Flu Shot Coding for 2017-2018

Confused about coding for the flu shot?

What’s new this flu season?

  • The recommendation to not use the nasal spray flu vaccine (LAIV) was renewed for the 2017-2018 season. Only injectable flu shots are recommended for use again this season. CDC recommends use of the flu shot (inactivated influenza vaccine or IIV) or the recombinant influenza vaccine (RIV).
  • Flu vaccines have been updated to better match circulating viruses (the influenza A(H1N1) component was updated).
  • Pregnant women may receive any licensed, recommended, and age-appropriate flu vaccine. (NOTE: there is some concern about administration of the flu shot during the first trimester – NPR news story today 9/25/17)
  • Two new quadrivalent (four-component) flu vaccines have been licensed: one inactivated influenza vaccine (“Afluria Quadrivalent” IIV) and one recombinant influenza vaccine (“Flublok Quadrivalent” RIV).
  • The age recommendation for “Flulaval Quadrivalent” has been changed from 3 years old and older to 6 months and older to be consistent with FDA-approved labeling.
  • The trivalent formulation of Afluria is recommended for people 5 years and older (from 9 years and older) in order to match the Food and Drug Administration package insert.

Cell-based Flu Vaccines

A candidate vaccine virus (CVV) is an influenza (flu) virus that has been prepared by CDC or its public health partners for use by vaccine manufacturers to mass produce a flu vaccine. During the 2017-2018 season, for the first time, a true cell-based CVV has been approved for use in flu vaccine production for the Northern Hemisphere. Traditionally, CVVs have been produced using fertilized chicken eggs. The cell-based CVV has been used to produce the influenza A (H3N2) component of cell-based flu vaccines for the Northern Hemisphere in 2017-2018. Recombinant flu vaccines also are based on genetic sequences of recommended vaccine viruses that have not been propagated in eggs. Cell-based flu vaccines that use cell-based CVVs or genetic sequences have the potential to offer better protection than traditional, egg-based flu vaccines as a result of being more similar to flu viruses in circulation. For more information, see CDC’s Cell-Based Flu Vaccines webpage.

Options this season include:

  • Standard dose flu shots. Most are given into the muscle (usually with a needle, but one can be given to some people with a jet injector). One is given into the skin.
  • High-dose shots for older people.
  • Shots made with adjuvant for older people.
  • Shots made with virus grown in cell culture.
  • Shots made using a vaccine production technology (recombinant vaccine) that does not require the use of flu virus.

Medicare Reimbursement for the Flu Shot

The Part B deductible and coinsurance amounts do not apply to influenza vaccines or vaccine administration. All physicians, nonphysician practitioners, and suppliers who administer the influenza virus vaccination and the pneumococcal vaccination must take assignment on the claim for the vaccine.

The following Medicare Part B payment allowances for HCPCS and CPT codes apply to 8/1/2017-7/31/2018:

  • 90630  $20.343
  • 90653  $50.217
  • 90654  Pending
  • 90655 Pending
  • 90656 $19.247
  • 90657 Pending
  • 90661 Pending
  • 90662 $49.025
  • 90672 Pending
  • 90673 $40.613
  • 90674 $24.047
  • 90682 $46.313
  • (New code) 90685 $21.198 
  • 90686 $19.032
  • 90687 $9.403
  • 90688 $17.835
  • Q2035 $17.685
  • Q2036 Pending
  • Q2037 $17.685
  • Q2038 Pending
  • Q2039/90756 $22.793 Until CPT code 90756 is implemented on 1/1/2018, Q2039 will be used for products described by the following language: influenza virus vaccine, quadrivalent (ccllV4), derived from cell cultures, subunit, antibiotic free, 0.5mL dosage, for intramuscular use. Providers and MACs will use HCPCS Q2039 for dates of service from 8/1/2017- 12/31/2017. HCPCS Q2039 Flu Vaccine Adult – Not Otherwise Classified. 

Flu Shot Administration Codes

Don’t forget to code the vaccine administration as well as the vaccine itself!

Administered by a Physician, NP, PA, RN, LPN, Medical Assistant (etc) WITHOUT COUNSELING:

  • 90471 –percutaneous, intradermal, subcutaneous, or intramuscular injections: one vaccine (single or combination vaccine/toxoid)
  • 90473 – intranasal or oral: one vaccine (single or combination vaccine/toxoid)

Administered by a Physician, NP, PA (etc) WITH COUNSELING:

  • 90460 – Immunization administration through 18 years of age via any route of administration, w/ counseling by physician or other qualified healthcare professional; first vaccine/toxoid component

Here’s that invaluable flu shot chart from the Immunization Action Coalition with flu vaccine manufacturer, trade name, how supplied, age group, and CPT/HCPCS codes for Medicare and non-Medicare plans.




2017 Medicare Deductibles and Premiums

Medicare Part B Deductible 2017 Medicare Parts A & B Premiums and Deductibles Announced

The Centers for Medicare & Medicaid Services (CMS) announced the 2017 premiums for the Medicare inpatient hospital (Part A) and physician and outpatient hospital services (Part B) programs.

Medicare Part B Premiums/Deductibles

Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and other items.

On October 18, 2016, the Social Security Administration announced that the cost-of-living adjustment (COLA) for Social Security benefits will be 0.3 percent for 2017. Because of the low Social Security COLA, a statutory “hold harmless” provision designed to protect seniors, will largely prevent Part B premiums from increasing for about 70 percent of beneficiaries. Among this group, the average 2017 premium will be about $109.00, compared to $104.90 for the past four years.

For the remaining roughly 30 percent of beneficiaries, the standard monthly premium for Medicare Part B will be $134.00 for 2017, a 10 percent increase from the 2016 premium of $121.80. Because of the “hold harmless” provision covering the other 70 percent of beneficiaries, premiums for the remaining 30 percent must cover most of the increase in Medicare costs for 2017 for all beneficiaries. This year, as in the past, the Secretary has exercised her statutory authority to mitigate projected premium increases for these beneficiaries, while continuing to maintain a prudent level of reserves to protect against unexpected costs. The Department of Health and Human Services (HHS) will work with Congress as it explores budget-neutral solutions to challenges created by the “hold harmless” provision.

“Medicare’s top priority is to ensure that beneficiaries have affordable access to the care they need,” said CMS Acting Administrator Andy Slavitt. “We will continue our efforts to improve affordability, access, and quality in Medicare.”

Medicare Part B beneficiaries not subject to the “hold harmless” provision include beneficiaries who do not receive Social Security benefits, those who enroll in Part B for the first time in 2017, those who are directly billed for their Part B premium, those who are dually eligible for Medicaid and have their premium paid by state Medicaid agencies, and those who pay an income-related premium. These groups represent approximately 30 percent of total Part B beneficiaries.

CMS also announced that the annual deductible for all Medicare Part B beneficiaries will be $183 in 2017 (compared to $166 in 2016).

 

Medicare Part A Premiums/Deductibles

Medicare Part A covers inpatient hospital, skilled nursing facility, and some home health care services. About 99 percent of Medicare beneficiaries do not have a Part A premium since they have at least 40 quarters of Medicare-covered employment.

The Medicare Part A inpatient hospital deductible that beneficiaries pay when admitted to the hospital will be $1,316 per benefit period in 2017, an increase of $28 from $1,288 in 2016. The Part A deductible covers beneficiaries’ share of costs for the first 60 days of Medicare-covered inpatient hospital care in a benefit period. Beneficiaries must pay a coinsurance amount of $329 per day for the 61st through 90th day of hospitalization ($322 in 2016) in a benefit period and $658 per day for lifetime reserve days ($644 in in 2016). For beneficiaries in skilled nursing facilities, the daily coinsurance for days 21 through 100 of extended care services in a benefit period will be $164.50 in 2017 ($161 in 2016).

Enrollees age 65 and over who have fewer than 40 quarters of coverage and certain persons with disabilities pay a monthly premium in order to receive coverage under Medicare Part A. Individuals who had at least 30 quarters of coverage or were married to someone with at least 30 quarters of coverage may buy into Part A at a reduced monthly premium rate, which will be $227 in 2017, a $1 increase from 2016. Uninsured aged and certain individuals with disabilities who have exhausted other entitlement and who have less than 30 quarters of coverage will pay the full premium, which will be $413 a month, a $2 increase from 2016.




It’s Not Too Late to Launch CCOF on January 1st

Plan Your 2017 Collection Strategy Using CCOF

High Deductible Plans and CCOF Are Becoming Mainstream

When we first starting teaching practices how to implement credit card on file (CCOF) in their practices in 2010, only a few practices had ever heard of it. Today, we get calls weekly from practices who need help collecting patient balances, especially from patients with high-deductible plans, many whom do not understand how their plan works. Note that almost 25% of persons covered by employer health plans are enrolled in high-deductible plans, and almost 90% of enrollees in the healthcare exchange (Affordable Care Act Marketplaces) have a high-deductible plan!

The time-honored tradition of sending patients monthly statements and allowing them to pay on their own timetable has increasingly become untenable for medical practices, especially small practices that have limited financial resources to wait out patient payments. Physicians are paying their staff, medical supplies, utilities and rent monthly while waiting for insurance plans to pay in 30 to 45 days and patients to pay anywhere from 60 to 120 days or more past the date of service.

Having the Talk With Patients

Credit card on file opens the patient payment dialogue by changing the conversation from “We’ll send you a bill when insurance pays their portion” to “Once we receive the insurance Explanation of Benefits (EOB), we’ll charge your card for the patient-responsible balance. If the balance is over $____, we’ll call you to discuss your payment.”

On January 1st, the deductible starts afresh for most plans, and any practice not using credit card on file to collect those deductibles is in for a particularly tough quarter – what I’ve always called “The Black Months”. With the size of deductibles however, many practices are in for another tough year. Contrary to plans of the past that applied the deductibles only to very high-priced services or hospital events, many deductibles apply to office visits, medications, labs – essentially every healthcare service one can have. Some patients will never meet their deductible and will be paying your practice out of their pocket for every service all year long.

Is 2017 the year you streamline and improve patient collections?

It’s not too late to get it together to launch your program now to be ready for the new year. Here are the steps:

  1. Integrate software that allows you to keep patient credit cards on file on an offsite, secure, third-party server as an add-on to your current merchant services (credit card processing). Call your current credit card processor to see if they have CCOF, but be careful – there is a lot of confusing language around the CCOF part and CC processing charges. My recommendation for CCOF software is here.
  2. Educate patients on the change. Inform and educate patients about your new policy between now and when you launch.
  3. Rewrite your financial policy to include CCOF. If no one ever reads your financial policy, now is the time to make it simpler and clearer.
  4. Educate the staff. Explain why you’re making the change, how it works and how to communicate with patients that might have questions.
  5. Change your patient scripts to include CCOF language when you schedule and confirm appointments.
  6. Get rid of patient statements. Decide how you will handle current patient statements to clear those balances. You eliminate statements when you implement CCOF.
  7. Determine your philosophy. How are going to deal with patients who say they don’t have a credit or debit card, or refuse to give you their card to place on file? Most practices will lose a few patients, but it is always less than you expect. Most patients who refuse are patients who never intended to pay you anyway!

I ask physicians this question:

If you collected the same amount of money each month whether you saw 500 patients who paid you part of what they owed, or 350 patients who paid you everything they owed, which would you prefer?

Of course, every physician would love to see less patients, having more quality time with each patient! What’s wrong with having a practice full of patients who agree to pay you what they owe? FYI, CCOF does not mean you cannot also serve patients who need help with medical expenses – that’s a different conversation!

For more information and help, see our CCOF page here, or watch this 30-minute YouTube video here.

NOTE: I use the term “credit card” in this article, but you can accept, if you so choose, debit cards, health savings account cards, flexible spending account cards – even gift cards.




Flu Shot Information: 2016 – 2017

This season's flu shot recommendations bring several changes.

 

 

CDC Updates Flu Shot Recommendations for 2016-2017 Flu Season

A few things are new this season:

  • Only injectable flu shots are recommended for use this season.
  • Flu vaccines have been updated to better match circulating viruses.
  • There will be some new vaccines on the market this season.
  • Live attenuated influenza vaccine (LAIV) – or the nasal spray vaccine – is not recommended for use during the 2016-2017 season because of concerns about its effectiveness.
  • CPT code 90674 is a new code for 2017, and some code descriptions are revised for 2017 to indicate dosage as opposed to age.
  • The recommendations for vaccination of people with egg allergies have changed.

The recommendations for people with egg allergies have been updated for this season:

  • People who have experienced only hives after exposure to egg can get any licensed flu vaccine that is otherwise appropriate for their age and health.
  • People who have symptoms other than hives after exposure to eggs, such as angioedema, respiratory distress, lightheadedness, or recurrent emesis; or who have needed epinephrine or another emergency medical intervention, also can get any licensed flu vaccine that is otherwise appropriate for their age and health, but the vaccine should be given in a medical setting and be supervised by a health care provider who is able to recognize and manage severe allergic conditions. (Settings include hospitals, clinics, health departments, and physician offices). People with egg allergies no longer have to wait 30 minutes after receiving their vaccine.

Options this season include:

  • Standard dose flu shots. Most are given into the muscle (usually with a needle, but one can be given to some people with a jet injector). One is given into the skin.
  • A high-dose shot for older people.
  • A shot made with adjuvant for older people.
  • A shot made with virus grown in cell culture.
  • A shot made using a vaccine production technology (recombinant vaccine) that does not require the use of flu virus.

 

Medicare and the Flu Shot

The Medicare Part B payment allowance limits for seasonal influenza and pneumococcal vaccines are 95% of the Average Wholesale Price (AWP) as reflected in the published compendia except where the vaccine is furnished in a hospital outpatient department. When the vaccine is furnished in the hospital outpatient department, payment for the vaccine is based on reasonable cost.

Providers should note that:

  • All physicians, non-physician practitioners and suppliers who administer the influenza virus vaccination and the pneumococcal vaccination must take assignment on the claim for the vaccine.
  • The annual Part B deductible and coinsurance amounts do not apply.

 

Medicare Payment Allowances and Effective Dates for the 2016-2017 Flu Season

Effective Dates 8/1/2016 – 7/31/2017

  • CPT 90630 Payment allowance is $20.343.
  • CPT 90653 Payment allowance is $37.383.
  • CPT 90656 Payment allowance is $17.717.
  • CPT 90657 Payment allowance is pending.
  • CPT 90661 Payment allowance is pending.
  • CPT 90662 Payment allowance is $42.722.
  • CPT 90672 Payment allowance is $26.876.
  • CPT 90673 Payment allowance is $40.613.
  • CPT 90674 Payment allowance is $22.936.
  • CPT 90685 Payment allowance is $26.268.
  • CPT 90686 Payment allowance is $19.032.
  • CPT 90687 Payment allowance is $9.403.
  • CPT 90688 Payment allowance is $17.835.
  • HCPCS Q2035 Payment allowance is $16.284.
  • HCPCS Q2037 Payment allowance is $16.284.
  • HCPCS Q2039 Flu Vaccine Adult – Not Otherwise Classified payment allowance is to be determined by the local claims processing contractor with effective dates of 8/1/2016-7/31/2017.

Click here for a handy flu shot chart with CPT codes and manufacturers.

 




Heart Failure Patient Innovation Leads to New Service Line

Transitional Care for Heart Failure Patients

Setting up new practices and healthcare businesses gives me the opportunity to meet some very creative and dedicated people. An exceptional case in point – Elizabeth Blanchard-Hills, the founder of CareConnext. She and I met several years ago while she was piloting a Transitional Care Management program for Heart Failure patients and she wanted a business model to match the care model.

Fast forward several years,and Elizabeth has taken her experience and her success and made it available to organizations who are looking for a proven way to improve care to patients, reduce healthcare costs by preventing hospital readmissions, and improve patient satisfaction.

Elizabeth agreed to an interview to update me on CareConnext.

Mary Pat: What is CareConnext?

Elizabeth: CareConnext is a care transition service giving heart failure patients renewed hope and a sense of personal control over their emotional well-being and physical health. Patients meet weekly for one month in a small group; they are coached by a multidisciplinary team and encouraged by their peers.

Mary Pat: Why would CareConnext be of interest to hospitals, physician practices or home health agencies?

Elizabeth:Hospitals interested in lowering their heart failure readmissions and improving their HCAHPS scores would benefit from CareConnext. Nurse practitioners and doctors who want to increase revenue by saving time would also benefit from CareConnext, as Medicare and private insurers will pay for this model of care. Home health agencies tell us CareConnext offers them a unique marketing edge over their competitors.

Mary Pat: What is the science behind CareConnext?

Elizabeth: CareConnext is the result of a randomized clinical trial (then called SMAC-HF) which followed more than 200 patients for five years. The results were recently published in Circulation, an American Heart Association journal for cardiologists.

Mary Pat: What is the business rationale for CareConnext?

Elizabeth: My company currently has the privilege of “transitioning” the results of the randomized clinical trial into practice.  We have been conducting an on-going pilot project with The University of Kansas Hospital since November 2013, and our results are corroborating the results of the randomized clinical trial. Happily, we also discovered that Medicare and private insurers are willing to pay us for the work we do. This is an important benefit when attempting to persuade executive leadership to implement CareConnext.

There are dozens of very good interventions for heart failure, such as software solutions or post-discharge case management tools. Very few are able to pay for themselves; fewer still have the rigor of a randomized clinical trial behind their results.

Mary Pat: What are the main findings of the study?

Elizabeth: That we could, in fact, significantly lower hospital readmissions among heart failure patients.

Mary Pat: What was most surprising about the results?

Elizabeth: We have found several surprises:

  • The importance of managing emotions when managing a chronic disease such as heart failure;
  • The randomized clinical trial showed depression puts heart failure patients at risk for readmission; this mirrors what we are now finding in the literature; helping patients feel emotionally and spiritually better is now a signature piece of CareConnext. We screen for depression using the PHQ9, and watch our patients rebuild hope by regaining a sense of control. We do so by talking frankly and directly about sensitive issues that are often time-consuming to address: end-of- life planning, the loss of independence, or asking family members to participate in a change of diet.
  • The value of peer-to- peer coaching; because of the time constraints we as health care professionals face, we too often resort to “lecturing” our patients, leaving us little time to validate our patients’ understanding, or their ability to take positive action. For example, it is easy to “tell” someone to limit their sodium intake to 2 grams a day. But does the patient even understand how to read a food label? If not, would he or she feel comfortable revealing that? CareConnext provides a safe environment for patients to recognize and overcome knowledge gaps, as they rely on one another for real-life strategies and emotional support. Our providers are mostly on “standby,” available to address specific questions or misconceptions that specifically require the expertise of an advanced practice nurse or physician.
  •  Our data holds across varying patient populations; patients who struggle with literacy or language benefit from our intervention as do patients who are affluent, well-educated and compliant. Only the “sickest of the sick” (Heart Failure Class III and IV) were included in the randomized clinical trial.
  • Our physicians and nurse practitioners enjoy the CareConnext model, too. Our team is quite talented, and therefore much in demand at The University of Kansas Hospital. They are often recruited for interesting projects always in play at a large academic medical center. They tell us CareConnext is professionally rewarding, and a welcome change from the standard, one-on- one office visit.

Mary Pat: What should clinicians and patients take away from your report?

Elizabeth: This particular patient population will remain engaged if they find something of value. Being “noncompliant” is a convenient label we often misuse with our patients. Heart Failure patients have logical reasons for being skeptical of what they perceive as “yet another doctor’s appointment,” such as a lack of energy.

We have been quite strategic in attempting to meet our patients’ emotional needs. The “clinical stuff” (monitoring fluid volume, especially overload) we offer as part of CareConnext are the ‘greens fees’ we pay so we can address and change patient behavior.  By making patients feel emotionally and spiritually empowered, we help them change the feelings they have and the choices they make.

Mary Pat: How does a reader get more information?

Elizabeth: Many organizations have approached us over the past couple of years about implementing CareConnext within their own institutions, using their own staff. We now have the experience, “lessons learned” and tools to help them be successful. Readers can email me directly to start the conversation at ehills@careconnext.org and can also visit our website: www.careconnext.org

Mary Pat: Anything else you’d like to say about CareConnext?

Elizabeth: Yes, I’d like to give you a special shout-out, Mary Pat. I first approached you with what I saw as an insurmountable problem several years ago: We had a unique care model that delivered outstanding outcomes for patients with Heart Failure, but no way to get paid for it. Using both common sense and a “roll up your shirt sleeves” approach, you helped us figure it out. Now I am excited to help others do the same, and I am grateful for your belief in me, my team and CareConnext.

Mary Pat: Thank you for the kind words, Elizabeth!

 

Elizabeth Blanchard Hills, BSN MSJ Founder of CareConnext for Heart Failure Patients

ehills@careconnext.org

800-794-0118 (w)

913-485-0387 (m)

www.careconnext.org

 




Solo and Small Medical Practices Benefit from New Manage My Practice and The Billing Department Partnership

Manage My Practice and The Billing Department Join ForcesDurham, North Carolina and Falmouth, Maine: Today, Manage My Practice, LLC, a full-service consulting firm specializing in services to solo and small medical practices and The Billing Department, Inc., a company that provides revenue cycle management services to healthcare providers, announced a partnership to offer practice consulting, coding, medical billing and a range of other services to physicians and other healthcare providers nationally.

Of the decision to form a partnership to jointly provide high-quality coding and billing services, Mary Pat Whaley, founder and president of Manage My Practice said “I’ve been recommending The Billing Department to my clients for several years and they report back to me that The Billing Department’s services are always exceptional. It seemed a natural step that The Billing Department and Manage My Practice collaborate to offer a wider range of services together.”

Vanessa Higgins, founder and president of The Billing Department stated “ Manage My Practice is well-established as the premier consulting company specializing in solo and small medical practices in the United States today. It is a thrill to be able to partner with such a well-respected company to serve an often-overlooked market such as solo physicians and other small practice healthcare providers.”

Among the services the new partnership will offer are:

  • New Practice Start-up
  • End-to-end Revenue Cycle Management including Credit Card on File implementation
  • Consulting on medical practice organizational and operational issues
  • Professional Coding and Clinical Documentation Improvement for primary care and other specialties

About Manage My Practice: Mary Pat Whaley, FACMPE, CPC, founder and president of Manage My Practice, LLC, has 30+ years managing physician practices of all sizes and specialties in the private and public sectors In addition to her Board Certification in Medical Practice Management, she is also a Certified Professional Coder and a Fellow in the American College of Medical Practice Executives. Her company, Manage My Practice, LLC, a full-service practice management consulting firm, has assisted practices nationally and internationally since 2008.

About the Billing Department: Established in 1999, The Billing Department, Inc. has steadily grown. Providing practice and revenue cycle management services for healthcare providers nationwide, The Billing Department offers a fully-integrated, end-to-end solution which simplifies every step of the revenue cycle management process — from the initial scheduling of an appointment to the cumbersome billing process following each patient visit. The company’s ultimate goal is to reduce the expenses and increase the income of their clients.

Manage My Practice and The Billing Department Form Partnership

 

Mary Pat Whaley, FACMPE, CPC

Manage My Practice

www.managemypractice.com

(919) 370-0504

 

 

 

The Billing Department and Manage My Practice Partner

 

 

 

Vanessa Higgins

The Billing Department

www.billingdepartment.com

(877) 270-7191

 

Photo Credit: inabstracting via Compfight cc




Advance Beneficiary Notice FAQs

The advance beneficiary notice (ABN) is a powerful tool for practices to educate patients about their benefits and responsibilities for Medicare non-covered services. Many of our readers still write us to ask questions about the form and the correct way to use it in the office, so we developed this Frequently Asked Questions list for the ABN to clear up some of the confusion.

We always tell the physicians we work with: “If you are going to accept insurance, you need to be the expert on insurance.” In practice this means knowing your patient’s benefits and working with them to communicate with them about what, if anything, they will owe before or after payer adjudication. No one enjoys being surprised about money!

The ABN is also a tremendous opportunity to talk about financial responsibilities with a patient. If you don’t have a credit card on file program in your practice, it’s important to be proactive about patient financial responsibilities and how they will be handled. Having a patient sign that they understand they will be financially responsible for payment for a non-covered service is a natural way to start that process.

Here are some of your most frequently asked ABN questions.

What is the ABN? What does it do?

The ABN was originally developed by the Centers for Medicare and Medicaid Services (CMS) to make sure Medicare patients were aware that if they received services that were not covered by Medicare, payment for these services would be their responsibility. By signing the ABN, the patient agrees that if Medicare (or other payer) does not pay the physician then the patient will have to pay for it. The document affirms that the patient knows they could be required to pay out of pocket. Once the ABN is signed, if you are sure Medicare won’t pay you can (and probably should) collect the patient portion listed on the form immediately. You can charge in full for the services if the ABN is signed, however the service is self-pay at that point, so I always suggest you charge your self-pay rate.

What won’t Medicare pay for?

The classic example is an annual physical, which many people assume is part of their Medicare coverage. Medicare will pay for an initial “Welcome to Medicare” visit, as well as an “Annual Wellness” visit, but the key word to hear is “visit”. These are not physical examinations. If a patient wants a physical, they will need to sign an ABN before the service saying they understand that Medicare will not pay for it. Other things that Medicare will not pay for include services without specific medical need, like labs or imaging diagnostics without diagnoses that are accepted as medically necessary. Medicare will also only pay for certain services at regular intervals, for example women who are considered “low risk” for cervical cancer can only receive a pap smear every 24 months. Note that you are not required by Medicare to get an ABN signed for services that are never covered, such as the annual physical, however, it pays to be absolutely clear when discussing payments, so I suggest you get an ABN signed by the patient regardless.

Should we just have everybody sign an ABN?

No. The ABN is to be used in specific instances for a specific service. You cannot require a patient to sign a “blanket” ABN for the year, just in case. If Mr. Smith wants a service that Medicare is unlikely to, or definitely will not pay for and the physician is comfortable ordering or performing the service, a staff member should present an ABN to Mr. Smith for that specific day’s procedure, before it is performed. If the patient is a having a series of recurring services that will not be covered, you can have one ABN signed for up to twelve months of the specific service. An example of this might be a series of physical therapy sessions.  The ABN is not a catch- all to protect from denial, however, and persistent misuse will not only be denied, but could open the door to an audit.

We are a small, busy practice; that sounds like a lot of work!

It is a lot of work for a practice! Many practices choose to not use the ABN rather then work out a protocol to implement it. The practice has to have a system in place so that the physician or staff member can explain the situation, fill out the form, answer the patient’s questions and file the ABN for posterity (they have to be kept seven years, like other records). It can be the physician in a micropractice, or a dedicated billing or customer service employee in a larger setting. Also, a note has to be made of the ABN signing in the patient’s chart so that modifiers can be added to the CPT codes for billing.

Are ABNs for Medicare only?

No. You can also have a patient sign an ABN for a private payer. This helps the patient to understand that if their insurance doesn’t cover the service specified, the patient will have to pay for it.  Medicare requires an ABN be signed in order to bill the patient, but for patients with private insurance it’s still a great opportunity to talk about non-covered services, deductibles, copays, coinsurance or any past balances if you haven’t already. A few private payers actually require a waiver/ABN to bill patients for non-covered services – check your contract to be sure.

 

Mary Pat has created a generic non-Medicare ABN; if you’d like a copy, just email Mary Pat and she can send you one.




2016 CPT Code Changes

New Year CPT Codes for 2016

The 300 new, deleted, revised, and converted CPT codes for 2016 are here and you will need to make sure they are loaded in your billing and EMR system(s) on or before January 1, 2016. This is also a great time to upload the 2016 Medicare allowables for your locality and for any payer contracts that apply a multiplier to the current Medicare fee schedule for their own allowables (for instance, XYZ payer pays 125% of 2016 Medicare).

Only a few areas do not have any changes this year – there are no deleted or changed modifiers and there are no changes to the anesthesia chapter of CPT. As for everything else, grab your 2016 CPT code book or digital version and follow along. Note that this is not an all-inclusive list; review your CPT book for complete description of all codes.

Don’t forget to scroll down to the bottom of this post to see the new category three (temporary) codes that may apply to your specialty.

 

Evaluation and Management Codes (E/M)

  • Add-on codes for Prolonged Services +99354 and +99355 now apply to prolonged face-to-face outpatient psychotherapy as well as to prolonged face-to-face E/M codes. Use a primary E/M or psychotherapy code, one 99354 (30-74 minutes in addition to the time spent on the initial/primary service) per day and as many units of 99355 as needed to match the time spent. NOTE: check the table in your CPT book to report the correct codes by time. OUTPATIENT ONLY.
  • Two new add-on Prolonged Services codes have been created. +99415 and +99416 are to be used to report prolonged face-to-face clinical staff service with physician, NP OR PA supervision. Same rules as above. Prolonged codes start at >45 minutes. NOTE: Document what you did and how long you did it. If you are reporting additional procedures, document the time and note that they are excluded from the prolonged service so no one thinks you’re double-dipping. OUTPATIENT ONLY.
  • Any code with a “+” prefix must be reported with a primary code. These add-on codes can never appear on a claim by itself.

Integumentary System

  • New: 10035, placement of soft tissue locations devices such as clips, markers, etc., first lesion
  • New add-on: +10036, placement of soft tissue locations devices such as clips, markers, etc., additional lesions (Not be used for breast, use existing breast codes (19081-19086), w/biopsy (19281-19288)

Musculoskeletal System

  • Deleted: 21805 – open treatment w/o fixation for rib fracture (Closed treatment or uncomplicated to use E/M code, Open treatment with fixation, use 21811- 21813)

Respiratory System

  • Revised: 31632 and 31633 bronchoscopy codes now include moderate sedation
  • Deleted: 31620
  • New: Bronchoscopy codes with EBUS 31652 (one or two node stations or structures), 31653, (three or more node stations or structures), +31654 (peripheral lesions – look in the CPT book for primary codes this add-on code can be used with)

Cardiovascular System

  • New: Category III code 0262T has been replaced with 33477, Transcatheter pulmonary valve implantation, includes procedure, angioplasty and imaging guidance, supervision and interpretation when performed
  • Revised: 37184, 37185, and 37186 were revised to include description “non-intracranial vessels”. Fluoroscopy is included.
  • New: 37211 is for intracranial vessels
  • Deleted: +37250 and +37251
  • Newadd-on: +37252 (intravascular ultrasound, initial noncoronary vessel) and +37253 (intravascular ultrasound, each additional noncoronary vessel. Look in the CPT book for primary codes this add-on code can be used with.)
  • Deleted: 39400
  • New: 39401 (Mediastinoscopy with biopsy of mediastinal mass, when performed) and 39402 (Mediastinoscopy with lymph node biopsy, when performed)

Digestive System

  • New: 43210 transoral approach using endoscope, not open, partial or complete

Biliary

  • Deleted: 47560 and 47561 (see 47579, 47531, or 47532 for percutaneous cholangiography)
  • Deleted: 47630 (see 47544)
  • Deleted: 47500, 47505, 47510, 47511, 47525, 47530, 74305, 74320, 74327
  • New: 47531 Injection procedure for cholangiography, includes RSI – radiologic supervision and interpretation, existing access and 47532 Injection procedure for cholangiography, includes RSI – radiologic supervision and interpretation, new access.
  • New: 47533 Placement of biliary drainage catheter, includes cholangiography, includes RSI – radiologic supervision and interpretation, external and 47534 Placement of biliary drainage catheter, includes RSI – radiologic supervision and interpretation, internal-external.
  • New: 47535 Conversion of external biliary drainage catheter to internal-external biliary drainage catheter, includes cholangiography, includes RSI – radiologic supervision and interpretation
  • New: 47536 Exchange of biliary drainage catheter, all types, includes cholangiography, includes RSI – radiologic supervision and interpretation
  • New: 47537 Removal of biliary drainage catheter, includes cholangiography, includes RSI – radiologic supervision and interpretation
  • New: 47538 Placement of stent into bile duct, includes cholangiography, includes balloon dilation and catheter exchange(s) and removal(s), includes RSI – radiologic supervision and interpretation, each stent, existing access
  • New: 47539 Placement of stent into bile duct, includes cholangiography, includes balloon dilation and catheter exchange(s) and removal(s), includes RSI – radiologic supervision and interpretation, each stent, new access, without placement of separate biliary drainage catheter (Handy table for reference in CPT book before this code!)
  • New: 47540 Placement of stent into bile duct, includes cholangiography, includes balloon dilation and catheter exchange(s) and removal(s), includes RSI – radiologic supervision and interpretation, each stent, new access, with placement of separate biliary drainage catheter
  • New: 47541 Rendezvous Procedure, new access, includes RSI – radiologic supervision and interpretation
  • New add-on: +47542 Balloon dilation of biliary duct, each duct (look for primary codes this can be used with and use modifier -59 if a second unit/duct is treated)
  • New add-on:+47543 Endoluminal biopsy of biliary tree, single or multiple, includes RSI – radiologic supervision and interpretation , report this code once per session
  • New add-on:+47544 Removal of calculi or debris from biliary ducts or gallbladder, includes RSI – radiologic supervision and interpretation (look for primary codes this can be used with)

Digestive System: Sclerotherapy

  • New: 49815 – one unit per lesion treated, report subsequent lesion(s) with modifier -59

Urinary System: Kidney

  • Revised: 50387 deleted transnephric ureteral stent and added “nephroureteral catheter”, see 50688 for removal and replacement of externally accessible ureteral stent (removal of stent without a replacement falls under E/M)

Kidney: New Heading Called Injection, Change or Removal

  • Deleted: 50392, 50393, 50394, 50398
  • New: 50430 (new access) and 50431 (existing access) both include RSI – radiologic supervision and interpretation
  • New: 50432 and 50433 (new access) both include RSI – radiologic supervision and interpretation, report one unit of 50432 for each renal collecting system or ureter accessed
  • New: 50434 (pre-existing nephrostomy tract) and 50435 (exchange catheter), both include RSI – radiologic supervision and interpretation, report one unit of 50435 for each renal collecting system or ureter accessed
  • New add-on: +50606 non-endoscopic endoluminal biopsy, once per ureter per day, includes RSI – radiologic supervision and interpretation (look in the CPT book for primary codes this add-on code can be used with)
  • New: 50693 (placement of ureteral stent, existing access) 50694 (new access  separate nephrostomy catheter) and 50695 (new access with separate nephrostomy catheter), all include RSI – radiologic supervision and interpretation
  • New add-on: +50705 (ureteral embolization or occlusion) includes RSI – radiologic supervision and interpretation, once per ureter treated per day (look in the CPT book for primary codes this add-on code can be used with)
  • New add-on: +50706 (balloon dilation) includes RSI – radiologic supervision and interpretation (look in the CPT book for primary codes this add-on code can be used with)

Male Genital

  • New: 54437 Penis Repair (repair of urethra may be reported separately)
  • New: 54438 Penis Replantation, complete amputation (for partially amputated see 54437,  for urethra repair see 54310 and 54315)

Nervous System

  • New: 61645 Mechanical thrombectomy, intracranial
  • New: 61650 Endovascular intracranial prolonged administration of pharmacologic agents not for thrombolysis, arterial, initial vascular territory
  • New add-on: +61651 Endovascular intracranial prolonged administration of pharmacologic agents, arterial, not for thrombolysis, each additional vascular territory
  • Deleted: 64412, use 64999
  • New: 64461 Paravertebral Block (PVB), thoracic, single injection, includes imaging guidance when performed
  • New add-on: +64462 Second and any additional injection sites, can only be reported once per day, includes imaging guidance when performed
  • New: 64463 Continuous infusion by catheter, includes imaging guidance when performed

Eye

  • New: 65785 Implantation of intrastomal corneal ring segments, revised to state “one session” (Category III code 0099T was replaced by this code)
  • Revision: 67101 Trabeculoplasty by laser surgery, revised to state “including drainage when performed” and revised to replace “with or without” with “including when performed”
  • Revision: 67105 Trabeculoplasty, photocoagulation, repair of retinal detachment, revised to state “including drainage when performed” and revised to replace “with or without” with “including when performed”
  • Deleted: 67112 Retinal detachment, use 67107, 67108, 67110 or 67113 as appropriate
  • Revised: 67107 Repair of retinal detachment, scleral buckling, revised to replace “with or without” with “including when performed”
  • Revised: 67108 Repair of retinal detachment with vitrectomy, revised to replace “with or without” with “including when performed”
  • Revised: 67113 Repair of complex retinal detachment, revised to replace “with or without” with “including when performed”
  • Revision: 67227 Destruction of extensive or progressive retinopathy, revised to remove “one or more sessions”
  • Revision: 67228 Treatment of extensive or progressive retinopathy, photocoagulation, revised to remove “one or more sessions”

Auditory System

  • New: 69209 Removal of impacted cerumen using irrigation/lavage, unilateral
  • New: 69210 Removal of impacted cerumen requiring instrumentation, unilateral, NOTE: For removal of non-impacted cerumen, use E/M code, append modifier -50 for bilateral (both ears), do not report 69209 and 69210 for the same ear!

Diagnostic Radiology

  • Deleted: 70373 (see unlisted code 76499 for contrast laryngography)
  • Revised: 72080 Spine, thoracolumbar junction, minimum of two views
  • Deleted: 72069 and 72090
  • New: Scoliosis Evaluation Codes 72081 (one view), 72082 (two or three views), 72083 (four or five views) and 72084 (minimum six views)
  • Deleted: 73500, 73510, 73520, 73530 and 73540
  • New: Hip With Pelvis (when performed) Unilateral 73501 (one view), 73502 (two or three views), 73503 (minimum four views)
  • New: Hip With Pelvis (when performed) Bilateral 73521 (two views), 73522 (three or four views), 73523 (minimum five views)
  • Deleted: 73550
  • New: 73551 Femur (one view) and 73552 (two or more views)
  • The word “film” has been replaced by “image” in 74240, 74241, 74245, 74246, 74247, 74250 and 74340
  • New: MRI of Fetus 74712 (single gestation) and +74713 (each additional gestation) only if fetus is imaged

Radiology: Brachytherapy

  • New: 77767 and 77768 (multiple lesions or channels)
  • Deleted: 77785 and 77786
  • New: 77770 (one channel), 77771 (two to twelve channels), 77772 (more than twelve channels)
  • Deleted: 77776 and 77777 (see 77799 for intermediate service)
  • Revised: 77778  to include “supervision, loading and handling of the radiation source”

Radiology: Nuclear Medicine

  • Revised: 78624 to include “imaging study” and “(solid food, liquid food or both)”
  • New: 78265 (small bowel transit) and 78266 (small bowel and colon transit)

Pathology and Laboratory

  • New: 80081 addition of HIV testing the standard OB panel (must have all elements of the panel performed to use 80085 or 80081, otherwise must code each test separately
  • NOTE: Refer to the CPT book for many additional changes

Medicine: Vaccines

  • Deleted: 13 outdated codes deleted
  • Revised: 40+ codes reworded to improve clarity
  • New: 90625 Cholera Vaccine
  • New: 90697 DTap-IPV-Hib-HepB
  • New: 90620 Meningococcal, 2 dose schedule
  • New: 90621 Meningococcal, 3 dose schedule

Otolaryngology

  • Deleted: 92543
  • New: 92537 (bilateral, bithermal, 4 irrigations) and 92538 (bilateral, monothermal, two irrigations)

Cardiovascular and Pulmonary

  • New: 93050 Arterial pressure waveform analysis (Category III code 0311T deleted)
  • Revised: 94640 “for therapeutic purposes” and includes “sputum induction”

Neurology and Neuromuscular

  • Deleted: 95973
  • Revised: 95972 revised to remove the time element

Dermatology

  • New primary and add-on codes: RCM Codes 96931 (image acquisition, interpretation and report, first lesion), 96932 (image acquisition only, first lesion), and 96933 (interpretation and report only, first lesion), +96934 (image acquisition, interpretation and report, each additional lesion), +96935 (image acquisition only, each additional lesion), and +96936 (interpretation and report only, each additional lesion) NOTE: Technical is image acquisition, Professional is interpretation and report. Both components are included in 96931 and 96934.

Medicine: Other

  • Revised: Ocular Screening 99174 to include “remote analysis and report”
  • New: Ocular Screening 99177 onsite analysis

Category III Codes

  • Sunset Codes: 0103T, 1223T, 0123T, 0223T, 0224T, 0225T, 0233T, 0240T, 0241T, 0243T, 0244T (codes not replaced by a Category I code)
  • Replaced Codes: 0099T see 65785, 0182T see 0394T and 0395T, 0262T see 33477, 0311T see 93050
  • New: 0381T (Epilepsy seizure recording up to 14 days with review and report), 0382T (14-day with review and report only), 0383T (Epilepsy seizure recording for 15 to 30 days with review and report), 0384T (15 to 30 days with review and report only), 0385T (Epilepsy seizure recording for more than 30 days with review and report), and 0386T (>30 days with review and report only)
  • New: Permanent Leadless Pacemaker 0387T (insertion/replacement), 0388T (removal), 0389T (programming), 0390T (evaluation) and 0391T (interrogation)
  • New: Esophageal Sphincter Augmentation Device 0392T (placement), and 0393T (removal)
  • New: Electronic Brachytherapy 0394T (skin surface) and 0395T (interstitial or intracavitary)
  • New add-on: +0396T Implant stability testing during knee replacement
  • New add-on: +0397T Optical endomicroscopy during ERCP
  • New: 0398T MRI-guided ultrasound for intracranial lesion ablation
  • New: +0399T Myocardial strain imaging
  • New: 0400T (Digital skin lesion analysis, one to five lesions) and 0401T (digital skin lesion analysis, six or more lesions)
  • New: 0402T Collagen cross-linking of cornea
  • New: 0403T Behavior change in high-risk patients for diabetes prevention, group setting, 60 minutes per day
  • New: 0404T Uterine fibroid ablation with ultrasound guidance, radiofrequency,reported once regardless of number of fibroids treated
  • New: 0405T Thirty minutes or more per month non-face-to-face liver assist care oversight
  • New: 0406T Nasal endoscopy, placement of drug-eluding implant and 0407T endoscopy with biopsy, polypectomy or debridement

CPT Copyright American Medical Association. All rights reserved.




2016 Medicare Deductibles and Premiums

Medicare Part B Deductible Increases

Yesterday the Centers for Medicare & Medicaid Services (CMS) announced the 2016 premiums and deductibles for the Medicare inpatient hospital (Part A) and physician and outpatient hospital services (Part B) programs.

Part B Premiums/Deductibles

As the Social Security Administration previously announced, there will be no Social Security cost of living increase for 2016. As a result, by law, most people with Medicare Part B will be “held harmless” from any increase in premiums in 2016 and will pay the same monthly premium as last year, which is $104.90.

Beneficiaries not subject to the “hold harmless” provision will pay $121.80, as calculated reflecting the provisions of the Bipartisan Budget Act signed into law by President Obama last week. Medicare Part B beneficiaries not subject to the “hold-harmless” provision are those not collecting Social Security benefits, those who will enroll in Part B for the first time in 2016, dual eligible beneficiaries who have their premiums paid by Medicaid, and beneficiaries who pay an additional income-related premium. These groups account for about 30 percent of the 52 million Americans expected to be enrolled in Medicare Part B in 2016.

“Our goal is to keep Medicare Part B premiums affordable. Thanks to the leadership of Congress and President Obama, the premiums for 52 million Americans enrolled in Medicare Part B will be either flat or substantially less than they otherwise would have been,” said CMS Acting Administrator Andy Slavitt. “Affordability for Medicare enrollees is a key goal of our work building a health care system that delivers better care and spends health care dollars more wisely.”

Because of slow growth in medical costs and inflation, Medicare Part B premiums were unchanged for the 2013, 2014, and 2015 calendar years. The “hold harmless” provision would have required the approximately 30 percent of beneficiaries not held harmless in 2016 to pay an estimated base monthly Part B premium of $159.30 in part to make up for lost contingency reserves, according to the 2015 Trustees Report. However, the Bipartisan Budget Act of 2015 mitigated the Part B premium increase for these beneficiaries and states, which have programs that pay some or all of the premiums and cost-sharing for certain people who have Medicare and limited incomes. The CMS Office of the Actuary estimates that states will save $1.8 billion as a result of this premium mitigation.

CMS also announced that the annual deductible for all Part B beneficiaries will be $166.00 in 2016.

Premiums for Medicare Advantage and Medicare Prescription Drug plans already finalized are unaffected by this announcement.

To get more information about state-by-state savings, visit the CMS website here.

Since 2007, beneficiaries with higher incomes have paid higher Part B monthly premiums. These income-related monthly adjustment amount (IRMAA) affect fewer than 5 percent of people with Medicare. Under the Part B section of the Bipartisan Budget Act of 2015, high income beneficiaries will pay an additional amount. The IRMAA, additional amounts, and total Part B premiums for high income beneficiaries for 2016 are shown in the following table:

Medicare Premiums Vary Based on Income and Type of Tax Return

Premiums for beneficiaries who are married and lived with their spouse at any time during the taxable year, but file a separate return, are as follows:
2016 Medicare Monthly Premiums

Part A Premiums/Deductibles 

Medicare Part A covers inpatient hospital, skilled nursing facility, and some home health care services. About 99 percent of Medicare beneficiaries do not pay a Part A premium since they have at least 40 quarters of Medicare-covered employment.

The Medicare Part A annual deductible that beneficiaries pay when admitted to the hospital will be $1,288.00 in 2016, a small increase from $1,260.00 in 2015. The Part A deductible covers beneficiaries’ share of costs for the first 60 days of Medicare-covered inpatient hospital care in a benefit period. The daily coinsurance amounts will be $322 for the 61stthrough 90th day of hospitalization in a benefit period and $644 for lifetime reserve days. For beneficiaries in skilled nursing facilities, the daily coinsurance for days 21 through 100 in a benefit period will be $161.00 in 2016 ($157.50 in 2015).

Enrollees age 65 and over who have fewer than 40 quarters of coverage and certain persons with disabilities pay a monthly premium in order to receive coverage under Part A. Individuals with 30-39 quarters of coverage may buy into Part A at a reduced monthly premium rate, which will be $226.00 in 2016, a $2.00 increase from 2015. Those with less than 30 quarters of coverage pay the full premium, which will be $411.00 a month, a $4.00 increase from 2015.

Part A Deductibles and Coinsurance for 2016

Slight Increases for Medicare 2016 Part A

For more information on the 2016 Medicare Parts A and B premiums and deductibles (CMS-8059-N, CMS-8060-N, and CMS-8061-N), click here.




Is This Physician Crazy? She Walked Away From a “Big Five” Payer Contract!

Feel All Alone Contracting With Payers?I recently helped a physician start a new practice and we began applying for enrollment with the Big Five insurance companies. The physician was stunned to find:

  • Insurance companies regularly “lost” her applications and we had to submit the same information numerous times. Some companies require an online application which provides no ability to track. They will not accept paper applications which can be tracked by the delivery service.
  • She was offered contracts with no fee schedule attached. When we asked for the fee schedule, we were told it was available in the physician portal. When we went to the physician portal, we were told that only enrolled physicians have access to the portal.
  • Contracts she received made reference to the physician adhering to the rules of the Provider Manual. When we asked for a copy of the Provider Manual, we were told it was available in the physician portal. You guessed it – only enrolled physicians have access to the portal.
  • Some insurance companies routinely took 90-120 days or more to complete the application process, then another 60-90 days to enter the contract into the system so physician claims would be paid. This means that a physician may not be able to get paid by one or more payers for 6-7 months after opening a practice.

The physician ultimately decided to walk away from the most egregious of the payers.

After having numerous potential new patients call the practice to find out if she was contracted with this payer, she had to tell them that she would not be contracting with this payer.

Here’s the letter she wrote to the Insurance Company Representative:

Good Afternoon:

Thank you for your follow-up note.  I am uncertain why, but the information you provided, once again, is in direct conflict with the data provided by our local physician’s organization as well as the objective data of looking at pricing vs reimbursement for the ___ vaccination.

I have included for your review comments made by an 18-year veteran of contract negotiations, Ron Howrigon.  It appears being evasive and obtuse in how you negotiate with physicians is an intentional cultural value.

The tenets of our practice require honesty, good-faith and integrity from all of our partners in healthcare.  This article and our experience with you suggests a different and unacceptable organizational value displayed by your company.

At this time, given the disorganized credentialing process, the poor interactions with your company and the vexatious conversation with you, we will not be partnering with you.  We have notified all of our patients insured by your company that we will not be accepting your plans in our practice.  This is a values and ethics-based decision.  We regret you and your company have chosen to conduct yourselves with such hostility and disregard for physicians and the important work we do on behalf of our patients.

Sincerely,

Physician in a New Practice