Archive for Medicare & Reimbursement

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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.

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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.

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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.

 

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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

 

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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.

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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.

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Telemedicine Pioneers: HiTech-Doctors

Communicating With Our Physicians At Home

 

 

 

 

 

 

 

We introduced readers to HiTech-Doctors several years ago before the telemedicine boom really hit. Today, many physicians are thinking seriously about telemedicine and how adding it to their practices could meet patient demand for convenience and ease overcrowded schedules. We decided to catch up with Philip Gideon, MD, cardiologist and Chief Medical Officer of HiTech-Doctors and see what’s new.

Mary Pat: Describe HiTech-Doctors.

Dr. Gideon: HiTech-Doctors is a web-based heath care portal created to open Internet communications between provider and patient. We seek to create the safest and easiest environment for videoconferencing encounters, electronic messaging, clinical data entry, data transfer, and clinical education. Connected care is the future and is here.

 

Mary Pat: How can a practice improve patient communication using HiTech-Doctors?

Dr. Gideon: We have a high definition videoconferencing service with quality and utilities not yet seen in this industry.

  • We have developed an email service that allows safe communication with your patients.
  • For each encounter a history and physical document is generated. This data can be used in the normal workflow of generating the electronic patient chart.
  • There is a patient data entry service that allows general clinical data to be populated by the patient.
  • Interactive encounter scheduling is available to make life easier for the patient and the provider.
  • Other providers and family members can be invited into the video encounter.
  • The patients can transmit their health information in to their chart.

 

Mary Pat: How has HiTech-Doctors evolved?

Dr. Gideon: We wanted to create the next generation of electronic health record. An EHR is needed that allows the provider and patient to communicate and learn through multiple technologies in a safe easy way. We have begun to accomplish this “open chart” with our current system platform.

Additionally, the platform needed to aid providers in meeting Meaningful Use (MU) criteria for participation in government incentive programs. MU2, and particularly MU3 criteria, have some specific technological requirements that cannot at this time be fully met by most available EHR providers. We have been able to meet many of these criteria by:

  • Demographic recording and record of smoking status
  • Patient-generated data entry (medication reconciliation, BP, heart rates, blood sugars, weights, BMI, etc.)
  • Use of secure electronic messaging to communicate with patients
  • Allowing immediate ability for patients to view and download their encounter record by both document and video format.
  • Increasing after hours provider accessibility
  • Gives ability to provide summary of care record electronically

There are so many useful aspects to the platform. We believe that as MU criteria evolve and the repealed SGR mandates develop, our product will lead in the industry. We believe that, but we know HiTech-Doctors will lead in health care communication.

 

Mary Pat: What does it cost physicians and patients?

Dr. Gideon: For the provider, it is $300 for lifetime enrollment. No additional charge for individual providers.

The communications platform (secure electronic messaging or emailing) is $300 per month per practice.

For the patient, it is $20 lifetime enrollment for an individual and this includes family.

$10 will be added to the patient bill in all encounters as payment for the service to HiTech-Doctors.

 

Mary Pat: Does insurance pay for telemedicine?

Dr. Gideon: Provider practices are encouraged to notify private insurance providers of the intent to see their patients by telemedicine. The intent should state that the encounter would be billed at an appropriate level of office visit using a QT modifier. The patient would be billed a set amount which should be considered a copay or as part of the total reimbursement. A description of the service being used (HiTech-Doctors) and the cost of service should be included. Some insurance carriers may need to negotiate the fee schedule, but this is commonplace when a new service is offered in a practice.

Encounters can alternatively be billed by the provider as cash or fee-for-service. This is specifically true for Medicare and Medicaid patients using the system outside of Medicare/Medicaid telemedicine criteria (cms.gov).

Either means of payment require a credit card transaction prior to starting the encounter.

 

Mary Pat: How does a practice implement telemedicine?

Dr. Gideon: The Hitech-Doctors team has put together an implementation plan to accommodate any office or medical center.

  1. Setting up computers, tablets and phones to accommodate the best virtual experience.
  2. Modification of patient scheduling workflow to allow a choice of in office or online encounters.
  3. Acquire and categorize patient email contact list.
  4. Email, postal, and in office advertisement of the new online service.

The implementation involves strategic scheduled learning teams early in the initiation. Both in-person and online availability of the HiTech-Doctors team is present as the roll out takes place and after. This combination of staff and provider education, hardware setup, advertisement, and ongoing technical and clinical support offers the best success.

 

Mary Pat: Is there technical support?

Dr. Gideon: Yes, 24/7 technical and user support are available buy phone at 1-480-588-2512. Try it!

 

Mary Pat: Since we last talked, the national conversation about telemedicine has changed radically. How has the conversation changed HiTech-Doctors?

Dr. Gideon: HiTech-Doctors has continued to promote the use of telemedicine as another form of patient:provider communication. Many levels of acceptance and regulation of video encounters need to be in place to allow broad use of telemedicine. This is the conversation at present, and it will need to continue. HiTech-Doctors hopes to help keep the momentum in the right direction towards sustaining the patient doctor relationship.

 

Mary Pat: What do you think about the interstate telehealth licensing compact?

Dr. Gideon: The compact addresses serious questions about healthcare, such as physician shortage in both rural and urban regions and poor access to care. Telemedicine stands to be an efficient tool in the solution.

There are tremendous benefits to having interstate licensure. Electronic visits are already a proven means of healthcare communication that can be gap-filling technology where there is poor access to healthcare. The compact has had progressively more backing by states and congressional leaders. Allowing providers to have interstate license gives the ability to optimize the use of the available technology.

Recently UHC announced it would cover telemedicine services for its subscribers, however, only if the services were procured through specific telemedicine intermediaries. What are your thoughts about this development?

Insurance providers are at a stage where they need to, and can, set the physician fee schedules for telemedicine given no specific value or code has been yet assigned by CMS. Blue Cross Blue Shield of Arizona recently also consented to paying for telemedicine at only 80% of the billed visit. United Healthcare doing business with only specific telemedicine companies is a normal practice of insurance providers in this current time of managed healthcare. HiTech-doctors offers a platform that allows real medical practice to occur. It is far more than triage to keep insurance company clients out of the ER or urgent care. The real winner is the telemedicine service that allows confident and safe communication.

 

Mary Pat: What is in the future for HiTech-Doctors?

Dr. Gideon: We are excited to move with the growing pains of our healthcare system so that we stay connected to actual need. Technology through HiTech-Doctors will continue to help in producing the best health outcomes at a low cost. The other side of the HiTech-Doctors healthcare portal is better outcomes and living.

More information on HiTech Doctors is available at their website here or by calling 480-588-2512.

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Posted in: Innovation, Medicare & Reimbursement, Practice Marketing

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CMS and AMA Make ICD-10 “Family” Clarification

Medicare will reimburse claims with ICD-10 codes as long as they are in the correct code "family" for 12 months.

Clarifying Questions and Answers Related to the July 6, 2015 CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities

Question 1:

When will the ICD-10 Ombudsman be in place?

Answer 1:

The Ombudsman will be in place by October 1, 2015.

Question 2:

Does the Guidance mean there is a delay in ICD-10 implementation?

Answer 2:

No. The CMS/AMA Guidance does not mean there is a delay in the implementation of the ICD-10 code set requirement for Medicare or any other organization. Medicare claims with a date of service on or after October 1, 2015, will be rejected if they do not contain a valid ICD-10 code. The Medicare claims processing systems do not have the capability to accept ICD-9 codes for dates of service after September 30, 2015 or accept claims that contain both ICD-9 and ICD-10 codes for any dates of service. Submitters should follow existing procedures for correcting and resubmitting rejected claims.

Question 3:

What is a valid ICD-10 code?

Answer 3:

ICD-10-CM is composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth, fifth, sixth or seventh characters to provide greater specificity. A three-character code is to be used only if it is not further subdivided. To be valid, a code must be coded to the full number of characters required for that code, including the 7th character, if applicable. Many people use the term billable codes to mean valid codes. For example, E10 (Type 1 diabetes mellitus), is a category title that includes a number of specific ICD-10-CM codes for type 1 diabetes. Examples of valid codes within category E10 include E10.21 (Type 1 diabetes mellitus with diabetic nephropathy) which contains five characters and code E10.9 (Type 1 diabetes mellitus without complications) which contains four characters.

A complete list of the 2016 ICD-10-CM valid codes and code titles is posted on the CMS website at http://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-and-GEMs.html. The codes are listed in tabular order (the order found in the ICD-10-CM code book). This list should assist providers who are unsure as to whether additional characters are needed, such as the addition of a 7th character in order to arrive at a valid code.

Question 4: What should I do if my claim is rejected? Will I know whether it was rejected because it is not a valid code versus denied due to a lack of specificity required for a NCD or LCD or other claim edit?

Answer 4:

Yes, submitters will know that it was rejected because it was not a valid code versus a denial for lack of specificity required for a NCD or LCD or other claim edit. Submitters should follow existing procedures for correcting and resubmitting rejected claims and issues related to denied claims.

Question 5:

What is meant by a family of codes?

Answer 5:

“Family of codes” is the same as the ICD-10 three-character category. Codes within a category are clinically related and provide differences in capturing specific information on the type of condition. For instance, category H25 (Age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved. Examples include: H25.031 (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters. One must report a valid code and not a category number. In many instances, the code will require more than 3 characters in order to be valid.

Question 6:

Does the recent Guidance mean that no claims will be denied if they are submitted with an ICD-10 code that is not at the maximum level of specificity?

Answer 6:

In certain circumstances, a claim may be denied because the ICD-10 code is not consistent with an applicable policy, such as Local Coverage Determinations or National Coverage Determinations. (See Question 7 for more information about this). This reflects the fact that current automated claims processing edits are not being modified as a result of the guidance.

In addition, the ICD-10 code on a claim must be a valid ICD-10 code. If the submitted code is not recognized as a valid code, the claim will be rejected. The physician can resubmit the claims with a valid code.

Question 7:

National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) often indicate specific diagnosis codes are required. Does the recent Guidance mean the published NCDs and LCDs will be changed to include families of codes rather than specific codes?

Answer 7:

No. As stated in the CMS’ Guidance, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family of codes. The Medicare review contractors include the Medicare Administrative Contractors, the Recovery Auditors, the Zone Program Integrity Contractors, and the Supplemental Medical Review Contractor.

As such, the recent Guidance does not change the coding specificity required by the NCDs and LCDs. Coverage policies that currently require a specific diagnosis under ICD-9 will continue to require a specific diagnosis under ICD-10. It is important to note that these policies will require no greater specificity in ICD-10 than was required in ICD-9, with the exception of laterality, which does not exist in ICD-9. LCDs and NCDs that contain ICD-10 codes for right side, left side, or bilateral do not allow for unspecified side. The NCDs and LCDs are publicly available and can be found at http://www.cms.gov/medicare-coverage-database/.

Question 8:

Are technical component (TC) only and global claims included in this same CMS/AMA guidance because they are paid under the Part B physician fee schedule?

Answer 8:

Yes, all services paid under the Medicare Fee-for-Service Part B physician fee schedule are covered by the guidance.

Question 9:

Do the ICD-10 audit and quality program flexibilities extend to Medicare fee-for-service prior authorization requests?

Answer 9:

No, the audit and quality program flexibilities only pertain to post payment reviews. ICD-10 codes with the correct level of specificity will be required for prepayment reviews and prior authorization requests.

MEDICAID

Question 10:

If a Medicare paid claim is crossed over to Medicaid for a dual-eligible beneficiary, is Medicaid required to pay the claim?

Answer 10:

State Medicaid programs are required to process submitted claims that include ICD-10 codes for services furnished on or after October 1 in a timely manner. Claims processing verifies that the individual is eligible, the claimed service is covered, and that all administrative requirements for a Medicaid claim have been met. If these tests are met, payment can be made, taking into account the amount paid or payable by Medicare. Consistent with those processes, Medicaid can deny claims based on system edits that indicate that a diagnosis code is not valid.

Question 11:

Does this added ICD-10 flexibility regarding audits only apply to Medicare?

Answer 11:

The official Guidance only applies to Medicare fee-for-service claims from physician or other practitioner claims billed under the Medicare Fee-for-Service Part B physician fee schedule. This Guidance does not apply to claims submitted for beneficiaries with Medicaid coverage, either primary or secondary.

Question 12:

Will CMS permit state Medicaid agencies to issue interim payments to providers unable to submit a claim using valid, billable ICD-10 codes?

Answer 12:

Federal matching funding will not be available for provider payments that are not processed through a compliant MMIS and supported by valid, billable ICD-10 codes.

OTHER PAYERS

Question 13:

Will the commercial payers observe the one-year period of claims payment review leniency for ICD-10 codes that are from the appropriate family of codes?

Answer 13:

The official Guidance only applies to Medicare fee-for-service claims from physician or other practitioner claims billed under the Medicare Fee-for-Service Part B physician fee schedule. Each commercial payer will have to determine whether it will offer similar audit flexibilities.

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Posted in: Headlines, ICD-10, Medical Coding Education, Medicare & Reimbursement, Medicare This Week

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What Tools Will You Need for the ICD-10 Transition? Q & A with Swiftaudit

Learn How to Crosswalk Your ICD-9s to ICD-10s

 

 

October 1, 2015 is a date that looms large for everyone involved in the operational and financial functions of any medical practice. At the time of this post’s publishing, practice administrators, managers, billers and coders have less than three months to make sure they have the processes and systems in place to minimize the business disruption from the changeover. As we talked to clients and readers about the challenges they are facing with the ICD-10 upgrade over the past several years, we started looking for tools that could help practices ease the transition.

One tool really stood out more than the others. Swiftaudit Search is a web-based coding conversion and look-up tool for both ICD-9 and ICD-10 code sets that we strongly endorse for its ability to supercharge ICD-10 coding, audits and upgrade preparations. We’ve been using Swiftaudit Search here at Manage My Practice for months now and we are very excited about how it can help our readers and clients.

We sat down with the creators of Swiftaudit Search, Chicago’s SpringSoft to ask them more about how practices can prepare for the upgrade.

Manage My Practice: Tell us about SpringSoft and how you starting working in the healthcare software market.

SpringSoft: We’ve provided software to the healthcare coding and compliance market since 1995. Our first product was E&M Coder™ for evaluation and management coding and audits. It all started when a few forward thinking doctors told us “the auditors are coming.” Given our background in corporate business systems, our research provided a couple of interesting observations at that time. One – physician offices had few easy to use software applications. Two – from a business point of view, physician offices needed help with coding and compliance. So we tackled a challenging little-understood coding issue in 1994 – the introduction of evaluation and management codes.

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Manage My Practice: Your product that is designed for medical coding has gone through several iterations since the ICD-10 mandate was first announced – how did your product evolve?

SpringSoft: We started designing what is now Swiftaudit Pro several years ago. As we designed the coding components, we realized that our ICD-10 Search features would benefit physicians during the transition to ICD-10. Again, we took on a daunting challenge. We knew we had to design an intuitive ICD-10 Search Feature. Once you find a group of codes, the next problem was to be present all of the ICD-10 coding information to describe the patient’s health condition. So now, as Swiftaudit evolves, our goal is to present the ICD-10 coding guidelines in a quick and straightforward way.

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Manage My Practice: We‘ve seen a wide variety of encoder-type products designed for hospitals and large organizations, and some designed for billing companies and consultants. What target market is the best fit for your products and why?

SpringSoft: Currently, we see our market as physician offices. Hospital and large organization coding systems have to address ‘packet’ coding, such as DRG (Diagnosis Related Groups) and HCCs (Hierarchical Condition Categories). Hospitals and large organizations will benefit from our auditing platform – SwiftAudit Pro. Providers who need to code ICD-10s will benefit from Swiftaudit Search. They can use our product to learn how code their common ICD-9 diagnosis in ICD-10 language.

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Manage My Practice: What do you hear are the biggest challenges faced by practices in making the transition to I-10?

SpringSoft: We hear that immediacy and time are the biggest challenges. Immediacy – it is always easier to learn new methods when you can consistently work in the new method. A baseline understanding helps provide context and what the changes are. We will all learn when everyone starts coding in ICD-10. Time – the change to ICD-10 is not trivial. It impacts the office’s income. Everyone will need to spend a little more time – coding in ICD-10, and time in improving their coding as payers respond to codes submitted. A practice can reduce frustration if they understand and prepare for their learning curve. Like all new methods, it takes practice to perfect.

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Manage My Practice: For many practices, their ability to utilize ICD-10 will come down to the support the EHR or Practice Management vendor has built into the software, yet many practices have not even seen how their software will work with ICD-10. What do recommend for practices whose software has not yet been updated to I-10, or whose software makes no useful correlation between I-9 and I-10?

SpringSoft: We agree with many consultants and trainers. Transition your top ICD-9 codes to specific ICD-10 codes. Be cautious of depending on published crosswalks. ICD-9s which describe ‘unspecified’ elements often are crosswalked to ‘unspecified’ ICD-10s. Experts in the industry are cautioning that ‘unspecified’ ICD-10s may not be paid. Ask your EMR vendor, will you handle all of the ICD-10 coding guidelines, such as Code First, Code Also, Use Additional Codes? Will you map to ‘unspecified’ ICD-10 codes or warn me of ‘unspecified’ ICD-10 codes? How will you help me find more specific codes? You can use Swiftaudit Search to build your Favorites Lists. We will provide you the ICD-10 coding guidelines, and provide a communication platform for your expert coders to provide you with coding tips and alerts.

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Manage My Practice: What are some of the features in Swiftaudit Search that your product has that others you’ve seen do not?

SpringSoft: We feel that our ease of use and screen design makes us stand out from the crowd. The ICD-10 code set is overwhelming. We’ve worked very hard to provide the information you need at a glance.

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Manage My Practice: Swiftaudit Pro (as opposed to Swiftaudit Search) is more for the coding and billing side of the practice. How do you see coders and billers using this product in their practices?

SpringSoft: Our background is in coding and compliance. Managers and auditors can use Swiftaudit Pro to improve their coding accuracy and educate their providers. We built Swiftaudit Pro to be a communication platform to aid discovery and process improvement between a practice’s providers and expert coders.

Readers who would like more information or would like to try Swiftaudit Search for free for 30-days can click here.

NOTE: We’ve heard of so many practices that have not started preparations for ICD-10 that that we made the 20-minute webinar “ICD-10 CM: Getting Started Today.” The video addresses strategies for the first step – crosswalking your most used ICD-9 codes into ICD-10.

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July 15-16 CMS Webinars: New Payment Model for Joint Replacements

Surgeons Should Weigh In On Proposed CMS Joint Replacement Payment Model

UPDATED INFO: These recorded webinars are now available here.

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On July 9, 2015 the Centers for Medicare & Medicaid Services (CMS) announced the Comprehensive Care for Joint Replacement (CCJR) model, a proposed payment, quality, and care improvement initiative for hip and knee replacements.

The Center for Medicare & Medicaid Innovation (CMS Innovation Center) will host two offerings of a webinar to describe the proposed rule and respond to questions. The dates and registration links for these webinars are as follows:

Additional information on this Model can be accessed through the CCJR Model web page.

The proposed rule will undergo a 60-day comment period during which time CMS welcomes the input of stakeholders and the public. You can read the proposed rule in the Federal Register.

We encourage all interested parties to submit comments to the rule electronically through the CMS e-Regulation website at http://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/eRulemaking/index.html?redirect=/eRulemaking or on paper by following the instructions included in the proposed rule. Submissions must be received by September 8, 2015.

*Large audiences are anticipated. Plan on joining a few minutes early.

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Posted in: Medicare & Reimbursement, Medicare This Week

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