JUNE 2017 COMPLIANCE UPDATES

by Becky Amann, Compliance Manager

CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)

PROVIDER COMPLIANCE

CMS’s website contains a Provider Compliance section that provides Compliance-related and Fraud and Abuse-related resources. This section includes a link to their “Fast Facts” that is updated regularly. Some of the topics include Preventive Services, Evaluation and Management Services, Hospital Discharge Day, Medical Necessity Documentation…. just to name a few.

These resources are located at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ProviderCompliance.html

MEDICAID – REQUEST FOR PROVIDER DOCUMENTATION – PAYMENT ERROR RATE MEASUREMENT (PERM)

CMS in conjunction with the NYS Office of the Medicaid Inspector General (OMIG) will be measuring improper payments for Medicaid and Child Health Plus programs, under the Payment Error Rate Measurement (PERM) program.

Documentation for medical review of randomly selected claims will be requested by Chickasaw Nation Industries Advantage, LLC, who is the new CMS review contractor. Requests for documentation began in May and could be requested for claims paid during the timeframe of October 1, 2016 through September 30, 2017.

Failure to provide the requested documentation will result in a determination of erroneous payment and OMIG will pursue recovery.

Please ensure your staff is aware of these documentation requests.

OFFICE OF THE INSPECTOR GENERAL (OIG)

PROVIDER COMPLIANCE – REPORTING CHANGES IN OWNERSHIP

A recent report issued by the Office of the Inspector General (OIG) has indicated that providers may not be informing CMS of ownership changes. Providers must update their enrollment information within 30 days of any changes in ownership.

Owners are individuals or corporations with a 5 percent or more ownership or controlling interest. Failure to comply could result in revocation of your Medicare billing privileges. Please refer to the following MLN Matters Article for further information:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1617.pdf

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

JULY 2017 COMPLIANCE UPDATES

by Becky Amann, Director of Compliance

OFFICE OF THE INSPECTOR GENERAL (OIG)

In June, the OIG reported that Medicare has paid millions of dollars in Electronic Health Record (EHR) Incentive Payments that did not comply with Federal Requirements.

As an incentive for using certified EHR technology, the Federal Government makes payments to Eligible Professionals (EP’s) that attest to “meaningful use” of EHR’s, by self-reporting data to the Centers for Medicare and Medicaid Services (CMS).

The OIG reviewed EHR incentive payments that Medicare issued to EP’s from May 2011 to June 2014 and selected a random sample of EP’s who received payment. Based on the sample reports, the OIG has estimated that CMS inappropriately paid $729.4 million to EP’s who did not meet the meaningful use requirements.

The OIG has recommended that CMS recover $291,000 in payments made to the sampled EP’s who did not meet meaningful use requirements. In addition, the OIG recommends that CMS review EP incentive payments to determine which EP’s did not meet meaningful use for each program year to attempt to recover the $729.4 million in estimated inappropriate incentive payments.

For OIG’s full report, please access their website at: https://oig.hhs.gov/oas/reports/region5/51400047.asp

For Compliance questions, please contact Becky Amann at 716-389-3202 or beckya@pracfirst.com

BILLING UPDATES – DECEMBER 2016

By Tammy Bartlett, Billing Manager

UNIVERA

TWO NEW PRODUCTS AVAILABLE

Univera is introducing two new products in January 2017 which will be available to small-group community-rated customers, called Univera Access and Univera Preferred Access. Reimbursements for these products will be in accordance with their Special Programs Fee schedule.

DIAGNOSTIC MAMOGRAPHY COVERAGE MANDATE

Based on a NYS coverage mandate effective January 1st, Univera Healthcare is expanding the existing health insurance benefit for screening mammography to include diagnostic imaging for the detection of breast cancer.

The expanded services include: diagnostic mammograms, breast ultrasounds, digital breast tomosynthesis and MRI’s in addition to already covered screening mammograms. The mandate applies only to their commercial line of business.

BLUE  CROSS – PAY FOR PERFORMANCE (P4P) PROGRAM

Medicaid Managed Care (MMC) and Child Health Plus (CHP) patients and the impact on individual provider performance will be excluded from the final P4P program. Participating providers were paid incentives at the end of the third quarter of 2016 for current closed HEDIS gaps for MMC and CHP patients regardless of achievement of threshold targets. Incentive payments will be distributed by the end of the first quarter of 2017. This change in program is due to the transition of quality management of Blue Cross’s MMC and CHP members to a shared partnership with Amerigroup.

For Billing questions, please contact Tammy Bartlett at 716-348-3923 or tammyb@pracfir

BILLING UPDATES – NOVEMBER 2016

By Tammy Bartlett, Billing Manager

CENTERS FOR MEDICARE AND MEDICAID (CMS)

PQRS PAYMENT ADJUSTMENTS

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 2017 dates of service. The payment adjustments are based on services rendered in 2015. We will forward the letters to the applicable clients, as we receive them.

If you received a letter from CMS regarding reduction in payments and believe you have been incorrectly assessed, please review the payment adjustment resources located on the PQRS webpage at:

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Payment-Adjustment-Information.html

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.

MVP

MVP issued FASTFAX #50W on October 20, 2016 to the provider community regarding Preventive Visits and Modifier 25. Preventive visits (codes 99381-99397) are payable on the same date of service as a separately identifiable E&M service (i.e. 99213). The E&M would be submitted with modifier 25. The additional services for the E&M must be documented in the medical record and the claim should include both the preventive visit diagnosis code(s) and the relevant condition diagnosis code(s).

If the preventive code is not billed, the visit will not count for the preventive service quality measures (well child, adolescent and adult measures).

For additional information, please visit MVP’s website at http://www.mvphealthcare.com/provider/provider-resource-manual.html, select Section 15 for Payment Policies and then select the Modifier Policy from their bookmarks.

For Billing questions, please contact Tammy Bartlett at 716-348-3923 or tammyb@pracfirst.com

BILLING UPDATES – MARCH 2016

by Jackie Lucas, Medical billing Manager

Billing Updates

MEDICARE

Mandatory Payment Reduction of 2% Continues until Further Notice for the Medicare FFS Program – “Sequestration”

Medicare Fee-For-Service (FFS) claims will continue to incur a two percent reduction in Medicare payment until further notice. The claims payment adjustment will continue to be applied to all claims after determining coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments. Though beneficiary payments for deductibles and coinsurance are not subject to the two percent payment reduction, Medicare’s payment to beneficiaries for unassigned claims is subject to the two percent reduction. CMS encourages Medicare physicians, practitioners, and suppliers who bill claims on an unassigned basis to continue discussions with beneficiaries on the impact of sequestration on Medicare’s reimbursement. Questions about reimbursement should be directed to your Medicare Administrative Contractor (http://go.usa.gov/cymuF).

RAILROAD MEDICARE

Railroad Medicare’s (RMC) Medical Review (MR) unit will begin a service-specific review of Evaluation and Management (E/M) CPT code 99285, emergency department visit, requiring highly complex medical decision making. RMC selected this code based on internal data analysis. At the conclusion of this review, they will publish their findings on their website.

UNIVERA

On March 27, 2016 electronic prescribing of all controlled and non-controlled prescriptions (including syringes and medical devices), commonly referred to as e-prescribing will become mandatory for all prescribers in New York State. This regulation is one of the multiple sections of the Internet System for Over-Prescribing Act (I-STOP) program passed in 2012.  Most providers who use an electronic health record (EHR) can easily e-prescribe using the same software.  Those who do not have an EHR system in place will have to purchase an electronic prescribing computer application for one of the various software platforms based on their practice and e-prescribing needs.  For more information on electronic prescribing of controlled substances please visit

http://www.health.ny.gov/professionals/narcotic/electronic_prescribing/

BLUE CROSS

Changes to Performance and Quality Programs

Pay for performance (P4P) 2016—Focus will be on Primary Care Physicians (PCP’s)

  • Only PCP’s will be eligible to participate
  • P4P incentive payments will be contingent on PCP meeting threshold targets
  • The 2016 P4P program includes Medicaid members

The following measures have been added to the program:

  • HEDIS Medication Management for people with Asthma 75% Compliance
  • Measures replaced: HEDIS Appropriate Asthma Medications

The following measures have been eliminated from the program:

  • HEDIS Monitoring Persistent Meds ACE or ARB
  • HEDIS follow-up with 7 days after hospitalization for Mental Illness

For more information about Blue Cross’s 2016 P4P program, log onto bcbswny.com/provider and go to My Account>Reports>pay for performance>2016 P4P.

MEDICAID

In July 2015, we notified you that effective July 1, 2015 Medicaid would no longer reimburse partial Medicare Part B coinsurance amounts (20% of the Part B coinsurance). Medicaid did not implement this change until December 17, 2015. In February, Medicaid began making claim adjustments for dates of service 7/1/15 through their revision date of 12/17/15. Weekly Medicaid EFT’s/checks will be reduced until all of these claims are re-processed.

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

CODING CORNER…FEBRUARY 2016

By Betsy Priest, Coding Manager

ADVANCED CARE PLANNING

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 Betsyp@pracfirst.com

BILLLING UPDATES – MARCH 2015

By Sarah Howarth, Billing Manager

On March 27, 2015 electronic prescribing of all controlled and non-controlled prescriptions will be mandatory for all prescribers in New York.  E-Prescription is defined as a prescription that is created, recorded and transmitted electronically.  E-Prescriptions are transmitted directly from the prescriber to a pharmacy or pharmacist.  Prescriptions generated on an electronic system that is printed out or faxed prescriptions do not meet the requirements of E-Prescribing.

Providers may request a waiver to E-Prescribe if they meet one of the following criteria:

  • Economic hardship
  • Technological limitations that are not reasonably within the control of the practitioner
  • Or other exceptional circumstance demonstrated by the practitioner

Waivers are granted for a time period of one year.  To request a waiver from E-Prescribe contact the New York State Department of Health at 866-811-7957, option 1.

UNIVERA COMMUNITY HEALTH

Currently, Univera Healthcare and Monroe Plan for Medical Care are partners in Univera Community Health.  In July of 2015, Monroe Plan for Medical Care will become the sole owner of Univera Community Health.  A new name for the Community Health product will be released at that time.  Univera Community Health encompasses the PlusMed and Child Health Plus products.  Additional information will be released closer to the transition date.

UNIVERA Medicare Advantage

Effective January 1, 2015, if observation services are required for Univera Medicare Advantage patients, the member cost-sharing for these services will be included in the cost-sharing for hospital outpatient services.  The member will not pay a separate copayment for observation services.  If the patient’s status is changed to inpatient, only an inpatient copayment will be applied.

Independent Health Medicare Advantage

IHA Medicare Advantage is introducing a new “Enhanced Annual Visit” (EAV) for patients seen between January 1 and June 30, 2015.  The visit incorporates many of the services that are already provided during preventive and wellness visits, with an expanded focus on assessment and management of chronic diseases.  The EAV is reimbursed only once per calendar year for Primary Care Practitioners only, using the HCPCS code G8496. Reimbursement for the EAV performed between January 1 and June 30, 2015 is $300.00. Any additional preventative or wellness visits performed during the same calendar year, by the same provider group will be denied.  The EAV will be denied if a preventative and annual wellness visit has already been performed during the same calendar year by the same provider group.

In order to receive payment for the Medicare Advantage Enhanced Annual Visit (EAV), all of the following criteria must be met. Upon record review, if all criteria are not met and well documented the payment may be retracted.

  • Completion of a Health Risk Assessment (Independent Health form or other CMS compliant form).
  • Review of the patient’s Health Risk Assessment (HRA) and make it part of your permanent clinical record.
  • Document discussions related to issues noted by the patient on the HRA.
  • Document the status of each and every medical condition (even those identified and managed by specialists), including goals for treatment and management plans for each active problem.
  • Document standard visit elements: vital signs, interval history, past history, family history, medication reconciliation, review of systems, physical examination, update medication, problem and health maintenance lists, impression/assessment, plan and counseling of patient.
  • Provide a summary of the visit to the patient, including when to expect follow-up on test results Medical and Chronic Condition Management (must be performed by a physician, nurse practitioner or physician assistant).
  • Documentation of the entire visit including the Health Risk Assessment from your medical record must be submitted with the claim.

To assist providers in ensuring all of the requirements of the EAV are met, the Enhanced Annual Visit Program Guide is available on the IHA website.  Please contact Sarah Howarth at 716-348-3923 or sarahh@pracfirst.com for assistance in obtaining these materia

CODING CORNER…FEBRUARY 2015

By Lisa Kropp, Coding and Credentialing Manager

2015 DELETED HCPCS CODES:

Below, you will find a listing of all the 2015 deleted HCPCS codes.  Please see your HCPCS books for revisions or additions.  This information will be available to you, upon request.

HCPCS Description Date Deleted
D6053 implant/abutment supported removable denture for completely edentulous arch

1/1/2015

G8552 All quality actions for the applicable measures in the ischemic vascular disease (IVD) measures group have been performed for this patient

1/1/2015

G8547 I intend to report the ischemic vascular disease (IVD) measures group

1/1/2015

G8502 All quality actions for the applicable measures in the back pain measures group have been performed for this patient

1/1/2015

G8501 All quality actions for the applicable measures in the perioperative care measures group have been performed for this patient

1/1/2015

G8492 I intend to report the perioperative care measures group

1/1/2015

G8406 Clinician documented that patient was not an eligible candidate for lower extremity neurological exam measure

1/1/2015

G8128 Clinician documented that patient was not an eligible candidate for antidepressant medication during the entire 12 week acute treatment phase measure

1/1/2015

G8126 Patient with a diagnosis of major depression documented as being treated with antidepressant medication during the entire 84 day (12 week) acute treatment phase

1/1/2015

G0922 No documentation of disease type, anatomic location, and activity, reason not given

1/1/2015

G0920 Type, anatomic location, and activity all documented

1/1/2015

G0919 Influenza immunization ordered or recommended (to be given at alternate location or alternate provider); vaccine not available at time of visit

1/1/2015

G0910 Most recent hemoglobin level <= 12.0 g/dl

1/1/2015

G0909 Hemoglobin level measurement not documented, reason not given

1/1/2015

G0908 Most recent hemoglobin (HgB) level > 12.0 g/dl

1/1/2015

G0461 Immunohistochemistry or immunocytochemistry, per specimen; first single or multiplex antibody stain

1/1/2015

G0457 Negative pressure wound therapy, (e.g. vacuum assisted drainage collection) using a mechanically-powered device, not durable medical equipment, including provision of cartridge and dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area greater than 50 sq cm

1/1/2015

G0456 Negative pressure wound therapy, (e.g. vacuum assisted drainage collection) using a mechanically-powered device, not durable medical equipment, including provision of cartridge and dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area less than or equal to 50 sq cm

1/1/2015

G0419 Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, >60 specimens

1/1/2015

G0418 Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, 41-60 specimens

1/1/2015

G0251 Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment

1/1/2015

G0173 Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session

1/1/2015

C9735 Anoscopy; with directed submucosal injection(s), any substance

1/1/2015

C9135 Factor IX (antihemophilic factor, recombinant), Alprolix, per IU

1/1/2015

C9134 Factor XIII (antihemophilic factor, recombinant), Tretten, per 10 IU

1/1/2015

C9023 Injection, testosterone undecanoate, 1 mg

1/1/2015

C9022 Injection, elosulfase alfa, 1 mg

1/1/2015

C9021 Injection, obinutuzumab, 10 mg

1/1/2015

C1300 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval

1/1/2015

A7042 Implanted pleural catheter, each

1/1/2015

J0150 Injection, adenosine for therapeutic use, 6 mg (not to be used to report any adenosine phosphate compounds, instead use A9270)

1/1/2015

G9272 LDL value >= 100

1/1/2015

G9271 LDL value < 100

1/1/2015

G9253 Adenoma(s) or other neoplasm not detected during screening colonoscopy

1/1/2015

G9252 Adenoma(s) or other neoplasm detected during screening colonoscopy

1/1/2015

G9193 Clinician documented that patient with a diagnosis of major depression was not an eligible candidate for antidepressant medication treatment or patient did not have a diagnosis of major depression

1/1/2015

G8957 Patient not receiving maintenance hemodialysis in an outpatient dialysis facility

1/1/2015

G8932 Suicide risk assessed at the initial evaluation

1/1/2015

G8931 Assessment of depression severity not documented, reason not given

1/1/2015

G8930 Assessment of depression severity at the initial evaluation

1/1/2015

G8780 Counseling for diet and physical activity performed

1/1/2015

G8779 Diabetes screening test not performed, reason not given

1/1/2015

G8464 Clinician documented that prostate cancer patient is not an eligible candidate for adjuvant hormonal therapy; low or intermediate risk of recurrence or risk of recurrence not determined

1/1/2015

G8127 Patient with a diagnosis of major depression not documented as being treated with antidepressant medication during the entire 84 day (12 week) acute treatment phase

1/1/2015

G9248 Patient did not have a medical visit in the last 6 months

1/1/2015

G8892 Documentation of medical reason(s) for not performing LDL-C test (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate)

1/1/2015

D6975 coping

1/1/2015

D6079 implant/abutment supported fixed denture for partially edentulous arch

1/1/2015

D6078 implant/abutment supported fixed denture for completely edentulous arch

1/1/2015

D6054 implant/abutment supported removable denture for partially edentulous arch

1/1/2015

G8579 Antiplatelet medication at discharge

1/1/2015

G8552 All quality actions for the applicable measures in the ischemic vascular disease (IVD) measures group have been performed for this patient

1/1/2015

G8547 I intend to report the ischemic vascular disease (IVD) measures group

1/1/2015

G8502 All quality actions for the applicable measures in the back pain measures group have been performed for this patient

1/1/2015

G8501 All quality actions for the applicable measures in the perioperative care measures group have been performed for this patient

1/1/2015

G8492 I intend to report the perioperative care measures group

1/1/2015

G8406 Clinician documented that patient was not an eligible candidate for lower extremity neurological exam measure

1/1/2015

G8128 Clinician documented that patient was not an eligible candidate for antidepressant medication during the entire 12 week acute treatment phase measure

1/1/2015

G8126 Patient with a diagnosis of major depression documented as being treated with antidepressant medication during the entire 84 day (12 week) acute treatment phase

1/1/2015

G0922 No documentation of disease type, anatomic location, and activity, reason not given

1/1/2015

G0920 Type, anatomic location, and activity all documented

1/1/2015

G0919 Influenza immunization ordered or recommended (to be given at alternate location or alternate provider); vaccine not available at time of visit

1/1/2015

G0910 Most recent hemoglobin level <= 12.0 g/dl

1/1/2015

G0909 Hemoglobin level measurement not documented, reason not given

1/1/2015

G0908 Most recent hemoglobin (HgB) level > 12.0 g/dl

1/1/2015

G0461 Immunohistochemistry or immunocytochemistry, per specimen; first single or multiplex antibody stain

1/1/2015

G0457 Negative pressure wound therapy, (e.g. vacuum assisted drainage collection) using a mechanically-powered device, not durable medical equipment, including provision of cartridge and dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area greater than 50 sq cm

1/1/2015

G0456 Negative pressure wound therapy, (e.g. vacuum assisted drainage collection) using a mechanically-powered device, not durable medical equipment, including provision of cartridge and dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area less than or equal to 50 sq cm

1/1/2015

G0419 Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, >60 specimens

1/1/2015

G0418 Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, 41-60 specimens

1/1/2015

G0251 Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment

1/1/2015

G0173 Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session

1/1/2015

C9735 Anoscopy; with directed submucosal injection(s), any substance

1/1/2015

C9135 Factor IX (antihemophilic factor, recombinant), Alprolix, per IU

1/1/2015

C9134 Factor XIII (antihemophilic factor, recombinant), Tretten, per 10 IU

1/1/2015

C9023 Injection, testosterone undecanoate, 1 mg

1/1/2015

C9022 Injection, elosulfase alfa, 1 mg

1/1/2015

C9021 Injection, obinutuzumab, 10 mg

1/1/2015

C1300 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval

1/1/2015

A7042 Implanted pleural catheter, each

1/1/2015

J0150 Injection, adenosine for therapeutic use, 6 mg (not to be used to report any adenosine phosphate compounds, instead use A9270)

1/1/2015

G9272 LDL value >= 100

1/1/2015

G9271 LDL value < 100

1/1/2015

G9253 Adenoma(s) or other neoplasm not detected during screening colonoscopy

1/1/2015

G9252 Adenoma(s) or other neoplasm detected during screening colonoscopy

1/1/2015

G9193 Clinician documented that patient with a diagnosis of major depression was not an eligible candidate for antidepressant medication treatment or patient did not have a diagnosis of major depression

1/1/2015

G8957 Patient not receiving maintenance hemodialysis in an outpatient dialysis facility

1/1/2015

G8932 Suicide risk assessed at the initial evaluation

1/1/2015

G8931 Assessment of depression severity not documented, reason not given

1/1/2015

G8930 Assessment of depression severity at the initial evaluation

1/1/2015

G8780 Counseling for diet and physical activity performed

1/1/2015

G8779 Diabetes screening test not performed, reason not given

1/1/2015

G8464 Clinician documented that prostate cancer patient is not an eligible candidate for adjuvant hormonal therapy; low or intermediate risk of recurrence or risk of recurrence not determined

1/1/2015

G8127 Patient with a diagnosis of major depression not documented as being treated with antidepressant medication during the entire 84 day (12 week) acute treatment phase

1/1/2015

G9248 Patient did not have a medical visit in the last 6 months

1/1/2015

G8892 Documentation of medical reason(s) for not performing LDL-C test (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate)

1/1/2015

D6975 coping

1/1/2015

D6079 implant/abutment supported fixed denture for partially edentulous arch

1/1/2015

D6078 implant/abutment supported fixed denture for completely edentulous arch

1/1/2015

D6054 implant/abutment supported removable denture for partially edentulous arch

1/1/2015

G8579 Antiplatelet medication at discharge

1/1/2015

G8552 All quality actions for the applicable measures in the ischemic vascular disease (IVD) measures group have been performed for this patient

1/1/2015

G8547 I intend to report the ischemic vascular disease (IVD) measures group

1/1/2015

G8502 All quality actions for the applicable measures in the back pain measures group have been performed for this patient

1/1/2015

G8501 All quality actions for the applicable measures in the perioperative care measures group have been performed for this patient

1/1/2015

G8492 I intend to report the perioperative care measures group

1/1/2015

G8406 Clinician documented that patient was not an eligible candidate for lower extremity neurological exam measure

1/1/2015

G8128 Clinician documented that patient was not an eligible candidate for antidepressant medication during the entire 12 week acute treatment phase measure

1/1/2015

G8126 Patient with a diagnosis of major depression documented as being treated with antidepressant medication during the entire 84 day (12 week) acute treatment phase

1/1/2015

G0922 No documentation of disease type, anatomic location, and activity, reason not given

1/1/2015

G0920 Type, anatomic location, and activity all documented

1/1/2015

G0919 Influenza immunization ordered or recommended (to be given at alternate location or alternate provider); vaccine not available at time of visit

1/1/2015

G0910 Most recent hemoglobin level <= 12.0 g/dl

1/1/2015

G0909 Hemoglobin level measurement not documented, reason not given

1/1/2015

G0908 Most recent hemoglobin (HgB) level > 12.0 g/dl

1/1/2015

G0461 Immunohistochemistry or immunocytochemistry, per specimen; first single or multiplex antibody stain

1/1/2015

G0457 Negative pressure wound therapy, (e.g. vacuum assisted drainage collection) using a mechanically-powered device, not durable medical equipment, including provision of cartridge and dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area greater than 50 sq cm

1/1/2015

G0456 Negative pressure wound therapy, (e.g. vacuum assisted drainage collection) using a mechanically-powered device, not durable medical equipment, including provision of cartridge and dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area less than or equal to 50 sq cm

1/1/2015

G0419 Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, >60 specimens

1/1/2015

G0418 Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, 41-60 specimens

1/1/2015

G0251 Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment

1/1/2015

G0173 Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session

1/1/2015

C9735 Anoscopy; with directed submucosal injection(s), any substance

1/1/2015

C9135 Factor IX (antihemophilic factor, recombinant), Alprolix, per IU

1/1/2015

C9134 Factor XIII (antihemophilic factor, recombinant), Tretten, per 10 IU

1/1/2015

C9023 Injection, testosterone undecanoate, 1 mg

1/1/2015

C9022 Injection, elosulfase alfa, 1 mg

1/1/2015

C9021 Injection, obinutuzumab, 10 mg

1/1/2015

C1300 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval

1/1/2015

A7042 Implanted pleural catheter, each

1/1/2015

J0150 Injection, adenosine for therapeutic use, 6 mg (not to be used to report any adenosine phosphate compounds, instead use A9270)

1/1/2015

G9272 LDL value >= 100

1/1/2015

G9271 LDL value < 100

1/1/2015

G9253 Adenoma(s) or other neoplasm not detected during screening colonoscopy

1/1/2015

G9252 Adenoma(s) or other neoplasm detected during screening colonoscopy

1/1/2015

G9193 Clinician documented that patient with a diagnosis of major depression was not an eligible candidate for antidepressant medication treatment or patient did not have a diagnosis of major depression

1/1/2015

G8957 Patient not receiving maintenance hemodialysis in an outpatient dialysis facility

1/1/2015

G8932 Suicide risk assessed at the initial evaluation

1/1/2015

G8931 Assessment of depression severity not documented, reason not given

1/1/2015

G8930 Assessment of depression severity at the initial evaluation

1/1/2015

G8780 Counseling for diet and physical activity performed

1/1/2015

G8779 Diabetes screening test not performed, reason not given

1/1/2015

G8464 Clinician documented that prostate cancer patient is not an eligible candidate for adjuvant hormonal therapy; low or intermediate risk of recurrence or risk of recurrence not determined

1/1/2015

G8127 Patient with a diagnosis of major depression not documented as being treated with antidepressant medication during the entire 84 day (12 week) acute treatment phase

1/1/2015

G9248 Patient did not have a medical visit in the last 6 months

1/1/2015

G8892 Documentation of medical reason(s) for not performing LDL-C test (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate)

1/1/2015

D6975 coping

1/1/2015

D6079 implant/abutment supported fixed denture for partially edentulous arch

1/1/2015

D6078 implant/abutment supported fixed denture for completely edentulous arch

1/1/2015

D6054 implant/abutment supported removable denture for partially edentulous arch

1/1/2015

G8932 Suicide risk assessed at the initial evaluation

1/1/2015

G8931 Assessment of depression severity not documented, reason not given

1/1/2015

G8930 Assessment of depression severity at the initial evaluation

1/1/2015

G8780 Counseling for diet and physical activity performed

1/1/2015

G8779 Diabetes screening test not performed, reason not given

1/1/2015

G8464 Clinician documented that prostate cancer patient is not an eligible candidate for adjuvant hormonal therapy; low or intermediate risk of recurrence or risk of recurrence not determined

1/1/2015

G8127 Patient with a diagnosis of major depression not documented as being treated with antidepressant medication during the entire 84 day (12 week) acute treatment phase

1/1/2015

G9248 Patient did not have a medical visit in the last 6 months

1/1/2015

G8892 Documentation of medical reason(s) for not performing LDL-C test (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate)

1/1/2015

D6975 coping

1/1/2015

D6079 implant/abutment supported fixed denture for partially edentulous arch

1/1/2015

D6078 implant/abutment supported fixed denture for completely edentulous arch

1/1/2015

D6054 implant/abutment supported removable denture for partially edentulous arch

1/1/2015

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

 

THE PHO (PHYSICIAN HOSPITAL ORGANIZATION) IN BRIEF

By Emilie J DiChristina for PracticeFirst

As noted last month, physicians are facing increased pressures ranging from increased competition in the market, increased managed care penetration, decreasing reimbursement and increased paperwork related to the volume of exchange plans, etc.

As a result, there are many new types of organizations offering the potential to reduce some of the impact on physicians and their practices, including PHOs, MSOs, and more,

This month we briefly review the PHO. The PHO or physician-hospital organization is a joint venture between one or more hospitals and a group of physicians.

A PHO is usually a lower end stepping stone to MSOs, IHOs or Foundation models (which we will discuss in later months). The selling points to both physicians and hospitals which make the PHO an easier sell are:

  • The ability for the parties (hospital and physicians) to present a united front to payers, particularly in the managed care arena. This allows for greater leverage when bargaining and negotiating contracts.
  • The parties also come together to develop standards of care, standardization of equipment, formularies, implants, and sometimes even staffing models as a method of controlling cost and demonstrating value.
  • There are shared services (supported financially by both parties) related to payer credentialing, quality, utilization management including care coordination – all taking pressure off of the physician offices to meet these requirements according to contract requirements.
  • There is usually an IT services component as well, assisting all parties in aggregating the data necessary to meet requirements related to demonstrating value.
  • Other than sharing services (for which there is shared financial risk), and presenting a united front to payers, each party to the PHO retains their autonomy.

Some potential downsides to the PHO include:

  • To avoid concerns of antitrust, the PHO must entail significant elements of risk sharing for the both parties.
  • Individual autonomy can result in roadblocks to agreements on standards of care, equipment to be used, and patterns of utilization reducing the PHOs bargaining power on value.

In summary, the PHO is often the starting point, and it does achieve the desired goals of increased bargaining power, increased hospital traffic to the hospital(s) part of the PHO, and certain operational efficiencies. It does not however offer the strongest corporate structures and shared risk/benefits of other models.

Look for more next mon

BILLING UPDATES – JANUARY 2014

By Sarah Howarth, Billing Manager

CHART RETURNS

Charge slips / Encounters that cannot be submitted to the insurance carrier due to pertinent billing information that is lacking are returned to your office on a weekly basis, as a Chart Return. For PF’s non-PBS Medcode Corp. clients, examples of lacking information can pertain to missing CPT codes, diagnosis codes, modifiers, dates of service, etc. For PF’s PBS Medcode Corp. clients, examples of lacking information can pertain to size of laceration, final diagnosis missing, chart pages missing, etc.

At the end of each month, you will receive a summary of all outstanding Chart Returns. These claims have not been paid or submitted to the insurance carrier. Please keep in mind that any Chart Returns that you have recently addressed may not have been reviewed by our staff yet and subsequently still appear on the month-end Chart Return summary.  

If you do not have an understanding of why the Charge slip / Encounter has been returned to you, please contact us.

UNIVERA

Beginning January 1, 2014, you may begin to see some Univera Healthcare member identification cards bearing the TPA (Third Party Administrator) logo.  Referral and preauthorization requirements for this line of business will be indicated on the back of the ID card.  Please provide Practicefirst with copies of the new insurance cards to ensure claim processing runs smoothly for your practice. 

CENTERS FOR MEDICARE & MEDICAID (CMS)

REMINDERS – MEDICARE EHR INCENTIVE PROGRAM

If you are participating in the Medicare EHR Incentive Program, you must attest to demonstrating meaningful use of the data collected in 2013 by February 28, 2014. 

2014 is the last year to begin participation in the EHR Incentive Program. The first year of participation requires reporting for a continuous 90-day period.  Reporting for following years involves meeting the requirements for the entire calendar year.

PQRS

January 1, 2014 will mark a new reporting period for the Medicare Physician Quality Reporting System. To avoid a payment reduction of 1.5% in 2016, providers must fulfill the reporting requirements for PQRS.  Providers must report on 3 measures or 1-2 measures for at least 50% of Medicare Part B patients seen in 2014. Additional information regarding the requirements for 2014 will be posted on the CMS website by December 31, 2013. 

FINALIZATION TO PHYSICIAN PAYMENT RATES FOR 2014

One of the provisions included in the CY 2014 Physician Fee schedule final rule includes a separate payment for chronic care management services which will begin in 2015.

Primary Care and Chronic Care Management: As part of CMS’s ongoing efforts to appropriately value primary care services, Medicare will begin making a separate payment for chronic care management services beginning in 2015. In last year’s final rule, CMS established separate payment for transitional care management services for a beneficiary making the transition from a facility to the community setting. In this final rule, CMS further emphasized their support for advanced primary care through their establishment of policies to facilitate separate payment for non-face-to-face chronic care management services for Medicare beneficiaries who have multiple (two or more), significant chronic conditions.

Chronic care management services include the development, revision, and implementation of a plan of care; communication with the patient, caregivers, and other treating health professionals and medication management. Medicare beneficiaries with multiple chronic conditions who wish to receive these services can choose a physician or other eligible practitioner from a qualified practice to furnish these services over 30-day periods.

To review the final policy fact sheet, please access:

http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2013-Fact-Sheets-Items/2013-11-27-2.html

VERIFYING PATIENT COVERAGE IN A HEALTH INSURANCE MARKETPLACE PLAN

CMS has issued the following guidance for the Health Insurance Marketplace:

It is the beginning of the New Year and you’ll be verifying your patient’s insurance status when they show up in your office. With the beginning of the Health Insurance Marketplace, also known as Health Insurance Exchange, over a million people will have a new insurance plan. In many cases, this will be the first time they have had insurance in years.   Many of these people will have signed up for their plan within the past few days. They may not have received their card yet or they may be unaware of the need to carry their insurance information. You may find your office needing to verify their coverage.

 How do you verify their coverage?

If the marketplace in your state is run by the Federal government, it is best to call their plan’s customer service line, a list of all plans and their customer service numbers can be found at: https://data.healthcare.gov/dataset/QHP-Customer-Service-Phone-Numbers/vryg-tdzf

 A fact sheet can be utilized for using the data base which is located:  http://marketplace.cms.gov/getofficialresources/publications-and-articles/contact-health-plan.pdf

If you can’t find the number, call the Marketplace Call Center (1-800-318-2596).

If your state has its own health insurance exchange, contact your state. To find the website for your state exchange, select the name of your state in the box at the left hand side of the health care website at:

https://www.healthcare.gov/marketplace/individual/#state=alaska

How else can you help your patient?

Remind your patients to keep all of their paperwork and receipts from all of their doctor’s appointments and from the pharmacy as well. They may need them for their insurer. Remind them they should carry their card at all times. If they don’t have a card, they can contact their plan to get a card.

 If the patient is uninsured, they have until March 31st to sign up for non-employer based coverage. They can go to HealthCare.gov to sign up for a plan and apply for financial assistance. The vast majority of uninsured will qualify for financial assistance to reduce their costs. You can also download copies of various fact sheets or educational material for your patients at: http://marketplace.cms.gov/getofficialresources/publications-and-articles/publications-and-articles.html

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