Revenue Cycle Management

Advance Care Planning

2018-09-10T05:04:00.001-04:00

CMS started paying for voluntary Advance Care Planning (ACP) from January 1, 2016.

ACP helps Medicare patients decide the plan of care that they would like to get when they are unable to take such decisions themselves.

Voluntary ACP is a face-to-face service between a physician (or other qualified health care professional) and a patient discussing advance directives with or without completing relevant legal forms. An advance directive is a document in which a patient appoints an agent and/or records the wishes of a patient pertaining to their medical treatment at a future time if they cannot decide for themselves at that time.

There are no limits on the number of times you can report ACP for a given patient in a given time period. When billing the service multiple times for a given patient, document the change in the patient's health status and/or wishes regarding their end-of-life care.

There are no place-of-service limitations on ACP services. You can appropriately furnish ACP services in facility and non-facility settings. ACP services are not limited to a
particular physician specialty.

CMS requires no specific diagnosis to bill the ACP codes.

CPT 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

CPT 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)

Retrieved from https://www.medicare.gov/coverage/advance-care-planning.html

For more information refer the following link : https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AdvanceCarePlanning.pdf

Are you Eligible for MIPS in 2018 ?

2018-05-30T07:04:00.001-04:00

You are eligible and are required to submit data for MIPS 2018, if you are a,

Physician (including doctors of medicine, doctors of osteopathy, osteopathic practitioners, doctors of dental surgery, doctors of dental medicine, doctors of podiatric medicine, doctors of optometry, and chiropractors)
Physician Assistant
Nurse Practitioner
Clinical Nurse Specialist
Certified Registered Nurse Anesthetist

OR

if you see more than 200 Medicare patients annually

OR

if you bill Medicare more than $90,000 in Allowed charges annually.

You are exempt from MIPS 2018, if you,

do not meet any of the criteria above
enroll in Medicare for the first time in 2018
participate in an advanced APM wherein you receive 25% of the Medicare payments or see 20% of the Medicare patients from an advanced APM

You can also know your MIPS 2018 eligibility by clicking this link https://qpp.cms.gov/participation-lookup and entering your 10-digit National Provider Identifier (NPI) number to view your MIPS participation status.

Abdomen X-ray coding in 2018

2018-01-12T02:35:00.001-05:00

Abdomen X-ray codes have changed, the old Abdomen X-ray codes 74000, 74020 are being deleted and are being replaced by 74018, 74019 and 74021.

As the new Abdomen X-ray codes are coded based on the number of views, from a documentation compliance standpoint it is imperative for the practice to ensure that the number of views are appropriately documented.

The new Abdomen X-ray codes are,

74018 Radiologic examination, abdomen; single view
74019 Radiologic examination, abdomen; two views
74021 Radiologic examination, abdomen; three or more views

Chest X-ray coding in 2018

2018-01-11T06:13:00.001-05:00

Chest X-ray coding has become simpler in 2018, the chest x-ray codes are some of the most frequently used imaging codes in healthcare.

Previously Chest X-ray codes used nine different codes, now these nine codes have been replaced with four codes that are simply determined by the number of views.

As the new Chest X-ray codes are coded based on the number of views, from a documentation compliance standpoint it is imperative for the practice to ensure that the different types / number of views are appropriately documented.

The new Chest X-ray codes are,

71045 Radiologic examination, chest; single view
71046 Radiologic examination, chest; 2 views
71047 Radiologic examination, chest; 3 views
71048 Radiologic examination, chest; 4 or more views

Merit-Based Incentive Payment System (MIPS)

2017-11-17T03:43:00.001-05:00

MACRA replaced three Medicare reporting programs with MIPS (Medicare Meaningful Use, the Physician Quality Reporting System, and the Value-Based Payment Modifier).

Under the combination of the previous programs, you would have faced a negative payment adjustment as high as 9% total in 2019, but the MACRA ended those programs, reduced the potential negative payment adjustments in the early years, and streamlined the overall requirements. While these three programs will end in 2018, if you have participated in these programs in the past, then you will have an advantage in MIPS because many of the requirements should be familiar.

To check if you need to submit data to MIPS, enter your 10-digit National Provider Identifier (NPI) number in the link below,

https://qpp.cms.gov/participation-lookup

MACRA defined four performance categories for MIPS, linked by their connection to quality and value of patient care.

Quality : Replaces the Physician Quality Reporting System (PQRS)

Most participants: Report up to 6 quality measures, including an outcome measure, for a minimum of 90 days.

Groups using the web interface: Report 15 quality measures for a full year. To submit data as a group through the CMS Web Interface, you must register your group between April 1, 2017 and June 30, 2017.

Groups in APMs qualifying for special scoring under MIPS, such as Shared Savings Track 1 APM or the Oncology Care Model one-sided risk APM: Report quality measures through your APM. You do not need to do anything additional for MIPS quality.

Advancing Care Information : Replaces the Medicare EHR Incentive Program, also known as Meaningful Use

Fulfill the required measures for a minimum of 90 days:

Security Risk Analysis

e-Prescribing

Provide Patient Access

Send Summary of Care

Request/Accept Summary of Care

Choose to submit up to 9 measures for a minimum of 90 days for additional credit.

For bonus credit, you can:

Report Public Health and Clinical Data Registry Reporting measures

Use certified EHR technology to complete certain improvement activities in the improvement activities performance category

You may not need to submit advancing care information if these measures do not apply to you.

Improvement Activities : New category

Most participants: Attest that you completed up to 4 improvement activities for a minimum of 90 days.

Groups with fewer than 15 participants or if you are in a rural or health professional shortage area: Attest that you completed up to 2 activities for a minimum of 90 days.

Participants in certified patient-centered medical homes, comparable specialty practices, or an APM designated as a Medical Home Model: You will automatically earn full credit.

Participants in certain APMs under the APM scoring standard, such as Shared Savings Program Track 1 or OCM: You will automatically receive points based on the requirements of participating in the APM. For all current APMs under the APM scoring standard, this assigned score will be full credit. For all future APMs under the APM scoring standard, the assigned score will be at least half credit.

Cost : Replaces Value-Based Modifier

No data submission required. Calculated from adjudicated claims.

Retrieved from https://qpp.cms.gov/

Quality Payment Program - MACRA

2017-11-17T03:42:00.001-05:00

The Quality Payment Program that is part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) improves Medicare by helping Providers focus on care quality and the one thing that matters most — making patients healthier. The Quality Payment Program is focused on moving the payment system to reward high-value, patient-centered care.

The Quality Payment Program has two tracks you can choose from:

1). Advanced Alternative Payment Models (APMs)

2). The Merit-based Incentive Payment System (MIPS).

Participate in the Advanced APM track:

If you receive 25% of Medicare covered professional services or see 20% of your Medicare patients through an Advanced APM in 2017, then you earn a 5% Medicare incentive payment in 2019.

You are eligible to participate in the MIPS track of the Quality Payment Program if you bill more than $30,000 to Medicare, and provide care to more than 100 Medicare patients per year, and you are a : Physician, Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Certified Registered Nurse Anesthetist. If 2017 is your first year participating in Medicare, then you are not required to participate in the Quality Payment Program in 2017.

Participate in the MIPS track:

If you choose the MIPS track of the Quality Payment Program, you have four options.

1.Don't Participate
Not participating in the Quality Payment Program: If you don't send in any 2017 data, then you receive a negative 4% payment adjustment.

2.Submit Something
Test: If you submit a minimum amount of 2017 data to Medicare (for example, one quality measure or one improvement activity), you can avoid a downward payment adjustment.

3.Submit a Partial Year
Partial: If you submit 90 days of 2017 data to Medicare, you may earn a neutral or small positive payment adjustment.

4.Submit a Full Year
Full: If you submit a full year of 2017 data to Medicare, you may earn a moderate positive payment adjustment.

The size of your payment adjustment will depend both on how much data you submit and your quality results.

Retrieved from https://qpp.cms.gov/

ICD 10 - Improving Clinical Documentation

2015-10-08T06:58:00.001-04:00

ICD-10 is finally here and what most of us do not realize is that, it is just not enough that we are able to code in ICD-10 and get the claims billed out, we need to ensure that the documentation is specific and supportive of the ICD-10 diagnoses billed.

We need to make sure that our clinical services are documented in greater detail, so that the documentation supports a more specific ICD-10 code. Physicians / staff involved in creating the documentation need to become more accustomed to the specific, detailed clinical documentation needed to assign ICD-10 codes.

For example, laterality is expanded in ICD-10-CM. Therefore, clinical documentation for diagnoses should include information about which side of the body is affected (i.e., right, left, or bilateral).

Some of the Clinical parameters that we need to document as per the diagnosis/condition, in order to be able to code in ICD-10-CM are,

Clinical Documentation Parameters:

Onset - when did it start
Manifestation - Paralysis, Loss of Consciousness
Comorbidities
Etiology/Causation - Infectious agent, Physical agent, Internal failure, Congenital
External Causes - Motor vehicle, Injury, Assault, Accidental, Work related, Intentional Self harm
Complication
Detailed Anatomical Location - Proximal, Distal, Medial, Lateral, Central, Peripheral, Superior, Inferior, Anterior, Posterior
Functional Impairment
Biological & Chemical Agents
Phase/Stage
Lateralization /Localization - Rt side, Lt side, Bilateral or Unilateral
Severity - Mild, Moderate or Severe
Time Parameters - Intermittent, Recurring, Postoperative, Postdelivery
Encounter type - Initial, Subsequent
Healing Level - Routine healing, Delayed healing, Non-Union, Malunion e.t.c

Below are some examples of the specific information that would have to captured and documented to accurately code the following common diagnoses in ICD-10:

Diabetes Mellitus:

Type of diabetes
Body system affected
Complication or manifestation
Long-term insulin use

Fractures:

Site
Laterality
Type - open, closed
Encounter type - Initial, Subsequent
Healing Level - Routine healing, Delayed healing, Non-Union, Malunion e.t.c

Injuries:

Place of occurrence
External cause - Cause of injury, how the injury happened
Activity code - what the patient was doing at the time of the injury ?
External cause status - Injury related to military, work or others

It will be important to make your documentation as detailed as possible, since ICD-10-CM gives more specific choices for coding diagnoses. This information is likely already being shared by the patient during the encounter, it is a matter of capturing all the pertinent information so that we can choose the most appropriate ICD-10 Dx. Proper documentation helps to reduce denials and increase compliance.

New Patient or Established Patient ?

2014-12-03T03:20:00.001-05:00

Who is a New Patient ? When do we bill a New Patient ? When does a Patient become an Established Patient ? These are some of the questions that confuse some practices when billing New/Established patients.

There are instances when a patient is seen by a Physician in the Hospital and in the Office and many Practices are not clear as to how to bill the patient visit.

Determining whether a Patient visit is to be billed as a New Patient visit or an Established Patient visit has significant implications from a Clinical, Financial, Billing and Coding standpoint.

"A New Patient visit is an evaluation and management service provided to a patient who has not received any face-to-face service from any physician of the same specialty who belongs to the same group practice for at least three years".

Conversely an "Established Patient visit is an evaluation and management service provided to a patient who has already received any face-to-face service from any physician of the same specialty who belongs to the same group practice in the last three years".

An established patient is one who has received professional services from the physician/qualified health care professional or another physician/ qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years - See more at: http://www.aap.org/en-us/professional-resources/practice-support/Coding-at-the-AAP/Pages/New-Vs-Established-Patient.aspx#sthash.O0LGrQSh.dpuf

New Patient visits

1. Patient John Doe comes to see Dr A in his practice after a period of 4 years.

2. Patient John Doe was seen by another physician belonging to a different specialty in the same multispecialty practice, but Patient John comes to see Dr A for the first time.

Established Patient visits

1. Patient John Doe comes to see Dr A in his practice for the first time, Dr A has never seen Patient John before but Dr B another physician in Dr A's practice has seen patient John last year.

2. Patient John Doe was seen by Dr A in the hospital a month ago, he comes to see Dr A in his practice for the first time. Since Dr A has seen patient John within the last 3 years, the office visit becomes an Established visit.

E&M and other Procedures

2014-10-23T07:37:00.001-04:00

In a Patient encounter we might perform procedures apart from the regular E&M procedure, in such instances payors would deny the E&M procedure but would pay the additional procedure alone.

Let us take an example of an encounter where a Trigger Point Injection (CPT 20553) is given and an E&M procedure (99213) is also performed.

The procedure 20553 has an Evaluation component built into its reimbursement, this is the reason why payors may deny the payment for the E&M procedure. So the Payors are right in denying the E&M procedure if the E&M procedure is not distinct and not separately identifiable from the other procedure performed.

But We are definitely allowed to bill a Procedure (20553) and a distinct E&M service (99213) on the same visit, as long as the E&M service is separate and distinct from the procedure, and the same is documented in the progress notes. A distinct E&M service refers to an evaluation where the service is significant and separately identifiable from the other procedure.

An example would be :

20553 Trigger point Inj
99213 - 25 E&M service for HTN, DM, CAD

Here the E&M service is separate and distinct from the Procedure 20553, the E&M service needs to be submitted with modifier 25 to indicate that it is separate from the other procedure performed. If the E&M service is submitted without the 25 modifier, it would be denied.

E&M Coding & Documentation Guidelines

2014-09-12T07:07:00.001-04:00

It is essential that we code and document every patient encounter accurately so as to maximize revenues and avoid potential audits and recoupments later. It is imperative that we document all procedures that are performed. Any procedure that is not documented would be considered as not performed by the payors.

While coding the E&M codes, we need to be careful in choosing the right level of code. We should choose the right E&M code level based on the Complexity of MDM (Medical decision making that is involved in the evaluation of the patient), once we arrive at the level of code based on the level of medical decision making : MDM, we need to ensure that we have sufficiently documented the progress note to support the required level of History and Physical Exam.

For e.g if you see a Patient for f/u in hospital for whom the MDM is moderate then as per MDM which points to level 2, we should code only level 2 CPT 99232 and we need to document a EPF (Expanded problem focused) History and an EPF Exam, this would ensure that we comply with regard to Coding and Documentation
guidelines

Instead for the same patient if we have not adequately documented the progress note, let us assume that we have documented only a PF History and PF Exam and have billed CPT 99232, then we may get paid for CPT 99232, but in case of an audit later, CMS / other payors could recoup the payment for inadequate documentation

Another scenario for the same patient would be wherein, we have documented more than what is needed, let us assume that we have documented a Detailed History and a Detailed Exam and have billed CPT 99233 instead of CPT 99232 as per MDM, then again CMS / other payors may recoup the payment for lack of medical necessity / upcoding.

Hope the above examples give you some idea as to Coding the levels and the documentation required. Please refer the below link for CMS manuals on Coding and Documentation. http://www.cms.gov/Outreach-and-Education/Outreach-and-Education.html

Prolonged Services codes CPT 99354 - 99357

2014-08-12T08:09:00.001-04:00

Prolonged Services billing is allowed by Medicare in the Office, other Outpatient and Inpatient settings, the Prolonged Service codes are used as add-on codes to E&M codes to indicate the extra time that the Physician has spent face-to-face with the patient.

The Prolonged Service codes are billed based on the length of time spent with the patient beyond the usual time required for the E&M code billed, the time spent with the patient need not be continuous but it must be time spent in one calendar day and must be time spent face-to-face with the patient.

For Office/Outpatient settings :

CPT 99354 can be billed when the provider spends direct face-to-face time of more than one hour beyond the usual service/typical time for the E&M code. Additional 30 minutes of face-to-face time with patient can be reported by CPT Code 99355.

For Inpatient settings :

CPT 99356 can be billed when the provider spends direct face-to-face time of more than one hour beyond the usual service/typical time for the E&M code.
Additional 30 minutes of face-to-face time with patient can be reported by CPT Code 99357.

Prolonged service cannot be billed when the prolonged service duration is less than 30 minutes as then it would be considered as included in the E&M code billed.

Prolonged services of less than 15 minutes beyond first hour or less than 15 minutes beyond the final 30 minutes cannot be billed.

Total time of Prolonged services	Outpatient	Inpatient
(do not include visit code time)	Prolonged Services Code	Prolonged Services Code
Less than 30 minutes	Not reported	Not reported
30 – 74 minutes	99354	99356
75 – 104 minutes	99354 and 99355	99356 and 99357

As regards the documentation, the documentation needs to be explicit, documentation is required to be in the medical record about the duration and content of the medically necessary evaluation and management service and prolonged services that you bill.

You must sufficiently document in the medical record that you personally furnished the direct face-to-face time with the patient specified in the CPT code definitions. The progress note has to have the start and end times of the visit, along with the date of service.

Signing of Medical Records

2014-08-08T04:13:00.001-04:00

Medical Records need to be signed once the services are rendered, the medical record is authenticated when a Provider signs the document.

Payers expect records to be signed within 24 Hrs after services are rendered. In the case of EHR, the records need to be signed electronically.

Medical records that are not signed and records that are signed after a unreasonable delay may not be accepted and could lead to financial and legal implications.

Importance of Documentation

2014-08-08T03:55:00.001-04:00

Medical Documentation is very important from a Clinical, Financial and Legal standpoint.

From a Clinical perspective medical documentation establishes the following,

the Patient receiving the Service
the Physician providing the Service
the Plan of Care provided by the Physician
the Diagnosis justifying Medical necessity
the Procedures performed, the Labs ordered
the Quantity of Service such as consumables
other details such as Place of service / Date of service e.t.c

From a Financial perspective medical documentation establishes the following,

proper adjudication of claims
timely payment of claims

From a Legal perspective medical documentation establishes,

the justification for the procedures performed
Legal protection for the Patients and Physicians

The Physician / Provider has to document all the procedures performed and sign the document, procedures that are not documented would be considered as not performed and would not be eligible for payment.

Modifiers 52 & 53

2012-09-14T02:38:00.001-04:00

The usage of Modifiers 52 & 53 is very clear and straightforward but still many claims have these modifiers applied incorrectly opening up the possibility of a recoupment later on.

52 Modifier - Reduced Services.

In many instances a procedure or service is reduced at the discretion of a physician.

We need to apply the 52 modifier to that CPT code, when the physician is performing a reduced procedure rather than the entire procedure, as denoted by the CPT code and when that reduced procedure does not have a specific CPT code for billing. The 52 modifier should not be applied to a CPT code, when the procedure that was planned had to be discontinued / terminated for any reason whatsoever. In these instances we need to use modifier 53 to indicate that the procedure was discontinued.

If the reduced procedure is surgical, the claim needs to submitted with an Operative report and a separate report detailing how the reduced procedure differs from the normal procedure.

For procedures that are non-surgical, a report detailing how the reduced procedure differs from the normal procedure needs to be sent alongwith the claim.

Example :

The provider is planning on performing pure tone audiometry, air only, for a patient on only one ear. There is no CPT code for this test when performed on one ear, while we have CPT code 92552 pure tone audiometry (threshold), air only, for both ears ( bilateral procedure ).

In this instance since the provider plans to perform the test for one ear only, this becomes a reduced procedure. Hence we need to append modifier 52 to CPT code 92552.

53 Modifier - Discontinued Procedure.

In many instances a surgical or diagnostic procedure may need to be terminated / discontinued due to various reasons.

A procedure that was initiated may need to be terminated / discontinued due to various reasons, in such cases we need to apply Modifier 53 to the CPT code. A procedure may be discontinued / terminated due to various reasons, such as the patient not being able to tolerate the procedure. The 53 modifier basically indicates that the procedure was initiated but not completed.

If the discontinued procedure is surgical then a Operative report needs to be sent alongwith the claim.

For procedures that are non-surgical, a report detailing how the discontinued procedure differs from the normal procedure needs to be sent alongwith the claim.

The 53 modifier cannot be used, if a Procedure is discontinued by the Physician before administering anesthesia or surgical preparation in the operating room.

Example :

Colonoscopy was initiated on a patient. Polyps were removed by hot biopsy from the descending colon. The provider then attempted to move the colonoscope past the splenic flexure but due to a tortuous colon / blockage the colonoscope could not advance past the splenic flexure. The procedure was hence discontinued.

In this instance the physician had initiated a Colonoscopy by Hot biopsy CPT 45384, but the procedure was discontinued as the colonoscope could not move past the splenic flexure. Hence we need to append mofifier 53 to CPT code 45384.

Hemodialysis & E & M visits

2012-08-14T06:21:00.001-04:00

In general when Hemodialysis is billed alongwith an E&M procedure, the Hemodialysis procedure alone is paid while the E&M procedure is denied.

This is because the Hemodialysis procedure has an E&M component built into it and hence the additional E&M procedure is denied. The Evaluation and Management services related to dialysis treatment for ESRD are included in the Dialysis codes and so are not separately reimbursable.

However an E&M can be billed if it is for a separate and distinct service.

For example if a Physician treats a separate and unrelated condition, than the E&M code can be billed with modifier 25, the important point to note is that the documentation should substantiate that the E&M is for a separate and identifiable service apart from the Dialysis procedure on the same day.

Services that are generally included into the Dialysis code are the Physician's evaluation, treatment plan, phone calls, counselling, physician laboratory visits and overall management of the patient.

Key Indicators

2012-05-31T03:18:00.001-04:00

Knowing whether your practice is doing well financially is important for the successful running of any practice. Many practices flounder and go bankrupt because they were not monitored properly, leading to their financial ruin.

There are some key indicators which would guide us to make major course corrections where necessary, to bring the practice back on track. Monitoring these key indicators on a regular basis, will ensure that your practice remains financially healthy and continues to run smoothly.

Visits :
The number of Patient visits per month is a straightforward indicator, that is directly proportional to the monthly revenue.

New Patients :
Practices need to ensure that the percentage of New Patients to the total monthly visits is on the increase or steady, on a monthly basis, this would ensure that Old Patients dropping out are compensated by the New Patients, otherwise we would see a drop in the monthly revenue of the practice. When we see the percentage of New Patients decreasing on a monthly basis, this should serve as a warning for us to make course corrections in our practice.

Payor Mix :
An analysis of the Payorwise monthly collections will help us to identify which Payors contribute the most to the revenue of the practice and which payors will significantly impact the practice when their reimbursements change.

Days in AR :
Practices need to know how many days it takes, for them to collect one days charges. The days in AR reflect how quickly and efficiently the practice is able to work the AR and get paid. Higher the Days in AR could be due to a whole host of problems such as Charge / Demographic entry errors, Coding errors, delayed claim submission, not working the clearing house reports, improper handling of denials and poor AR management. Practices should aim to keep the days in AR under 40.

AR aging :
The AR bucketwise aging is an indicator of how the AR is distributed across different buckets. We can have upto 70% AR (70% of Average monthly charges) in the 0-30 day bucket, upto 15% AR in 30-60 day bucket, upto 10% AR in the 60-90 day bucket, upto 5% AR in the 90-120 day bucket and upto 25% AR in the 120+ days bucket. High AR in the 0-30 day bucket could be due to Charge entry errors, Demographic entry errors, Coding errors or delays in claim submission, high AR in the later buckets could point to improper denial / AR management.

Gross Collection Rate :
The ratio of Actual Collections to Total Charges for a month would be a good indicator of how well we are collecting against the total charges billed. But this ratio needs to be reviewed based on your contractual adjustments. So if you are overbilling your allowed amount by 180 % then a Gross Collection Ratio of 45-50 % is fine.

Net Collection Rate :
The ratio of Actual Collections to Net Charges (Total Charges Less Adjustments) for a month would be a more accurate indicator, than the Gross Collection Rate, of how well the practice is collecting its receivables, since this ratio measures Actual Collections against Actual Collectables, practices should aim for a ratio of 95% or higher.

Preventive Services

2012-05-22T05:53:00.001-04:00

Medicare has been reimbursing certain Preventive Services such as Annual Wellness Visits, Cardiovascular Disease Screenings, Diabetes Screening Tests, Screening Pelvic Exam, Glaucoma Screening, Smoking and Tobacco Cessation Counseling e.t.c for some time now.

Recently Medicare has started covering for Screening and Behavioral Counseling to reduce Alcohol misuse and Face-to-Face Behavioral Counseling for Obesity.

Alcohol misuse :

Effective for claims with dates of service October 14, 2011, and later, CMS shall cover annual alcohol screening, and for those that screen positive, up to four, brief, face-to-face behavioral counseling interventions per year for Medicare beneficiaries, including pregnant women.

Obesity Therapy :

Effective for claims with dates of service on or after November 29, 2011, CMS will allow coverage for Face-to-Face Behavioral Counseling for Obesity, 15 minutes, G0447, along with 1 of the ICD-9 codes for BMI 30.0-BMI 70 (V85.30- V85.39 and V85.41- V85.45), only when submitted with one of the following place of service (POS) codes: 11 – Physician’s Office, 22 – Outpatient Hospital, 49 – Independent Clinic or 71 - State or Local Public Health Clinic.

For more information on Medicare preventive services, visit http://www.cms.gov/PrevntionGenInfo on the CMS website.
For more information on Medicare Learning Network® (MLN) preventive services educational products, visit http://www.cms.gov/MLNProducts/35_PreventiveServices.asp on the CMS website.

Source CMS

Referral vs Authorization

2012-05-18T06:39:00.001-04:00

A Referral is not the same as an Authorization.

In general a referral is required when a PCP refers a patient to a specialist in-network provider for consultation, while an Authorization also known as Prior Authorization, is approval from the Insurance plan for the performance of certain specific medical procedures and services, based on medical necessity.

A typical scenario would be a PCP referring a patient to a in-network Nephrologist. A referral would be required without which the Insurance plan will not pay. If the Nephrologist performs only an evaluation, the referral alone would suffice, but if the Nephrologist chooses to administer a Procrit injection, than this procedure ( which is on the Prior authorization list of the Insurance plan ) would require a Prior authorization for the Insurance plan to make payment.

Referral :

A referral is required when a PCP refers a patient to a specialist
HMO Plans in general require a referral while PPO plans do not require a referral
A referral is valid for a certain period and for a certain number of visits
A referral is not required for Emergency services
A referral is not required for Routine / Preventive services
Without a referral the insurance plan will not pay

Prior Authorization :

A Prior authorization is required when a provider plans on performing a procedure which is on the Prior authorization list of the Insurance plan
A Prior authorization needs to be obtained from the Insurance plan before the performance of the medical procedure
A Prior authorization is provided by the Insurance plan when they are satisfied as to the medical necessity of the procedure
A Prior authorization is not required for Emergency services
Without a Prior authorization the Insurance plan will not pay for procedures that are on its Prior authorization list

Annual Wellness Visit

2012-01-04T04:07:00.004-05:00

From January 1, 2011 Medicare has initiated the Annual Wellness Visits. Medicare uses the codes G0438 and G0439 for these wellness visits.

G0438 Initial visit

Annual wellness visit, consisting of a personalized prevention plan of service (PPPS), first visit.

G0439 Subsequent visit

Annual Wellness visit, consisting of a personalized prevention plan of service (PPPS), subsequent visit.

Annual Wellness Visits can be for both new or established patients. The initial AWV, G0438, is used for patients enrolled with Medicare for more than a year.

A patient becomes eligible for their subsequent AWV, G0439, a year after the initial visit. During the first year a patient has enrolled with Medicare the patient is eligible for the Welcome to Medicare visit or IPPE, Initial Preventive Physical Exam. This visit is billed using HCPCS code G0402. The Annual wellness code of G0438 should not be used in this scenario and will be denied since the patient is eligible for the Welcome to Medicare visit G0402 during the first year.

Initial Annual wellness visit consists of,

– Medical and family history

– List of current providers

– Height, weight, BMI, BP and other parameters

– Detection of cognitive impairment

– Review risk factors

– Review of functional ability

– Establish a written screening schedule for next 5-10 years

– Establish list of risk factors

– Provide advice and referrals to health education and preventive counseling services

– Other elements as determined by the Secretary of Health and Human Services

The above list is just a summary. Check out http://www.cms.gov/MLNMattersArticles/downloads/MM7079.pdf for additional information and links to other Medicare resources on services that must be provided at the AWV and subsequent AWV.

5010

2012-01-03T07:05:00.001-05:00

The U.S. Department of Health and Human Services has issued a final rule to transition to the next generation of HIPAA electronic transaction standards (5010) by January 1, 2012.

January 1, 2012: Any healthcare entity that submiting electronic claims must comply with HIPAA 5010 by January 1, 2012. After January 1, version 4010A will no longer be valid.
Payors will reject any electronic claims that are not HIPAA 5010 compliant. This will impact claim payments. The new HIPAA 5010 standards has improved functionality and fully support NPI and the new International Classification of Diseases, Tenth Revision (ICD-10) code sets.

Why 5010 ?

The current format, is unable to meet some important new developments in health care such as supporting the ICD-10 code set and pay for performance. Other changes in the 5010 version will streamline reimbursements. Most of the changes are technical and geared toward improved standardization and uniformity. Many of these can be handled by your vendor and clearinghouse. However, it is important that you understand your own responsibilities in order to become 5010 compliant.

Billing Provider Address

With 5010, the Billing Provider Address you use on claims must be a physical address? Once 5010 is implemented, you can no longer use PO Box and lock box addresses as a billing provider address. This rule applies to both professional and institutional claim formats. However, you can still use a PO Box or lock box address as your location for payments and correspondence from payers as long as you report this location as a pay-to address. The pay-to- provider address is only needed if it is different than that of the billing provider. Work with your software vendor to ensure the correct addresses are captured and inserted in the necessary locations on your claim submission.

Nine Digit Zip Codes

In 5010, providers must submit a full 9-digit ZIP code when reporting billing provider and service facility locations? An easy way to determine the 4-digit extension to your standard ZIP code is to look it up on the U.S. Postal Service’s ZIP Code Lookup Tool. Work with your software vendors to ensure they can capture the full nine digits for the billing provider and service facility addresses.

Anesthesia Claims

In 5010, you must report anesthesia services in minutes rather than units if the procedure code does not define a specific time period? However, if the procedure code has minutes in its description, then you can continue to report those charges in units.
When you need to manually calculate the time period, you can only use minutes for the time measurement. For example, if the total time of anesthesia services is one hour and thirty minutes, services should be submitted as 90 minutes.
Anesthesia providers should verify that their systems can manage this change.

Subscriber vs. Patient Clarification

With 5010, the insurance plan subscriber/patient hierarchy has been clarified. Two possible situations can occur:

If the patient has a unique member identifier assigned by the payer, then the patient is considered to be the plan subscriber and is sent as the subscriber. There is no need to also enter their information in the patient section on the claim.
If the patient is a dependant of the plan subscriber and does not have their own unique member identifier, then both the subscriber and patient information will be required on the claim.

Providers must check the patient’s insurance card and/or check patient eligibility to ensure the information is appropriately documented for accurate submission in 5010.

Drug Reporting

In 5010, professional claims for injectable medications must include additional drug information and qualifiers, such as National Drug Code (NDC), quantity, composite unit of measure and prescription number.
Currently providers must submit a HCPCS code as the service-line procedure along with the total charge and units of service. In 5010, you will now be required to also submit the NDC Drug Quantity and Composite unit of measure. Providers who submit service-line drug charges must work with their software vendor to ensure that the drug quantity and unit of measure can be submitted. Claims that do not include this information may be rejected.
Providers should work with their software vendors to determine if the product supports these and other drug entry changes.

Compound Drug Claims

The 4010 standards made it difficult to select a single HCPCS code for a compound injectable medication because each ingredient pointed to a different HCPCS code. In 5010, all ingredients that make up a compound prescription must be identified on the claim, and a unique HCPCS must be assigned to each ingredient. The provider will be required to enter separate lines of service for each HCPCS. As with single ingredient drugs, the provider must also include their service line charge for each ingredient, the service line associated units, the NDC number, the NDC Drug Quantity, and the Composite unit of measure.
Providers should work with their software vendors to determine if the product supports these and other drug entry changes.

Durable Medical Equipment

The Durable Medical Equipment (DME) Service segment (2400 SV5) is used when it is required to report both the rental and purchase price information for durable medical equipment at the service line level. In 4010, only the procedure code, unit of measurement and quantity were required for this entry. In 5010, the DME Rental Price, DME Purchase Price and Rental Unit Price Indicator will also be required. If all three of these fields do not contain a valid value, the claim will be rejected.
Some claims may also require the DME Condition Indicator segment (2400 CRC) for a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN), a DMERC Information Form (DIF), or an Oxygen Therapy Certification. In 4010, you could repeat the segment more than once, but 5010 limits you to one DMERC condition indicator segment per service line. The number of condition indicator codes for this segment has also been reduced from five possible codes in 4010 to only two codes in 5010. If invalid indicator codes are used, the claim will be rejected.

Ambulance Claims

In 5010, ambulance suppliers who submit medical transportation claims will be required to report the pick-up and drop-off locations for ambulance transport. Previously, there were no dedicated fields for this information, but now it can be reported at the claim level (5010 loops: 2310E and 2310F) and service line level (5010 loops: 2420G and 2420H). 5010 also added another new segment (2400 QTY) that will be required to report the number of patients transported in the same vehicle for ambulance or non-emergency transportation services.
Additionally, CMS currently does not require ambulance suppliers to submit a diagnosis code on claims for payment. However, in 5010, a diagnosis code must be present on all professional electronic claims, including ambulance claims.
Your billing systems will need to be able to capture and report this information on your electronic claims to avoid rejection.

Line Item Control Number

While some practices have been entering a unique line item control number for each line of service for each patient, it will now be required to be unique in 5010. The line item control number segment is not required but if it is sent it will need to be unique to each line of service. In addition, payers are required to return the line item control number in the electronic remittance advice (ERA) transaction when the provider includes it in the original electronic claim or when they have split the claim or line item. This change is helpful because receiving the unique line item control number within the ERA gives you the capability to automatically post by service line.
If providers send a line item control number they should work with their software vendors to verify that their systems can create a unique line item control for each line of service.

Health Care Diagnosis Codes for Professional Claims

One of the main purposes of 5010 is to support the upcoming change to ICD-10 diagnosis and procedure codes – a change providers must make by October 1, 2013. To help prepare for ICD-10, 5010 now requires a Diagnosis Code on all claims, and the maximum number of Diagnosis Codes was increased from eight in 4010 to 12 in 5010. Although you can report 12 diagnosis codes at the claim level, you can only point or link four codes to a specific service at the service line level.
You need to work with your software vendor to ensure you have the ability to report the number of required diagnosis codes.

Primary Identification Code Qualifiers

Previously, you were allowed to report an Employer’s Identification Number (Tax ID) or Social Security Number (SSN) as a primary identifier for the billing provider. In 5010, you are only allowed to report a National Provider Identifier (NPI) as a primary identifier (ANSI loop 2010AA NM108/NM109). If the billing provider does not qualify for an NPI number, such as an Atypical provider, then only the Tax ID or SSN would be allowed in the REF segment of the billing provider loop.
In addition, 5010 standards have eliminated the use of payer-specific provider numbers in favor of NPI and Tax ID numbers.

R A C

2011-11-15T03:38:00.003-05:00

The RAC program has been established to identify and recover improper Medicare payments to providers that are under fee-for-service Medicare plans, including medical practices, hospitals and nursing homes.

Practices that bill Medicare may be subject to an audit to review inaccurate reimbursements and may be required to refund the money back to Medicare. There are four RACs, each pertaining to a region of the country.

Types of government audits :

Medicaid Integrity Contractors (MICs) conduct audits of Medicaid claims instead of Medicare. Unlike RACs and Zone Program Integrity Contractors (ZPICs), whose appeal processes are determined by federal regulations, MIC appeals processes vary by state.

ZPIC audits look for cases of fraud by analyzing claims data.

Medicare Administrative Contractor (MAC) audits determine whether particular billed services are medically necessary and should be covered under Medicare.

Looking to eliminate Medicare overpayments to providers, the Centers for Medicare and Medicaid Services from 2005 until early 2008 conducted pilot tests of a new program to audit provider billings, called the Medicare Recovery Audit Contractor program.

Medicare started rolling out the RAC program nationwide during 2009. But 2010 was when its effects were widely felt by hospitals, with some health systems undergoing multiple RAC audits while others were notified they'll soon be up to bat. CMS intends to eventually audit all U.S. hospitals, and is now expanding the RAC program to physicians, laboratories, pharmacies and other providers.

There was no shortage of health care payer audit programs before RACs came around. Medicare already conducts audits under the Medicare Administrative Contractors program, state Medicaid agencies have audit programs, and so do commercial insurers and quality improvement organizations. And a proposed federal rule published in November 2010 has put the wheels in motion for establishment of Medicaid RAC programs.

Lately, commercial carriers are starting to copy RACs and that has really increased audits across the country.

RAC Audits :

There are two types of RAC audits-automated and complex. An automated review, also called a claims review, is a computerized analysis of a provider's Medicare claims based on algorithms that look for specific discrepancies in the claims. These include medical procedure that don't match the patient's age or gender, inpatient claims without a discharge disposition, or two or more units for a colonoscopy when only one unit can be billed a year.

Medicare has contracted with four companies to serve as the Recovery Audit Contractors in four regions that span the nation. These contractors can and do subcontract with other companies to conduct audits.

RACs can conduct an automated review anytime without notifying providers. Following an automated review that finds discrepancies, a RAC will send a "demand letter" to a provider organization identifying the overpayments found and stipulating reimbursement. RACs also are finding underpayments in favor of providers, but those account for about a fifth of the findings.

Under a complex audit, RACs can demand up to 300 medical charts from a hospital every 45 days, based on Medicare claims volume, for comprehensive review. These charts include any paper and electronic documentation that support a flagged encounter.

How RACs work :

The biggest difference with the RAC program compared with other payer audits is how contractors are reimbursed. Contractors for other audit programs get paid a fixed amount for doing their work. But RAC contractors get paid via contingency fees. They make money finding overpayments and underpayments, and the more they find the more money they make. So, RACs tend to be more aggressive than other audit programs.

The payment set-up for RACs has been perceived as bounty-hunting by many industry stakeholders.

Physician practices also fall under the RAC program. The number of records that can be demanded every 45 days for a complex review is based on the practice size and tops out at 50 for the largest practices. RAC auditors spent much of 2010 focused on automated reviews of hospital claims, which give quick results and cash in the door, with complex hospital reviews and physician audits starting to build toward year-end.

Following the receipt of a demand letter, a provider can appeal the findings and present documentation to support its position.

After a provider submits the requested medical records for a complex audit-with the RAC contractor, the contractor then has 60 days to review the records and inform the provider of findings.

Providers increasingly are using software specifically designed for the RAC program and embedded with the RAC rules to manage request fulfillment within 45 days, and generating supporting documentation to use during the appeals process.

ACOs In Practice

2011-11-02T02:20:00.007-04:00

The accountable care organization ( ACO ) is a new model that has been proposed for health care reform.

The primary objectives of the ACO are to reduce costs, increase efficiency and improve the quality of patient care. The payer is basically aiming to reduce costs and at the same time improve quality of care. Since payers would give the ACO's a lump sum to cover all care, the ACO's would retain any savings that result from more efficient patient care. This is supposed to be the motive for physicians and hospitals to ensure that the patient is healthy and out of the hospitals and not do more procedures.

The ACO members will share in the savings that results from their cooperation and coordination. Thus, ACOs can–theoretically–act as a reform tool by incentivizing more efficient and effective care. This would help to combat the current perverse incentives of overutilization and overbuilding of health care facilities and technology.

ACOs In Practice :

The ACO would have to be a legal organization that can receive shared savings, and would have to incorporate primary care physicians who solely practice under the ACO. Furthermore, there would have to be at least 5,000 beneficiaries in the ACO for it to be viable. The ACO would provide CMS with a list of their providers willing to participate in the ACO. The beneficiaries would be determined by, among other things, the patterns of patient referrals in the region. However, beneficiaries would not be “locked in” to a given provider. The ACO would receive savings if their risk-adjusted, per beneficiary spending levels were below their benchmark.

An Example :

An hypothetical independent practice association (IPA) teams up with a community hospital to create an ACO. Medicare determines a benchmark, that is, what it will cost to treat the average beneficiary in that geographic area per year–let’s say $10,000. The physicians submit their traditional claims to Medicare under the RBRVS system while the hospital submits its typical DRG-base claim. Thus, the traditional fee-for-service system remains in place. At the end of the year, Medicare determines if the ACO has provided care for less than $10,000. If they have, the ACO is entitled to share in the cost savings, and the savings are divided among the providers and hospital. Though simple in theory, ACOs become more difficult when attempting to construct payment models that will distribute the savings of the ACO to the individual providers.

ACO

2011-11-01T02:25:00.005-04:00

The primary objectives of Accountable Care Organizations (ACO) are to reduce costs, increase efficiency, increase accountability and improve the quality of patient care.

The payer is basically aiming to reduce costs and at the same time improve quality of care. Since payers would give the ACO's a lump sum to cover all care, the ACO's would retain any savings that result from more efficient patient care. This is supposed to be the motive for physicians and hospitals to ensure that the patient is healthy and out of the hospitals and not do more procedures.

The patient is supposed to get better care and this model aims to provide a patient centric care plan. The physicians may need to do a lot of screening procedures and wellness checkups ensuring that the patient is taking the right labs and medicines and staying healthy. So the clinical perspective would be that of being proactive and ensuring that the patient requires the right care ensuring that he is in good health, and that he makes as few visits to the Hospital as possible. This is to mean that the physician will proactively care for the patient, instead of the regular model of treating patients after a health event.

Challenges :

ACO's would find it a challenge to construct a payment model that would distribute the savings of the ACO to its individual providers.
The patient may feel that he is being forced to see a small group of physicians in the ACO that he is participating.
The patient may not perceive the quality of care that the ACO model proposes.
Would patients continue to stay within their ACO ?
Would patients see value in the ACO and support the ACO ?

ACO's have a lot of challenges ahead but it looks very viable and feasible considering the advantages is has over existing HMOs, but then again there are some physicians who feel that the ACO's are a little ahead of time, and now may not be the good time.

The ACO debate is endless but its success or failure will depend on how the patients perceive it. If the patients see value for themselves in the ACO than the patients would support the ACO and it will succeed, if the patients do not see any value from the ACO than it would be very difficult for the ACO to succeed.

"Incident to" Services

2011-08-24T06:04:00.012-04:00

“Incident to” services are defined as services commonly furnished in a physician’s office, which are “incident to” the professional services of a physician or a Non-Physician Practitioner (NPP) and provided by auxiliary personnel.

"Incident to" is a Medicare billing provision that allows services provided by PAs in an office or clinic setting to be reimbursed at 100 percent of the physician fee schedule by billing using the physician's NPI. The Medicare Benefit Policy Manual defines "incident to," in part, as "services furnished as an integral although incidental part of a physician's personal professional service." This is limited to situations in which there is direct physician/non-physician personal supervision. This applies to auxiliary personnel under the supervision of the physician/non-physician, which includes, but is not limited to, nurses, technicians, therapists, NPPs, etc.

Requirements for “incident to” are:

The services are commonly furnished in a physician’s office.
The physician must perform the initial patient visit and ongoing services of a frequency that demonstrate active involvement of the physician in the patient’s care, thereby creating a physician service to which the non physician provider's services relate.
There is direct personal supervision by the physician of auxiliary personnel, regardless of whether the individual is an employee, leased employee or independent contractor of the physician.
A physician must be on the premises, but not necessarily in the room, when incident-to services are performed.
Incident-to services cannot be performed in the hospital.

Direct supervision in the office setting does not mean the physician must be present in the same room with his aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.

Stark Law

2011-08-23T05:26:00.002-04:00

Stark law, governs physician self-referral for Medicare and Medicaid patients. The law is named for United States Congressman Pete Stark, who sponsored the initial bill.

Physician self-referral is the practice of a physician referring a patient to a medical facility in which he has a financial interest, be it ownership, investment, or a structured compensation arrangement. Critics of the practice allege an inherent conflict of interest, given the physician's position to benefit from the referral. They suggest that such arrangements may encourage over-utilization of services, in turn driving up health care costs. In addition, they believe that it would create a captive referral system, which limits competition by other providers.

The physician referral law (section 1877 of the Social Security Act) prohibits a physician from referring patients to an entity for a designated health service (DHS), if the physician or a member of his or her immediate family has a financial relationship with the entity, unless an exception applies. (The exceptions are specified in 42 CFR Part 411, Subpart J.) The law also prohibits an entity from presenting a claim to Medicare or to any person or other entity for DHS provided under a prohibited referral. No Medicare payment may be made for DHS rendered as a result of a prohibited referral, and an entity must timely refund any amounts collected for DHS performed under a prohibited referral. Civil money penalties and other remedies may also apply under some circumstances.