by Becky Amann, Director of Compliance


The Office of Inspector General (OIG) has issued their Work Plan for 2016 which summarizes new and ongoing reviews and activities that they will pursue.

New investigations in 2016:

  • Physicians – Referring/ordering Medicare services and supplies:

The OIG will review select Medicare services and supplies referred/ordered by physicians and non-      physician practitioners to identify whether the payments were made in accordance with Medicare       requirements. CMS requires that physicians and non-physician practitioners who order certain services       and supplies are required to be Medicare-enrolled physicians or non-physician practitioners and legally       eligible to refer/order services and supplies. If they are not eligible, Medicare should not make payment       on the claims.

  • Anesthesia non-covered services

The OIG will review Medicare Part B claims for anesthesia services to determine whether they were       supported in accordance with Medicare requirements. Specifically, they will review anesthesia       services to determine whether the beneficiary had a related Medicare service. Medicare will not pay for items or services that are not “reasonable and necessary.”

  • Prolonged services – reasonableness of services

            The OIG will determine whether Medicare payments to physicians for prolonged evaluation and  management (E&M) services were reasonable and made in accordance with Medicare requirements. Prolonged services are for additional care provided to a beneficiary after an E&M service has been performed. Physicians submit claims for prolonged services when they spend additional time beyond  the time spent with a beneficiary for a usual companion E&M service. The necessity of prolonged             services is considered to be rare and unusual.

Continuing investigations in 2016:

  • Imaging Services: The OIG will review Medicare Part B payments for imaging services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices. For selected imaging services, they will focus on the practice expense components, including the equipment utilization rate. The report on their findings is expected to be issued in 2016.
  • Anesthesia Services: The OIG will continue to review Medicare Part B claims for personally performed anesthesia services to determine whether they were supported in accordance with Medicare requirements. They will also determine whether Medicare payments for anesthesiologist services reported on a claim with the “AA” modifier met Medicare requirements. Reporting an incorrect modifier on the claim, as if services were personally performed, when they were not, will result in Medicare paying a higher amount. The report on their findings is expected to be issued in 2016.

All practices and facilities should read the OIG Work Plan in its entirety and take steps to identify and rectify any potential issues they may have, before the OIG does.

The full 2016 Work Plan can be accessed at:

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


By Betsy Priest, Coding Manager


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


By Jacqueline Lucas, Medical Billing Director 


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 2015.  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 carriers are required to mail them by January 31st.  However, our past experience indicates that they do not comply with the due date and therefore they are not all generally received until the third week in February.  At that time, we will send them to you by mail or through our courier service. If you have any questions, please feel free to contact us.


To align with NYS Medicaid, Independent Health (IHA) will be eliminating coverage for immunization administration code 90461. This code is not covered by Medicaid. Effective April 1, 2016, 90461 will not be covered for IHA’s MediSource, Essential Benefit Plan or Child Health Plus members.


Univera has announced that Telemedicine services will be available to select members effective March 1, 2016. Telemedicine services will be delivered by MDLive, a nation-wide network of physicians who are board-certified in the state in which the patient is located at the time of service. MDLive physicians will be available by phone or secure video 24 hours a day, seven days a week, including holidays to provide advice and/or treatment for non-emergency medical conditions. If you have any questions regarding Telemedicine services, please contact Univera’s Customer Care Dept. at 866-265-5983.


In-mid January, YourCare issued duplicate EFT payments. They have been identified in providers’ bank accounts beginning on January 19, 2016.  PF has contacted YourCare provider representative, Tina Burns, who indicated they will be reaching out to the various providers requesting a refund check, for the duplicate payments.


Railroad Medicare’s Medical Review unit will begin a service-specific review of Evaluation and Management CPT Code 99214 (office or other outpatient visit of an established patient). This code was selected based on internal data analysis. At the conclusion of the review, they will publish their findings on their website.

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