated it will “aggressively push for legislation to establish a health insurance guarantee fund that would not only protect health care providers in the event of an insurer insolvency, but also be able to make retroactive payments.”

INDEPENDENT HEALTH (IHA) NEWS

MEDSOURCE PRODUCT ENDS 12/31/15 IN NIAGARA COUNTY

IHA will no longer be offering their MediSource (IHA’s Medicaid Managed Care product) in Niagara County effective December 31, 2015. All other IHA products, including Child Health Plus will remain in effect. They are in the process of notifying their members of other options to continue their coverage through another Medicaid Managed Care plan.

ESSENTIAL PLAN EFFECTIVE 1/1/16

IHA has been approved by NYS to administer a new plan beginning January 1, 2016, named the Essential Plan. This is a new program through the NYS of Health and should help fill the gaps that were created by the discontinuance of Family Health Plus and certain Medicaid plans. IHA will offer four versions of the Essential Plan in Erie and Niagara counties. The same reimbursement applies as this plan is part of IHA’s portfolio of Government Funded Programs.

Members will have “Essential Plan Program” on their identification cards, followed by the number 1, 2, 3 or 4. Member copays will vary, so please check WNY Healthenet for benefit details for your patients.

The plan covers essential health benefits, including inpatient and outpatient care, physician services, diagnostic services and prescription drugs. There is no annual deductible and has low out-of-pocket costs. Preventive care such as routine office visits and recommended screenings have no out-of-pockets expenses for members.

If you have any questions regarding this new plan, please contact IHA’s Provider Relations Department at providerservice@servicing.independenthealth.com.

CHANGE IN MEDISOURCE / CHILD HEALTH PLUS COVERAGE FOR NURSE PRACTITIONERS

Effective January 1, 2016, Independent Health will be updating services that Nurse Practitioners (NP’s) may perform to align with NYS Medicaid coverage for their MediSource and Child Health Plus members. Some of the services that will be affected by this coverage change include:

  • Providers of Consultation E&M Services
  • Providers of Critical Care E&M Services
  • Select OB and GYN Services
  • Select Psychotherapy Services
  • Select Laboratory/Pathology Services

For a complete list of services that will be covered when performed by NP’s, please reference the Nurse Practitioner Provider Manual on the NYS Medicaid Provider Portal at www.emedny.org.

UNIVERA NEWS – MOBILE ID CARDS

Mobile Identification cards are now available to Univera members. If a member uses his or her mobile ID card at your office, the mobile ID card will display exactly like a hard copy of the ID card. You will be able to view the front and back of the ID card. If you have questions regarding these new cards, contact Customer Care at 1-866-265-5983.

For Billing questions, please contact Tom Maher at 716-834-1193 or tom@pracfir

CODING CORNER…FOCUS ON ICD-10 DECEMBER 2015

 By Becky Priest, Coding Manager
 
Medical Record Documentation and Coding Tips:

1. State the diagnosis to the highest level of specificity known

  • Document all conditions treated or related to treatment at the time of the visit
  • State the conditions as worsening, improving, stable, acute, etc.
  • Clearly state how the condition is being treated or monitored

2. Create a clear relationship between the diagnoses

  • Use linking verbiage such as “due to”, “because of”, “related to”
  • Coding guidelines prohibit coders from making assumptions

3. Include all conditions related to health status

  • Document chronic and permanent diagnoses as often as they are assessed or treated
  • Document chronic and permanent diagnoses when they are a consideration in the care of the patient
  • Frequently overlooked, but significant conditions include: transplant status, quadriplegia, dialysis status, current ostomies, amputations and asymptomatic HIV infection

4. Abbreviations

  • Only use standard abbreviations
    • This includes  HIV, CHF, AIDS, CABG, HTN, UTI, ENT, and many others
  • Making your own abbreviations can cause coding issues including the wrong procedure or diagnosis being coded
  • If you are using abbreviations only use those that are universally known between other clinical staff, coders as well as the payers
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 orBetsyp@pracfirst.com