Today’s CMS call reviewed the guidelines for the IPPE (Initial Preventive Physical Exam) and the AWV (Annual Wellness Visit), what they include and how to code for them.
What is the IPPE (also called the “Welcome to Medicare Visit”)?
The IPPE is a one-time visit, covered within 12 months after the effective date of Part B coverage and including:
Review of medical and social history.
Review of risk factors for depression.
Review of functional ability and level of safety.
Measurement of height, weight, body mass index, blood pressure, visual acuity, and other factors deemed appropriate.
Discussion of end-of-life planning, if agreed upon by the patient.
Education, counseling and referrals based on results of review and evaluation services performed during the visit, including a brief written plan such as a checklist, and if appropriate, education, counseling and referral for obtaining an electrocardiogram (a/k/a EKG, ECG).
Note that although the IPPE has the word “exam” in it, there is NO physical exam associated with it. Most practices attempt to call it the Welcome to Medicare Visit and try never to use the word “exam” in association with it.
Who can provide the IPPE?
Physician (doctor of medicine or osteopathy)
Qualified non-physician practitioner including nurse practitioner physician assistant or Clinical nurse specialist
It’s a stark reality – at this time in American history, we are at the (or near the) highest level of funding for health care. The Ryan Medicare proposal and continued debate inside the Beltway and by state lawmakers makes it clear that while experts estimate that by 2082 health care spending could be 49% of our gross domestic product, this is not a sustainable reality. Further, as baby boomers retire, the contribution of working aged people through taxes and direct employer contribution to health care costs will fall.
Thus, lawmakers have been investigating ways to reduce health care costs for America’s elderly. A report released by the non-partisan Medicare Payment Advisory Commission (MedPAC) last week includes a number of recommendations for reforms aimed at “explor[ing] every avenue for protecting the access of Medicare beneficiaries to high-quality care while reducing the rate of growth in Medicare expenditures.” Chapter 2 of the report addresses “Improving payment accuracy and appropriate use of ancillary services” with recommendations to the Stark law, interim payment reforms for imaging services and a requirement for “high-use practitioners to participate in a prior authorization program for advanced diagnostic imaging services.”
CMS will host a national provider call on the upcoming mandatory accreditation program for all suppliers that furnish the technical component of advanced diagnostic imaging on Thursday, June 23, 2011 from 2:30 – 4:00 p.m. EST. Subject matter experts will discuss what the requirements are to meet the Sunday, January 1, 2012, deadline; who these requirements effect; and how to become accredited. CMS will update information previously discussed on Open Door Forums that will streamline the requirements. See my original post on this topic here.
The target audience for this call includes physician office staff and all Medicare fee-for-service providers; the agenda will include:
This is a busy time for most practices. Managers are preparing for the annual juggling act of getting staff and physicians coordinated for summer vacations. Practices are ramping up for new doctors joining their practice at the traditional end of residency programs in the summer. Many practices are in the midst of shopping for, negotiating for or implementing EMRs. And most everyone without an existing EMR is struggling with the e-prescribing deadline looming in 30 days. Read my first post on this topic here.
As a reminder:
Eligible professionals who are not successful e-prescribers, based on claims submitted between January 1, 2011 and June 30, 2011, may be subject to a “payment adjustment” (read payment cut) in their Medicare Part B Physician Fee Schedule (PFS) for covered professional services in 2012.
Those that do not e-prescribe as a part of 10 Medicare patient encounters by June 30, 2011 will only receive 99% of their Medicare payment for all encounters in 2012.
Those that do not e-prescribe as a part of 25 encounters by December 31, 2011, will only receive 98.5% of their Medicare payments for all encounters in 2013 and only 98% of their Medicare payments for encounters during 2014 and going forward.
Note: See my latest post on registering and attesting for the EHR Incentive Program here.
CMS has announced two national calls for attestation.
Tue May 3, 2-3:30pm ET (for Eligible Hospitals)
Thu May 5, 1:30-3pm ET (for Eligible Professionals)
CMS is holding conference calls for eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) participating in the Medicare Electronic Health Record (EHR) Incentive Program to provide information on the attestation process. Mark your calendars for one of the calls below.
Tuesday, May 3, 2:00 – 3:30 p.m. ET – Register to join this call if you are an eligible hospital or CAH who wants to learn more about the attestation process for the Medicare EHR Incentive Program.
Thursday, May 5, 1:30 – 3:00 p.m. ET– Register to join this call if you are an EP who wants to learn more about the attestation process for the Medicare EHR Incentive Program.
What the Calls Will Cover
Path to Payment – Highlighting the steps you need to take to receive your incentive payment
Walkthrough of the Attestation Process – Guiding you through CMS’ web-based attestation system
Troubleshooting – Helping you successfully attest through CMS’ system
Helpful Resources – Reviewing CMS’ resources available on the EHR website
Q&A – Answering your questions about the attestation process
Instructions on How to Register for a Call
To register for these calls, take the following steps:
The registration site for the Tuesday, May 3 eligible hospital and CAH call. Registration closes Monday, May 2 , 2:00 p.m. ET.
The registration site for the Thursday, May 5 EP call. Registration closes Wednesday, May 4, 1:30 p.m. ET.
Fill in all required information and click “Register.”
You will be taken to the “Thank you for registering” page and will receive a confirmation email shortly thereafter. Please save this page in case your server blocks the confirmation email. (If you do not receive the confirmation email, check your spam/junk mail filter as it may have been directed there.)
If assistance for hearing impaired services is needed, please email firstname.lastname@example.org later than 3 business days before the call.
Prior to each call, presentation materials will be available in the Upcoming Events section of the Spotlight Page on the CMS EHR website.
Registration closes when all available space has been filled, or 24 hours before each call; no exceptions will be made, so please register early.
How will I attest for the Medicare and Medicaid Incentive Programs?
Medicare eligible professionals, eligible hospitals and critical access hospitals will have to demonstrate meaningful use through CMS’ web-based Registration and Attestation System. In the Medicare & Medicaid EHR Incentive Program Registration and Attestation System, providers will fill in numerators and denominators for the meaningful use objectives and clinical quality measures, indicate if they qualify for exclusions to specific objectives, and legally attest that they have successfully demonstrated meaningful use. A complete EHR system will provide a report of the numerators, denominators and other information. Then you will need to enter that data into our online Attestation System. Providers will qualify for a Medicare EHR incentive payment upon completing a successful online submission through the Attestation System—immediately after you submit your results you will see a summary of your attestation, and whether or not it was successful. The Attestation System for the Medicare EHR Incentive Program will open on April 18, 2011.
For the Medicaid EHR Incentive Program, providers will follow a similar process using their state’s Attestation System. Check here to see states’ scheduled launch dates for their Medicaid EHR Incentive Programs.
Do you have questions about the EHR Incentive Programs? Do you want to find out if you are eligible, how much of an incentive payment you can earn, and learn more details about the program and what you need to do to qualify?
To attest for the Medicare EHR Incentive Program in your first year of participation, you will need to have met meaningful use for a consecutive 90-day reporting period. If your initial attestation fails, you can select a different 90-day reporting period that may partially overlap with a previously reported 90-day period. To attest for the Medicare EHR Incentive Program in subsequent years, you will need to have met meaningful use for a full year. Please note the reporting period for eligible professionals must fall within the calendar year, while the reporting period for eligible hospitals and critical access hospitals must fall during the Federal fiscal year.
April 18, 2011, is the earliest an eligible professional, eligible hospital or critical access hospital can attest that they have demonstrated meaningful use of certified EHR technology under the Medicare EHR Incentive Program.
Under the Medicaid EHR Incentive Program, providers can attest that they have adopted, implemented or upgraded certified EHR technology in their first year of participation to receive an incentive payment. Medicaid EHR Incentive Program participants should check with their state to find out when they can begin participation.
What can I do now to prepare for attestation?
Visit the Registration page and get registered for the EHR Incentive Programs right now. If you haven’t previously registered, you can complete the registration and attestation process at the same time.
Also, review the Attestation User Guides, which provide step-by-step instructions for login and completing attestation. You can find separate Attestation User Guides for eligible professionals and eligible hospitals in the Resources section below.
Finally, you can enter your information in our Meaningful Use Attestation Calculator prior to submitting your attestation to see if you would be able to meet all of the necessary measures to successfully demonstrate meaningful use and qualify for an EHR incentive payment.
What will I need to login to the Attestation System?
If you are an eligible professional, you’ll need:
Your Type 1 National Provider Identifier (NPI)
The same user ID and password you used to register
If you are working on behalf of an eligible hospital or critical access hospital, you’ll need:
An active National Provider Identifier (NPI)
The same user ID and password you used to register
If you did not register the facility, you’ll need an Identity and Access Management system (I&A) Web user account (User ID/Password) and be associated to the organization NPI, if you’re a user working on behalf of an eligible hospital or critical access hospital.Create a login in the I&A System if you’re working on behalf of an eligible hospital or Critical Access Hospital and don’t have an I&A web user account.
What is the CMS EHR Certification Number?
During attestation, CMS requires each eligible professional, eligible hospital and critical access hospital to provide a CMS EHR Certification ID or Number that identifies the certified EHR technology being used to demonstrate meaningful use. This unique CMS EHR Certification ID or Number can be obtained by entering the certified EHR technology product information at the Certified Health IT Product List (CHPL) on the ONC website here.
NOTE: The ONC CHPL Product Number issued to your vendor for each certified technology is different than the CMS EHR Certification ID. Only a CMS EHR Certification ID obtained through the CHPL will be accepted at attestation.
Eligible professionals, eligible hospitals and critical access hospitals can obtain a CMS EHR Certification ID or Number by following these steps:
Select your practice type by selecting the Ambulatory or Inpatient buttons.
Search for EHR Products by browsing all products, searching by product name or searching by criteria met.
Add product(s) to your cart to determine if your product(s) meet 100% of the CMS required criteria.
Request a CMS EHR Certification ID for CMS attestation.NOTE: The “Get CMS EHR Certification ID” button will not be activated until the products in your cart meet 100% of the CMS required criteria. If the EHR product(s) do not meet 100% of the CMS required criteria to demonstrate Meaningful Use, a CMS EHR Certification ID will not be issued.
The CMS EHR Certification ID contains 15 alphanumeric characters.
I’m an Eligible Professional (EP). Can I designate a third party to register and/or attest on my behalf?
In April 2011, CMS implemented functionality that allows an EP to designate a third party to register and attest on his or her behalf. To do so, users working on behalf of an EP must have an Identity and Access Management System (I&A) web user account (User ID/Password), and be associated to the EP’s NPI. If you are working on behalf of an EP(s), and do not have an I&A web user account, please visit I&A Security Check to create one. States will not necessarily offer the same functionality for attestation in the Medicaid EHR Incentive Program. Check with your State to see what functionality will be offered.
When will I get paid?
Incentive payments for the Medicare EHR Incentive Program will be made approximately four to six weeks after an eligible professional, eligible hospital or critical access hospital meets the program requirements and successfully attests they have demonstrated meaningful use of certified EHR technology. CMS expects that Medicare incentive payments will begin in May 2011. Payments will be held for eligible professionals until the eligible professional meets the $24,000 threshold in allowed charges.
Eligible hospitals and critical access hospitals attesting in April 2011 could receive their initial payments as early as May 2011. Final payment will be determined at the time of settling the hospital Medicare cost report.
Medicaid incentives will be paid by the states and are expected also to begin in 2011. States are required to issue incentive payments within 45 days of providers successfully attesting to having adopted, implemented or upgraded certified EHR technology during their first year of participation in the Medicaid EHR Incentive Program. Launch date for the Medicaid EHR Incentive Program varies by state, so the earliest date attestation can begin also varies by state. Several states have disbursed incentive payments as early as April 2011.
How will I get paid?
Payments to Medicare providers will be made to the taxpayer identification number (TIN) you selected at the time you registered for the Medicare EHR Incentive Program.
CMS will deposit payment in the first bank account on file. It will appear on your bank statement as “EHR Incentive Payment”
If you receive payments for Medicare services via electronic funds transfer, you will receive Medicare EHR Incentive Program payment the same way. If you currently receive Medicare payments by paper check, you will also receive your first Medicare EHR Incentive Program payment by paper check.
IMPORTANT: Medicare Administrative Contractors (MACs), carriers and fiscal intermediaries will not be making these payments. CMS has contracted with a Payment File Development Contractor to make these payments.
Have questions about your EHR incentive payment?
DON’T: Call your MAC/carrier/fiscal intermediary with questions
DO: Call the EHR Information Center
1-888-734-6433. TTY users should call 1-888-734-6563
Hours of Operation: 7:30 a.m. – 6:30 p.m. (Central Time) Monday through Friday, except federal holidays
Why the payment amount may be less than you thought: The Medicare & Medicaid EHR Incentive Program Registration and Attestation System contains a Status tab at the top which will contain the amount of the incentive payment, the amount of tax or nontax offsets applied, and the remittance advice reason code containing the reason for any reduction.
For those receiving paper checks, there will be a tear-off pay stub which identifies offsets made to the incentive payment.
Where you can find more information about the offsets: For more information about tax offsets, call the Internal Revenue Service (IRS) at 1-800-829-3903.
For more information about non tax offsets, call the Department of the Treasury, Financial Management Service (FMS) at 1-800-304-3107.
Will CMS conduct audits?
Any provider attesting to receive an EHR incentive payment for either the Medicare EHR Incentive Program or the Medicaid EHR Incentive Program potentially may be subject to an audit. Here’s what you need to know to make sure you’re prepared:
Overview of the CMS EHR Incentive Programs Audits
All providers attesting to receive an EHR incentive payment for either Medicare or Medicaid EHR Incentive Programs should retain ALL relevant supporting documentation (in either paper or electronic format used in the completion of the Attestation Module responses). Documentation to support the attestation should be retained for six years post-attestation. Documentation to support payment calculations (such as cost report data) should continue to follow the current documentation retention processes.
CMS, and its contractors, will perform audits on Medicare and dually-eligible (Medicare and Medicaid) providers.
States, and their contractors, will perform audits on Medicaid providers.
CMS and states will also manage appeals processes.
Preparing for an Audit
To ensure you are prepared for a potential audit, save the supporting electronic or paper documentation that support your attestation. Also save the documentation to support your Clinical Quality Measures (CQMs). Hospitals should also maintain documentation to support their payment calculations.
Upon audit, the documentation will be used to validate that the provided accurately attested and submitted CQMs, as well as to verify that the incentive payment was accurate.
Details of the Audits
There are numerous pre-payment edit checks built into the EHR Incentive Programs’ systems to detect inaccuracies in eligibility, reporting and payment.
Post-payment audits will also be completed during the course of the EHR Incentive Programs.
If, based on an audit, a provider is found to not be eligible for an EHR incentive payment, the payment will be recouped.
CMS will be implementing an appeals process for eligible professionals, eligible hospitals and critical access hospitals that participate in the Medicare EHR Incentive Program. More information about this process will be posted to the CMS Web site soon.
States will implement appeals processes for the Medicaid EHR Incentive Program. For more information about these appeals, please contact your State Medicaid Agency.
Where can I find user guides and other resources?
Below are step-by-step Attestation User Guides to help you attest for the Medicare EHR Incentive Program. You can also use our Attestation Worksheet, Meaningful Use Attestation Calculator, and educational webinar to help you prepare for and complete the attestation process:
Special Open Door Forum: Presentation and Listening Session on Hospital Wage Index Reform
Tuesday, April 12, 2011, 1:30 PM – 3:00 PM ET.
Section 3137(b) of the Affordable Care Act requires CMS to submit to Congress, by December 31, 2011, a report that includes a plan to reform the wage index under the Medicare hospital inpatient prospective payment system (IPPS). CMS acquired the services of Acumen, LLC to assist in its study of the wage index. During the first part of this special open door forum, Acumen will present its concept of an alternative methodology for the wage index. The second part will be a listening session, during which CMS would like to hear from you regarding your opinions about Acumen’s concept, as well as any suggestions on alternative methods for computing the wage index. If you wish to participate via conference call, dial 1-800-837-1935Conference ID 50101623. Please see the full participation announcement in the Downloads section here.
Electronic Health Record Incentive Program Attestation Begins This Week
Attestation for the Medicare Electronic Health Record (EHR) Incentive Program begins on Monday, April 18, 2011. In order to receive your Medicare EHR incentive payment, you must attest through CMS’s web-based Medicare and Medicaid EHR Incentive Programs Registration and Attestation System.
You can preview selected screenshots of the Attestation System to help you understand what the attestation process will involve. Please note that these screenshots are only examples – the final appearance and language may incorporate additional changes. CMS will release additional information about the Medicare attestation process soon, including User Guides that provide step-by-step instructions for completing attestation and educational webinars that describe the attestation process in depth.
You need to understand the required meaningful use criteria to successfully attest. Meaningful use requirements for eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) participating in the Medicare EHR Incentive Program are different:
EP Meaningful Use Criteria –Must report on 15 core measures, 5 of 10 menu measures, and 6 clinical quality measures, consisting of 3 required core measures and 3 additional measures.
You should also make sure that you begin your 90-day reporting period in time to attest and receive a Medicare payment in 2011. The last days to begin 90-day reporting periods for 2011 incentive payments are:
Sunday, July 3, 2011, for eligible hospitals and CAHs; and
Saturday, October 1, 2011, for EPs.
Under the Medicaid EHR Incentive Programs, the date when participants can begin attestation for adopting, implementing, upgrading, or demonstrating meaningful use of certified EHR technology varies by state. Visit the Medicaid State EHR Incentive Program web-tool for more information about your state’s participation in the Medicaid EHR Incentive Program.
The ABCs of Providing the Initial Preventive Physical Examination Quick Reference Chart provides Medicare Fee-For-Service providers a list of the elements of the IPPE, as well as coverage and coding information. View the chart here.
The ABCs of Providing the Annual Wellness Visit Quick Reference Chart provides Medicare Fee-For-Service providers a list of the elements of the AWV, as well as coverage and coding information. View the chart here.
The Medicare Preventive Services Quick Reference Chart provides Medicare Fee-For-Service providers coverage, coding, and payment information on the variety of preventive services covered by Medicare. View the chart here.
A hardcopy booklet containing all three charts, as well as the Quick Reference Information: Medicare Immunization Billing chart, will be available at a later date.
Latest HCPCS Code Set Changes
The Centers for Medicare & Medicaid Services is pleased to announce the scheduled release of modifications to the Healthcare Common Procedure Coding System (HCPCS) code set. These changes have been posted to the HCPCS web page here. Changes are effective on the date indicated on the update.
Revisions to ASP Pricing Files
The Centers for Medicare and Medicaid Services (CMS) has posted revised October 2010 and January 2011 ASP (average sales price) files, which are available for download here (see left menu for year-specific links).
Physician or NPP Signatures on Lab Requisitions
In the Monday, November 29, 2010, Medicare Physician Fee Schedule final rule, the Centers for Medicare & Medicaid Services (CMS) finalized its proposed policy to require a physician’s or qualified non-physician practitioner’s (NPP) signature on requisitions for clinical diagnostic laboratory tests paid under the clinical laboratory fee schedule effective Saturday, January 1, 2011. (A requisition is the actual paperwork, such as a form, which is provided to a clinical diagnostic laboratory that identifies the test or tests to be performed for a patient.)
On Monday, December 20, 2010, CMS informed its contractors of concerns that some physicians, NPPs, and clinical diagnostic laboratories are not aware of or do not understand this policy. As such, CMS indicated that it will focus in the first quarter of 2011 on developing educational and outreach materials to educate those affected by this policy. CMS indicated that once the first quarter educational campaign is fully underway, it will expect requisitions to be signed.
After further input from community, CMS has decided to focus for the remainder of 2011 on changing the regulation that requires signatures on laboratory requisitions because of concerns that physicians, NPPs, and clinical diagnostic laboratories are having difficulty complying with this policy.
Face-to-Face Encounter Requirements for Home Health and Hospice
Effective April 1, 2011, the Centers for Medicare & Medicaid Services (CMS) expects home health agencies and hospices have fully established internal processes to comply with the face-to-face encounter requirements mandated by the Affordable Care Act (ACA) for purposes of certification of a patient’s eligibility for Medicare home health services and of recertification for Medicare hospice services.
Section 6407 of the ACA established a face-to-face encounter requirement for certification of eligibility for Medicare home health services, by requiring the certifying physician to document that he or she, or a non-physician practitioner working with the physician, has seen the patient. The encounter must occur within the 90 days prior to the start of care, or within the 30 days after the start of care. Documentation of such an encounter must be present on certifications for patients with starts of care on or after January 1, 2011.
Similarly, section 3131(b) of the ACA requires a hospice physician or nurse practitioner to have a face-to-face encounter with a hospice patient prior to the patient’s 180th-day recertification, and each subsequent recertification. The encounter must occur no more than 30 calendar days prior to the start of the hospice patient’s third benefit period. The provision applies to recertifications on and after January 1, 2011.
On December 23, 2010, due to concerns that some providers needed additional time to establish operational protocols necessary to comply with face-to-face encounter requirements mandated by the Affordable Care Act (ACA) for purposes of certification of a patient’s eligibility for Medicare home health services and of recertification for Medicare hospice services, CMS announced that it will expect full compliance with the requirements, beginning with the second quarter of CY2011.
Throughout the first quarter of 2011, CMS has continued outreach efforts to educate providers, physicians, and other stakeholders affected by these new requirements. CMS has posted guidance materials including a MLN Matters article, questions and answers documents, training slides, and manual instructions which are available via CMS’ Home Health Agency Center and Hospice webpages. CMS’ Office of External Affairs and Regional Offices contacted state and local associations for physicians and home health agencies and advocacy groups to ensure awareness about the face-to-face encounter laws, and to distribute the educational materials.
CMS will continue to address industry questions concerning the new requirements, and will update information on the Web site here for home health and here for hospice.
Federally Qualified Health Center Fact Sheet Revised
The revised publication titled Federally Qualified Health Center (revised March 2011) is now available in downloadable format from the Medicare Learning Network® here. This fact sheet is designed to provide education about Federally Qualified Health Centers (FQHC), including background; FQHC designation; covered FQHC services; FQHC preventive primary services that are not covered; FQHC Prospective Payment System; FQHC payments; and Medicare Prescription Drug, Improvement, and Modernization Act of 2003 provisions that impact FQHCs.
Avoiding the Adjustment 2012 Medicare Payment Adjustment for Not ePrescribing in 2011
In November 2010, the Centers for Medicare & Medicaid Services announced that, beginning in calendar year 2012, eligible professionals who are not successful electronic prescribers based on claims submitted between Sat Jan 1 and Thu June 30, 2011, may be subject to a payment adjustment on their Medicare Part-B Physician Fee Schedule-covered professional services. Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorizes CMS to apply this payment adjustment whether or not the eligible professional is planning to participate in the eRx Incentive Program.
From 2012 through 2014, the payment adjustment will increase each calendar year. In 2012, the payment adjustment for not being a successful electronic prescriber will result in an eligible professional or group practice receiving 99% of their Medicare Part-B PFS amount that would otherwise apply to such services. In 2013, an eligible professional or group practice will receive 98.5% of their Medicare Part-B PFS-covered professional services for not being a successful electronic prescriber in 2011 or as defined in a future regulation. In 2014, the payment adjustment for not being a successful electronic prescriber is 2%, resulting in an eligible professional or group practice receiving 98% of their Medicare Part-B PFS-covered professional services. (The payment adjustment does not apply if less than 10% of an eligible professional’s or group practice’s allowed charges for the Sat Jan 1, 2011 through Thu June 30, 2011, reporting period are comprised of codes in the denominator of the 2011 eRx measure.) Also note that earning an eRx incentive for 2011 will NOT necessarily exempt an eligible professional or group practice from the payment adjustment in 2012.
How to Avoid the 2012 eRx Payment Adjustment:
Eligible professionals – An eligible professional can avoid the 2012 eRx Payment adjustment if (s)he:
Is not a physician (MD, DO, or podiatrist), nurse practitioner, or physician assistant as of Thu June 30, 2011, based on primary taxonomy code in NPPES;
Does not have prescribing privileges. Note that (s)he must report G8644 at least one time on an eligible claim prior to Thu June 30, 2011;
Does not have at least 100 cases containing an encounter code in the measure denominator;
Becomes a successful e-prescriber; and reports the eRx measure for at least 10 unique eRx events for patients in the denominator of the measure.
NOTE: Group Practices – For group practices that are participating in eRx GPRO-I or GPRO-II during 2011, the group practice MUST become a successful e-prescriber. Depending on the group’s size, the group practice must report the eRx measure for 75-2500 unique eRx events for patients in the denominator of the measure. For additional information, please visit the “Getting Started” webpage here or download the “Medicare’s Practical Guide to the Electronic Prescribing (eRx) Incentive Program”under “Educational Resources” on the same website.
Implementation of Errata for Version 5010 of HIPAA Transactions
BTW, errata is a list or lists of errors and their corrections. Errata is plural and the singular is erratum.
CMS does not have a version 4010A1 direct data entry and a separate version 5010 direct data entry. The Priority (Type) of Admission or Visit code is now required on all version 4010A1 institutional claims submitted or corrected via direct data entry, as well as on version 5010 institutional claims, regardless of how they are submitted. Providers that are unsure which code to use are to use code 9 (Information not Available). Additional Priority (Type) of Admission or Visit code values and descriptions are available from the National Uniform Billing Committee or from your servicing MAC. The Priority (Type) of Admission or Visit code is not required on 4010A1 institutional claims submitted or corrected via an 837. More information on Version 5010 here.
A new publication titled “Mental Health Services” is now available in downloadable format from the Medicare Learning Network®here. This booklet is designed to provide education on mental health services, including covered mental health services, mental health services that are not covered, mental health professionals, outpatient psychiatric hospital services, and inpatient psychiatric hospital services.
Ambulance Fee Schedule Fact Sheet Revised
The revised publication titled “Ambulance Fee Schedule” (revised March 2011) is now available in downloadable format from the Medicare Learning Network® here. This fact sheet is designed to provide education about the Ambulance Fee Schedule including background, ambulance providers and suppliers, ambulance services payments, and how payment rates are set.
Health Professional Shortage Area Fact Sheet Revised
The revised publication titled “Health Professional Shortage Area” (revised March 2011) is now available in downloadable format from the Medicare Learning Network®here. This fact sheet is designed to provide education on the Health Professional Shortage Area (HPSA) payment system and includes an overview of the program and general requirements.
The revised publication titled “Medicare Disproportionate Share Hospital” (revised March 2011) is now available in downloadable format here. This fact sheet is designed to provide education on Medicare Disproportionate Share Hospitals (DSH) including background; methods to qualify for the Medicare DSH adjustment; Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and Deficit Reduction Act of 2005 provisions that impact Medicare DSHs; number of beds in hospital determination; and Medicare DSH hospital payment adjustment formulas.
G0431QW is Deleted and G0434QW is Added to CLIA Waived Test Schedule
The Centers for Medicare & Medicaid Services (CMS) is updating the status of two codes on the Clinical Laboratory Fee Schedule (CLFS).
Effective April 1, 2011, code G0431QW is deleted from the CLFS. Code G0431 describes a high complexity test, and should not be reported with a QW modifier; the QW modifier indicates a CLIA waived test.
Effective April 1, 2011, code G0434QW is added to the CLFS. Code G0434 can describe a CLIA waived test. The use of the QW modifier to indicate a CLIA waived test is necessary for accurate claims processing.
Codes G0431 and G0434 will remain on the CLFS.
CMS Launches a Dedicated Web Page for the Medicare Shared Savings Program/Requirements for ACOs
On March 31, 2011, The Centers for Medicare & Medicaid Services (CMS) published in the Federal Register proposed rule CMS-1345-P, Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations that implements the Medicare Shared Savings Program (Shared Savings Program) and establishes the requirements for Accountable Care Organizations. CMS has launched a dedicated web page here for Medicare FFS providers and other providers of services and suppliers. Bookmark the web page and check back often, as CMS continues to add information on the program.
Program for Evaluating Payment Patterns Electronic Report (PEPPER) for CAHs
Beginning in April 2011, the Centers for Medicare & Medicaid Services (CMS) will make available free hospital-specific comparative data reports for critical access hospitals (CAHs) nationwide. The Program for Evaluating Payment Patterns Electronic Report (PEPPER) provides hospital-specific data statistics for Medicare discharges at risk for improper payments. Hospitals can use the data to support internal auditing and monitoring activities. PEPPER is the only free report comparing a CAH’s Medicare billing practices with other CAHs by state, Medicare Administrative Contractor (MAC) or Fiscal Intermediary (FI) jurisdiction and the nation. CMS has contracted with TMF Health Quality Institute to develop and distribute the reports.
PEPPER will be distributed electronically to CAH QualityNet Administrators and those who have basic user accounts with the PEPPER Recipient role on or about Monday, April 25, via a My QualityNet secure file exchange. In preparation for receiving and downloading PEPPER from My QualityNet, these individuals should verify that their computer systems are equipped with the software and configuration required to use My QualityNet by following the steps at www.qualitynet.org (see “Getting Started With QualityNet” and “Test Your System.”) Additional information about downloading PEPPER from My QualityNet can be found here (includes System Setup and Test Guide, Troubleshooting Tips and a guide for Configuration Changes for Compatibility with QualityNet).
CAHs may work with their Quality Improvement Organization (QIO) to obtain a QualityNet administrator account by visiting www.qualitynet.org and clicking on the Hospitals – Inpatient link. Obtaining a My QualityNet account may take several weeks; CAHs should plan accordingly.
TMF will conduct a web-based training session for CAH staff providing information on PEPPER and how to use it on Thursday, April 28, at 1 p.m. central time. To register for the training, CAH staff should visit https://tmfevents.webex.com. The training will be recorded and posted on http://www.pepperresources.org.
For more information, including the PEPPER distribution schedule, a sample PEPPER for CAHs and information about QualityNet accounts, visit the PEPPER website. CAH staff are encouraged to join the e-mail list on this website to receive important notifications about upcoming PEPPER distribution and training opportunities.
Today’s CMS Open Door Forum was a good one. The slides (pdf here), although reviewed quickly during the call, are a comprehensive resource for anyone needing in-depth information on qualifying for incentives through PQRI. The information is complex, but anyone can start the process tomorrow and successfully get their check (next year.)
PQRI has been renamed PQRS.
These are the key points of the information presented:
You can tell if you are eligible for the incentive program by checking the main PQRS site here. Scroll down to Downloads and click on “List of Eligible Professionals.”
There is no registration required to report quality data.
PQRS should not be confused with incentives offered for ePrescribing or meaningful use of a certified Electronic Health Record – these are three distinct systems.
There are new Physician Quality Reporting Measure Specifications every year – use the correct year.
Reporting can be done as individual eligible providers or as groups, however groups needed to be self-nominated by January 31, 2011, so that door is closed for this year.
Eligible providers can choose to report for 12 months: January 1”“December 31, 2011 or for 6 months: July 1-December 31, 2011 (claims and registry-based reporting only.)
There are two reporting methods for submission of measures groups that involve a patient sample selection: 30-patient sample method and 50% patient sample method. An “intent G-code” must be submitted for either method to initiate intent to report measures groups via claims. If a patient selected for inclusion in the 30-patient sample did not receive all the quality actions and that patient returns at a subsequent encounter, QDC(s) may be added (where applicable) to the subsequent claim to indicate that the quality action was performed during the reporting period.
Physician Quality Reporting analysis will consider all QDCs submitted across multiple claims for patients included in the 30-patient samples.
Eligible professionals who have contracted with Medicare Advantage (MA) health plans should not include their MA patients in claims-based reporting of measures groups using the 30 unique patient sample method. Only Medicare Part B FFS patients (primary and secondary coverage including Railroad Medicare) should be included in claims-based reporting of measures groups.
Choose which group measures OR individual measures (3 minimum) you want to report on based on your method of reporting. Review your choices here.
If you plan to report using a registry or EHR, make sure the systems are qualified by checking here.
Here is the schedule for PQRS incentives and “payment adjustments” (financial dings.)
Incentives (based on the eligible professional’s or group’s estimated total Medicare Part B PFS allowed charges)
2007 ”“1.5% subject to a cap
2009, 2010 ”“2.0%
2012, 2013, 2014 ”“0.5%
Payment Adjustments (you lose money)
2016 and subsequent years ”“98.0%
What follows are the Questions and Answers from the listeners.
Q: Do PQRS measures need to be reported once per encounter or once per episode?
A: It depends on the measure. Check the list to see what each measure requires.
Q: Is there a code to submit if we cannot qualify due to low numbers of Medicare patients?
A: No, CMS will calculate this and will know you cannot qualify and you will be exempt from the payment adjustment.
Q: Can both admitting physicians and consulting physicians submit the same quality codes?
A: Yes, all eligible providers working with a patient can report the same code if appropriate.
Q: How do we know if we qualified for the eRx incentive for 2010?
A: Payments will come early fall and feedback reports will be available that break down each provider’s incentive.
Q: For the eRx incentive, is it 10 eRxs before June 30, 2011 and 25 before January 31, 2011 for each PROVIDER or each PRACTICE?
A: Each provider.
Q: What is the difference between the numerator and the denominator in PQRS?
A: The numerator is the clinical quality action (for instance, putting a patient on a beta blocker) and the denominator is the group of patients for whom the quality action applies (which patients with appropriate diagnoses are eligible for beta blocker therapy.)
Q: Do all the preventive measures in this group have to be utilized?
A: Not all measures will apply to all patients, for instance mammograms for females only.
Q: Is there a code to be placed on the claim that says a measure is not applicable for this patient?
Q: How do you know if a measure code on a claim has been accepted?
A: You will receive a rejection code on your EOB that indicates the code was submitted for information purposes only. Remittance Advice (RA) with denial code N365 is your indication that Physician Quality Reporting codes were passed into the National Claims History (NCH) file for use in calculating incentive eligibility.
Q: How can a new provider get started with quality reporting?
A: Any provider can start any time by reporting through claims, a registry or an EHR.
Q: Should providers bill for PQRI under their individual number or under their group number?
A: Under their individual number.
Q: Can a physician delegate the eRx process to a staff member, just as they might have a nurse write a prescription for them?
Q: Can you clarify the three incentive programs and which a practice can participate in at the same time?
A: The Physician Quality Reporting System, eRx Incentive Program, and EHR Incentive Program are three distinctly separate CMS programs.
The Physician Quality Reporting System incentive can be received regardless of an eligible professional’s participation in the other programs.
There are three ways to participate in the EHR Incentive Program: through Medicare, Medicare Advantage, or Medicaid.
If participating in the EHR Incentive Program through the Medicaid option, eligible professionals are able to also receive the eRx incentive.
If participating in the Medicare or Medicare Advantage options for the EHR Incentive Program, eligible professionals can still report the eRx measure but are only eligible to receive one incentive payment. Eligible professionals successfully participating in both programs will receive the EHR incentive.
Eligible professionals should continue to report the eRx measure in 2011 even if their practice is also participating in the Medicare or Medicare Advantage EHR Incentive Program because claims data for the first six months of 2011 will be analyzed to determine if a 2012 eRx Payment Adjustment will apply to the eligible professional.
If an eligible professional successfully generates and reports electronically prescribing 25 times (at least 10 of which are in the first 6 months of 2011 and submitted via claims to CMS) for eRx measure denominator eligible services, (s)he would also be exempt from the 2013 eRx payment adjustment.
The transcript and a recording of today’s call will be posted on the CMS website within a few weeks.
Should I consider ePrescribing in 2011 if I’m not ready to install an EMR?
In 2012 eligible professionals who are not successful eprescribers, based on claims submitted between January 1, 2011 ”“ June 30, 2011, may be subject to a “payment adjustment” (read payment cut) in their Medicare Part B Physician Fee Schedule (PFS) for covered professional services.
Those that don’t eprescribe as a part of 10 Medicare patient encounters by June 30, 2011 will only receive 99% of their Medicare payment for all encounters in 2012.
Those that don’t ePrescribe as a part of 25 encounters by December 31, 2011, will only receive 98.5% of their Medicare payments for all encounters in 2013 and only 98% of their Medicare payments for encounters during 2014 and going forward.
The payment adjustment does not apply if <10% of an eligible professional’s (or group practice’s) allowed charges for the January 1, 2011 through June 30, 2011 reporting period are comprised of codes in the denominator of the 2011 eRx measure.
The DENOMINATOR is the visit code that is eligible for an eprescribing code (see list below.)
The NUMERATOR is a prescription generated and transmitted via a qualified eRx system and reported using a quality data code.
G8553: At least one prescription created during the encounter was generated and transmitted electronically using a qualified eRx system (reported via claims, a registry, or an EHR.)
Please note that earning an eRx incentive for 2011 will NOT necessarily exempt an eligible professional or group practice from the payment adjustment in 2012.
How to Avoid the 2012 Payment Adjustment
An eligible professional can avoid losing 1% in 2012 if (s)he:
Is not a physician (MD, DO, or podiatrist), nurse practitioner, or physician assistant as of June 30, 2011 based on primary taxonomy code in NPPES,
Does not have prescribing privileges. (S)he must report (G8644) at least one time on an eligible claim prior to June 30, 2011;
Does not have at least 100 cases containing an encounter code in the measure denominator;
Becomes a successful e-prescriber; and
Reports the eRx measure for at least 10 unique eRx events for patients in the denominator of the measure.
Exemptions from the Medicare Payment Adjustment in 2012
An (EP) eligible professional or selected group practice may request an exemption from the eRx Incentive Program and from the payment adjustment based upon a significant hardship.
The qualifying circumstances are based upon two “hardship codes” that need reported on at least one claim prior to June 30, 2011 should one of the following situations apply:
G8642 – The eligible professional practices in a rural area without sufficient high speed internet access and requests a hardship exemption from the application of the payment adjustment under section 1848(a)(5)(A) of the Social Security Act.
G8643 – The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing and requests a hardship exemption from the application of the payment adjustment under
section 1848(a)(5)(A) of the Social Security Act
Each Physician or practice that does not currently ePrescribe should consider whether or not ePrescribing is worthwhile. (Note: For group practices participating in eRx GPRO I or GPRO II during 2011, the group practice MUST become a successful e-prescriber. Depending on the group’s size, the group practice must report the eRx measure for 75-2,500 unique eRx events for patients in the denominator of the measure. Check out the Group Practice Reporting Option here.)
In estimating the value of ePrescribing, the practice manager must consider on one hand the expense (which there is, even for free standalone eRx systems) surrounding the implementation of ePrescribing, and the potential income from the ePrescribing Incentive.
The practice must also determine if an EMR is in their future, and if so, if the installation will take place soon enough to report the 10 encounters with Medicare patients.
Individual eligible professionals (EPs) may choose to participate in either the PQRI, eRx, or both. PQRI and eRx are separate incentive programs.
If an eligible professional (EP) earns an incentive under the Medicare EHR Incentive Program, he or she cannot receive an incentive payment under the eRx Incentive Program in the same program year, and vice versa. However, if an EP earns an incentive under the Medicaid EHR Incentive Program, he or she can receive an incentive payment under the eRx Incentive Program in the same program year.
Eligible professionals must have adopted a “qualified” eRx system. There are two types of systems: a system for eRx only (stand-alone) or an electronic health record (EHR system) with eRx functionality. Regardless of the type of system used, to be considered “qualified” it must be based on ALL of the following capabilities:
Generating a complete active medication list incorporating electronic data received from applicable pharmacies and benefit managers (PBMs) if available.
Providing information related to lower cost, therapeutically appropriate alternatives (if any). Selecting medications, printing prescriptions, electronically transmitting prescriptions, and conducting all alerts.
Providing information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient’s drug plan, if available.
For a list of qualified registries and qualified EHR vendors and products, click here.
An excellent article, Choosing the Right E-prescribing Application: Should you buy a standalone app or an EHR-integrated module? was published in January 2011 by Physicians Practicehere.
“Publications For Your Medicare Beneficiaries” New! The Medicare Learning Network® (MLN) has released a new product titled “Publications For Your Medicare Beneficiaries.” This factsheet lists a variety of beneficiary-related publications available to assist providers in responding to patients’ questions related to Medicare, all of which can be printed and provided to patients. This product is available in downloadable format here. Check it out – links to more than 70 different publications!
“The 2007 Physician Quality Reporting Initiative” New! A new Medicare Learning Network® publication titled “The 2007 Physician Quality Reporting Initiative (PQRI)” (November 2010) is now available in downloadable format here. This booklet is a compilation of CMS’s various educational resources relevant to the 2007 Physician Quality Reporting Initiative.
“Guidelines for Teaching Physicians, Interns, and Residents”
The “Guidelines for Teaching Physicians, Interns, and Residents” (revised December 2010) is now available in downloadable format here. This factsheet provides information about payment for physician services in teaching settings, general documentation guidelines, and evaluation and management documentation guidelines.
“HIPAA EDI Standards” Web-Based Training
The Medicare Learning Network® is now offering the revised “HIPAAEDI Standards” web-based training (revised January 2011) for CE credit. The goal of this activity is to provide information to physicians, suppliers, and healthcare professionals regarding electronic billing and other healthcare electronic transactions such as the Administrative Simplification provisions of HIPAA, electronic transaction standards and code sets required by HIPAA, and an overview of the steps involved in the Medicare electronic data interchange process. To take this training, go here and click on “Web-Based Training Modules” under “Related Links Inside CMS.” There are 15 other web-based training classes available on the same site.
“Understanding the Remittance Advice: A Guide for Medicare Providers, Physicians, Suppliers and Billers”
The publication titled “Understanding the Remittance Advice: A Guide for Medicare Providers, Physicians, Suppliers and Billers” (revised October 2010) is designed to educate institutional and professional providers who bill Medicare with general remittance advice (RA) information. It includes instructions to help you interpret the RA received from Medicare and reconcile it against submitted claims and provides guidance on how to read Electronic Remittance Advices (ERAs) and Standard Paper Remittance Advices (SPRs), as well as information on balancing an RA. This publication may be downloaded here. If you are training an employee to be a biller or post payments, or if you want to understand more about your billing yourself, this is an excellent resource.
“Evaluation and Management Services Guide”
The publication titled “Evaluation and Management Services Guide” (revised December 2010) is now available in downloadable format from the Medicare Learning Network®here. This guide is designed to provide education on medical record documentation and evaluation and management billing and coding considerations. The “1995 Documentation Guidelines for Evaluation and Management Services” and the “1997 Documentation Guidelines for Evaluation and Management Services” are included in this publication. This is another great resource that you can use to train staff, physicians, and other providers, or to get up to speed yourself if E & M codes are not part of your education or experience.
There are a number of different audits that are carried out by Medicare-contracted auditors. It’s important to know the differences and have a plan for responding.
CERT stands for Comprehensive Error Rate Testing and CERT audits were initiated in 2000. The program is responsible for measuring improperly paid claims. The CERT Program uses the following OIG-approved methodology:
A sample of approximately 120,000 submitted claims is randomly selected;
medical records from providers who submitted the claims are requested; and
the claims and medical records are reviewed for compliance with Medicare coverage, coding and billing rules.
RAC stands for Recovery Audit Contractor and began in early 2009. The RACs detect and correct past improper payments so that CMS and Carriers, FIs, and MACs can implement actions to stop future improper payments. RAC is currently focusing on inpatient services and physical therapy services. As of the date this post was published RAC was not focusing on physician services.
ZPIC (Zone Program Integrity Contractors) replaces the Medicare Program Safeguard Contractors (PSCs) and Medicare Drug Integrity Contractors (MEDICs) that are currently in use by CMS. ZPICs are be responsible for detection and deterrence of fraud, waste and abuse across all claim types. ZPICs have access to CMS National Claims History data, which can be used to look at the entire history of a patient’s treatment no matter where claims were processed. Being able to look at the overall picture will enable them to more readily spot over billing and fraudulent claims. Among other things, ZPICs will look for billing trends or patterns that make a particular provider stand out from the other providers in that community. Once a ZPIC identifies a case of suspected fraud and abuse, the issue is referred to the Office of Inspector General (OIG) for consideration and possible initiation of criminal or civil prosecution. ZPIC is widely considered to be the greatest threat to physician practices.
Seven ZPIC zones have been identified. The zones include the following states and/or territories and most have been assigned contractors:
Zone 1 – CA, NV, American Samoa, Guam, HI and the Mariana Islands http://www.safeguard-servicesllc.com/zpic.asp
Zone 2 – AK, WA, OR, MT, ID, WY, UT, AZ, ND, SD, NE, KS, IA, MO AdvanceMed was just purchased by NCI – site not current
Zone 3 – MN, WI, IL, IN, MI, OH and KY – not awarded
Log all requests for records from all payers. Time and date all communications received and all communications sent.
Scan all records sent and include a cover letter itemizing contents of response.
Send records via certified mail.
If you get a request for a large amount of records at one time, consider getting advice from a consultant or attorney who specializes in Medicare audits as a large scale record request may cripple the practice operations.
How can you be proactive before you get an audit letter?
Check the audit sites monthly to see if your specialty or any services you provide are being targeted for an audit.