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Updated 2011 CMS Policies: Incentive Payments, GPCI Revisions, Multiple Procedure Payment Reductions for Therapy, and Modification of Multiple Procedure Payment Policy for Advanced Imaging Services

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Elimination of Deductible and Coinsurance for Most Preventive Services

Effective January 1, 2011, the Affordable Care Act waives the Part B deductible and the 20 percent coinsurance that would otherwise apply to most preventive services.

Note: I covered this in my post here and it’s pretty straightforward.


Coverage of Annual Wellness Visit (AWV) Providing a Personalized Prevention Plan

The Affordable Care Act extends the preventive focus of Medicare coverage, which currently pays for a one-time initial preventive physical examination (IPPE or the “Welcome to Medicare Visit”), to provide coverage for annual wellness visits in which beneficiaries will receive personalized prevention plan services (PPPS). The law states that the AWV will include at least the following six elements, as determined by the Secretary of Health and Human Services:

  • Establish or update the individual’s medical and family history;
  • List the individual’s current medical providers and suppliers and all prescribed medications;
  • Record measurements of height, weight, body mass index, blood pressure and other routine measurements;
  • Detect any cognitive impairment
  • Establish or update a screening schedule for the next 5 to 10 years including screenings appropriate for the general population, and any additional screenings that may be appropriate because of the individual patient’s risk factors; and
  • Furnish personalized health advice and appropriate referrals to health education or education or preventive services.

CMS has developed two separate Level II HCPCS codes for the first annual wellness visit (G0438 – Annual wellness visit, including personalized prevention plan services, first visit), to be paid at the rate of a level 4 office visit for a new patient (similar to the IPPE), and for subsequent annual wellness visits (G0439 – Annual wellness visit, including personalized prevention plan services, subsequent visit), to be paid at the rate of a level 4 office visit for an established patient.

Note: Payment for annual wellness visits (AWV) is now covered by Medicare and the payment will be equivalent to a established level 4 visit. I’ve received a lot of questions about who can perform the PPPS and CMS says A medical professional (including a health educator, registered dietitian, or nutrition professional or other licensed practitioner) or a team of such medical professionals, working under the direct supervision of a physician.”

An evaluation and management code (EM) may be billed with the annual wellness visit if the EM service is medically necessary.  If so, a modifier 25 must be appended to the EM service and the documentation for the EM service must have no components of the annual wellness visit used in determining the level of service for the EM visit.  A separate note containing the history, exam and medical decision making, relative to the presenting problem, must be separately documented.


Incentive Payments to Primary Care Practitioners for Primary Care Services

The Affordable Care Act provides for incentive payments equal to 10 percent of a primary care practitioner’s allowed charges for primary care services under Part B, furnished on or after January 1, 2011, and before January 1, 2016. Under the final policy, primary care practitioners are: (1) physicians who have a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; as well as nurse practitioners, clinical nurse specialists, and physician assistants; and (2) for whom primary care services accounted for at least 60 percent of the practitioner’s Medicare Physician Fee Schedule (MPFS) allowed charges for a prior period as determined by the Secretary of Health and Human Services.

The law also defines primary care services as limited to new and established patient office or other outpatient visits (CPT codes 99201 through 99215); nursing facility care visits, and domiciliary, rest home, or home care plan oversight services (CPT codes 99304 through 99340); and patient home visits (CPT codes 99341 through 99350).

In the final rule with comment period, CMS excluded consideration of allowed charges for hospital inpatient care and emergency department visits in determining whether the 60 percent primary care threshold is met. These exclusions will make it easier for practitioners of eligible specialties to become eligible for the payment incentive program. The incentive payments will be made quarterly based on the primary care services furnished in CY 2011 by the primary care practitioner, in addition to any physician bonus payments for services furnished in Health Professional Shortage Areas (HPSAs).  CMS will determine a practitioner’s eligibility for incentive payments in CY 2011 using claims data and the provider’s specialty designation from CY 2009 for practitioners enrolled in CY 2009. For newly enrolled practitioners, CMS will use claims data from CY 2010 to make an eligibility determination regarding CY 2011 incentive payments. For subsequent years, CMS will revise the list of primary care practitioners on a yearly basis, based on updated data regarding an individual’s specialty designation and percentage of allowed charges for primary care
services.

Note: There is nothing to count or report: the bonuses arrive quarterly. Providers in HPSAs will receive two bonuses. Want to know if you’re in a HPSA? Click here.


Incentive Payments for Major Surgical Procedures in Health Professional Shortage Areas

The Affordable Care Act also calls for a payment incentive program to improve access to major surgical procedures ”“ defined as those with a 10-day or 90-day global period under the MPFS ”“ that are furnished by physicians in HPSAs on or after January 1, 2011, and before January 1, 2016.  To be eligible for the incentive payment, the physician must be enrolled in Medicare as a general surgeon. The amount of the incentive payment is equal to 10 percent of the MPFS payment for the surgical services furnished by the general surgeon. The incentive payments will be made quarterly to the general surgeon when the major surgical procedure is furnished in a zip code that is located in a HPSA. CMS will use the same list of HPSAs that it has used under the existing HPSA bonus program.

Note: 10% bonus for general surgeons in HPSAs. Want to know if you’re in a HPSA? Click here.


Revisions to the Practice Expense Geographic Adjustment

As required by the Medicare law, CMS adjusts payments under the MPFS to reflect local differences in practice costs. CMS assigns separate geographic practice cost indices (GPCIs) to the work, practice expenses (PE), and malpractice insurance cost components of each of more than 7,000 types of physicians’ services. The final rule with comment period discusses CMS’ analysis of PE GPCI data and methods, and incorporates new data as part of the sixth GPCI update, while maintaining the current GPCI cost share weights pending the results of further CMS and Institute of Medicine studies.

The Affordable Care Act establishes a permanent 1.0 floor for the PE GPCI for frontier states (currently, Montana, Wyoming, Nevada, North Dakota, and South Dakota). The Affordable Care Act limits recognition of local differences in employee wages and office rents in the PE GPCIs for CYs 2011 and 2012 as compared to the national average. Localities are held harmless for any decrease in CYs 2011 and 2012 in their PE GPCIs that would result from the limited recognition of cost differences. CMS will continue to review the GPCIs in CY 2011, in accordance with the Affordable Care Act provision that requires the Secretary of Health and Human Services to analyze current methods of establishing PE GPCIs in order to make adjustments that fairly and reliably distinguish the costs of operating a medical practice in the different fee schedule areas.

Note: Check your GPCI (pronounced “gypsy”) for changes this year and every year.  The GPCI changes the RVU values so they are specific to your location.

Where do I find my GPCI? Click here, click on Physician Fee Schedule Search at the top, click to accept the AMA terms, click on Geographic Practice Cost Index, enter your locality and click submit.

Improved Access to Certified Nurse-Midwife Services

The Affordable Care Act increases the Medicare payment for certified nurse-midwife services from 65 percent of the PFS amount for the same service furnished by a physician to 100 percent of the PFS amount for the same service furnished by a physician (or 80 percent of the actual charge if that is less). The increased payment amount is effective for services furnished on or after Jan. 1, 2011.

Misvalued Codes under the Physician Fee Schedule

The Affordable Care Act requires CMS to periodically review and identify potentially misvalued codes and make appropriate adjustments to the relative values of the services that may be misvalued. CMS has been engaged in a vigorous effort over the past several years to identify and revise potentially misvalued codes. The final rule with comment period identifies additional categories of services that may be misvalued, including codes with low work RVUs commonly billed in multiple units per single encounter and codes with high volume and low work RVUs. The final rule also includes CMS’ response to recommendations from the American Medical Association (AMA) Relative Value Update Committee (RUC) for CY 2011 regarding the work or direct practice expense inputs for 325 CPT codes.

Note: People and organizations are always lobbying to change the work or practice expense component of RVUs and some portion of the codes change every year. Make sure your computer is updated with the correct RVU components and total so your productivity reports are spot on.


Multiple Procedure Payment Reduction Policy for Therapy Services

The Affordable Care Act requires CMS to identify and make adjustments to the relative values for multiple services that are frequently billed together when a comprehensive service is furnished. CMS is adopting a multiple procedure payment reduction (MPPR) policy for therapy services in order to more appropriately recognize the efficiencies when combinations of therapy services are furnished together. The policy, as described in the CY 2011 MPFS final rule with comment period, states that the MPPR for “always” therapy services will reduce by 25 percent the payment for the practice expense component of the second and subsequent therapy services furnished by a single provider to a beneficiary on a single date of service. This policy will apply to all outpatient therapy services paid under Part B, including those furnished in office and facility settings.

Since publication of the CY 2011 MPFS final rule with comment period, this policy has been modified by the Physician Payment and Therapy Relief Act of 2010.  Per this Act, CMS will apply the CY 2011 MPFS final rule policy of a 25 percent MPPR to therapy services furnished in the hospital outpatient department and other facility settings that are paid under section 1834(k) of the Social Security Act (referring to durable medical equipment), and a 20 percent therapy MPPR will apply to therapy services furnished in clinicians’ offices and other settings that are paid under section 1848 (payments to physicians) of the Act.

Note: The reduction applies solely to the practice expense (PE) portion of the fee schedule payment for “Always Therapy Services” when more than one service is provided the same patient on the same day. “Always therapy” services are always considered to be therapy regardless who provides the service (qualified therapist, physician, non-physician practitioner (NPP)). This is the list of services being referred to:

  • 92506””Speech /hearing evaluation
  • 92507””Speech/hearing therapy
  • 92508””Speech/hearing therapy
  • 92526””Oral function therapy
  • 92597””Oral speech device evaluation
  • 92604””Exam for speech device
  • 92609””Use of speech device service
  • 96125””Standardized cognitive performance test
  • 97001””PT evaluation
  • 97002””PT re-evaluation
  • 97003””OT evaluation
  • 97001””OT re-evaluation
  • 97012””Mechanical traction
  • 97016””Vasopneumatic device
  • 97018””Paraffin bath
  • 97022””Whirlpool
  • 97024””Diathermy (microwave)
  • 97026””Infrared
  • 97028””Ultraviolet
  • 97032””Electrical stimulation
  • 97033””Electric current
  • 97034””Contrast bath
  • 97035””Ultrasound
  • 97036””Hydrotherapy
  • 97110””Therapeutic exercise
  • 97112””Neuromuscular reeducation
  • 97113””Aquatic therapy
  • 97116””Gait training
  • 97124””Massage
  • 97140””Manual therapy
  • 97150””Group therapeutic
  • 97530””Therapeutic activities
  • 97533””Sensory integration
  • 97535””Self-care management
  • 97537””Community work reintegration
  • 97542””Wheelchair management
  • 97750””Physical performance test
  • 97755””Assistive technology assessment
  • 97760””Orthotic management & training
  • 97761””Prosthetic training
  • 97762””Checkout for orthotic or prosthetic use
  • G0281””Electrical stimulation for ulcers (unattended)
  • G0283””Electrical stimulation other than wound (unattended)
  • G0329””Electromagnetic therapy for ulcers

Modification of Equipment Utilization Factor and Modification of Multiple Procedure Payment Policy for Advanced Imaging Services

The Affordable Care Act adjusts the equipment utilization rate assumption for expensive diagnostic imaging equipment. Effective January 1, 2011, CMS will assign a 75 percent equipment utilization rate assumption to expensive diagnostic imaging equipment used in diagnostic computed tomography (CT) and magnetic resonance imaging (MRI) services. In addition, beginning on July 1, 2010, the Affordable Care Act increased the established MPFS multiple procedure payment reduction for the technical component of certain single-session imaging services to consecutive body areas from 25 to 50 percent for the second and subsequent imaging procedures performed in the same session.

Note: These are the services that were added by this policy:

  • 70496-CT angiography, head
  • 70498-CT angiography, neck
  • 70544-MR angiography head w/o dye
  • 70545-MR angiography head w/dye
  • 70546-MR angiography head w/o & w/dye
  • 70547-MR angiography neck w/o dye
  • 70548-MR angiography neck w/dye
  • 70549-MR angiography neck w/o & w/dye
  • 71275-CT angiography, chest
  • 71555- MRI angiography chest w/ or w/o dye
  • 72159-MRI angiography spine w/o & w/dye
  • 72191-CT angiography, pelvis w/o & w/ dye
  • 72198-MRI angiography pelvis w/ or w/o dye
  • 73206-CT angio upper extremity w/o & w/dye
  • 73225-MR angio upper extremity w/o & w/dye
  • 73706-CT angiography lower ext w/o & w/dye
  • 73725-MR angio lower extremity w or w/o dye
  • 74175-CT angiography, abdomen w/o & w/ dye
  • 74185-MRI angiography, abdomen w/ or w/o dye
  • 75565-Cardiology MRI velocity flow map add-on
  • 75574-CT angiography heart w/3d image
  • 75635-CT angiography abdominal arteries
  • 76380-CAT scan follow-up study
  • 77079-CT bone density, peripheral

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Due to PECOS Backlog, CMS Announces Delay of January 3, 2011 Automated Edits & Claims Denial

Oneonta Gorge, Logjam

NOTE: The date has been changed to July 5, 2011 delayed indefinitely.

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The following statement was released by CMS on November 26, 2010:

The Centers for Medicare & Medicaid Services (CMS) previously announced that, beginning January 3, 2011, if certain Part B billed items and services require an ordering/referring provider and the ordering/referring provider is not in the claim, is not of a profession that is permitted to order/refer, or does not have an enrollment record in the Medicare Provider Enrollment, Chain and Ownership System (PECOS), the claim will not be paid.  The automated edits will not be turned on effective January 3, 2011. We are working diligently to resolve enrollment backlogs and other system issues and will provide ample advanced notice to the provider and beneficiary communities before we begin any automatic nonpayment actions.

Previous posts on enrolling physicians in PECOS  are here and here.

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Posted in: Medicare & Reimbursement, PECOS

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The Cohen Report: Free Webinar on Auditing the RAC Auditors

NOTE: If you need the basics on RACs, click here for my article.

Finance - Financial injection - Finance

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From our friend Frank Cohen:

Over the past year or so, I have been involved in conducting post RAC (and other) audit analyses to determine whether the RAC (or other auditing agency) was using appropriate statistics and calculations to create their overpayment estimates.

As you can probably imagine, in nearly every case, I have found this not to be true. In fact, as it turns out, the errors I find nearly always are in favor of the auditor, not the healthcare provider.

RAC is able to take advantage of the practice in three areas

The first area has to do with pulling samples for review. If these samples are not random or worse yet, if they are intentionally biased, they can create a misrepresentation of overpayment that unfairly penalizes the provider and because RACs are paid a commission, benefits them.

The second area has to do with the way in which the overpayment point estimate is calculated. This is where they come up with something like the average overpayment per audited unit (i.e., claim, claim line, member event, etc.).

The third has to do with the methodology used to extrapolate the point estimate for the sample to the universe of units for the healthcare provider. An error in any one of these areas can result in a gross exaggeration of the final overpayment demand.

Understanding how to defend yourself from the results of an audit

I have developed a series of three short, free webinars to teach you how to catch potential errors in each of three areas.

Part 1 will be on validating random samples and is scheduled for Monday, December 13 from 1:00 to 2:00 EST.

Part 2 is on how to calculate the overpayment point estimate and is scheduled for Tuesday, December 14 from 1:00 to 2:00 EST.

Part 3 is on verifying extrapolation results and is scheduled for Wednesday, December 15 from 1:00 to 2:00 EST.

Each webinar will probably last around 30 minutes with an additional 30 minutes for questions.  I plan to record these and post them later so if you can’t make it, don’t worry.  Each session will be available for review after the last one is completed.

For more info or to register, go to www.frankcohen.com and click on the Webinar tab. Also, feel free to forward this on to co-workers or to post wherever you think folks may benefit.

Frank Cohen
The Frank Cohen Group, LLC
www.frankcohen.com
frank@frankcohen.com
727.442.9117

Posted in: Medicare & Reimbursement, The Cohen Report (NCCI & RVUs)

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White Coat Wednesday: Call Congress November 17th to Protest the Medicare Physician Cuts

My lab coat and scrubs -- Samir धर्म 11:07, 7 ...

Please call the AMA Grassroots Hotline, and have everyone in your office/department/building/campus call the Hotline on Wednesday, November 17th (White Coat Wednesday) and every day thereafter until November 30th to insist that Congress vote for the 13-month patch to the SGR formula.

AMA’s toll-free Grassroots Hotline – 1.800.833.6354


AMA website discussing the issues here.

AMA flyer to post in your office here.

Posted in: Finance, Headlines, Medicare & Reimbursement

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Digging Into the Details of “Certified EMR” & Tips For Buying an EMR

Steps to digging under the meaning of EMR certification: 

Cocker Spaniel digging

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  1. Click to see the most recent alphabetical list (by product name not company) of all products certified here.
  2. Find the company or companies you are using or are considering using.
  3. Check that the exact name of the product is what you have or might purchase.
  4. Check to find out if a module or part of the product is certified or if the complete product is certified.
  5. Check to make sure the version of the product is the version you have or will have.

If you have questions about each company’s exact criteria met, you are in luck!  On the ONC site here, you can click on each company’s detail (“View Criteria”) on the far right column labeled “Certification Status” to see what they have and don’t have.  Compare this to how you are anticipating using your EMR to meet meaningful use.  The more check marks a company has, the better-equipped they are (and more flexible) to meet your practice needs and to qualify for the stimulus money.

The ONC site with the Certified Health IT Product List (CHPL) is Version 1.0.  Version 2.0 is now being developed and will provide the Clinical Quality Measures each product was tested on, and the capability to query and sort the data for viewing. The next version will also provide the reporting number that will be accepted by CMS for purposes of attestation under the EHR (“meaningful use”) incentives programs.

You can tell ONC what you think would be helpful in the new version by emailing your ideas to ONC.certification@hhs.gov, with “CHPL” in the subject line.

If you’d like a list of just outpatient/medical practice EMR products or just inpatient / hospital products, I’ve split the big list into two smaller printable lists here:

Medical Practice / Outpatient

Hospital / Outpatient

Tips On Buying An EMR

To-do list book.

Remember that meeting meaningful use does not tell the whole story – if you are shopping for an EMR be prepared to go beyond a product’s certification status to consider:

  • Flexibility – does it make the practice conform to it or can it conform to the practice? How?
  • Templates and best practices – are you starting from scratch in developing protocols, templates and cheat sheets for your practice, or does it have a storehouse of examples to choose from or tweak?
  • Built for the physician, or the billing office, or the nurses, but doesn’t really meet the needs of all three? Make sure the functionality is not too skewed to one user group, but if it is, it should be somewhat skewed to the provider.
  • Interface and integration with your practice management system. Does the information flow both ways? Do you ever have to re-enter information because one side doesn’t speak to the other?
  • Interface with other inside and outside systems: Labs, imaging, hospital systems, ambulatory surgical center systems?
  • Built-in Resources: annual upgrade of HCPCS and ICD codes, drug compendium (Epocrates), comparative effectiveness prompting?
  • Mobile applications – EMR on your providers’ phones?
  • Data entry systems – laptops, notebooks, tablets, iPads, smartphones, voice recognition?
  • Hosting – in your office? at the hospital? at the vendor’s data center? in the cloud of your choice?
  • What’s the plan for ICD-10? Will they provide practice support and education for the change or will they just change the number of characters in the diagnosis code field?
  • Price, including annual maintenance and additional costs for training, implementation, on-site support during go-live, and additional licenses for providers or staff.

Posted in: Electronic Medical Records, Headlines, Medicare & Reimbursement

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Providing and Billing for the Flu Vaccine: Guidance from CMS, the CDC and the Affordable Care Act

Update posted 8-14-2012: For flu shot updates for the 2012-2013 influenza season, click here.

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Update posted 9-22-2011: For flu shot updates for the 2011-2012 influenza season, click here.

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Update Posted 12-20-2010 – Medicare posted code changes for flu vaccines billed to Medicare after January 1, 2011.  Click here for the changes.

For dates of service on or after September 1, 2010, the corrected Medicare Part B payment allowance for CPT 90655 is $14.858.

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It’s that time again, and despite delayed deliveries to some hospitals and practices, the word on the street is that there will be enough flu vaccine (171 million doses) this year for all who want a flu shot.

Model of Influenza Virus from NIH

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The Center for Disease Control (CDC) recommends that everyone 6 months and older get a flu shot.  Each year’s flu vaccine cocktail is unique and this season’s (2010-2011) flu vaccine will protect against three different flu viruses: an H3N2 virus, an influenza B virus and the H1N1 virus that caused so much illness last season.

The Affordable Care Act and the Influenza Vaccine

Just in time for flu season is the Affordable Care Act’s emphasis on preventive care.  The ACA states:

This influenza season, children 6 months through 18 years, certain high-risk adults 19 through 49 years, and adults 50 years and older who are enrolled in new group and individual health plans will be eligible to receive the seasonal flu vaccine without cost-sharing when provided by an in-network provider.  Beginning in the plan year that starts after March 2, 2011, all adults 19-49 years of age will be eligible to receive the seasonal flu vaccine with no cost-sharing requirements when provided by an in-network provider.

This is great news for the patient and for healthcare in general.  You may consider it good news or bad news, depending on your view of the whole flu shot process.  Here’s how it works in many practices:

  1. The vaccine is ordered in the spring, with everyone trying hard to guess correctly how many patients will want flu shots in 6 months.
  2. The vaccine arrives in the fall and the first hurdle is pricing it, as you will have to decide how much to mark it up to cover the cost of the ordering, handling and stocking and possibly a teeny profit.
  3. The administration of the vaccine also has to be priced to cover the cost of supplies (syringe, alcohol swab, sometimes a bandaid, printed Vaccine Administration Sheets) and the cost of labor (assessing the patient to make sure they can get the flu shot, giving the shot, and documenting the lot numbers in case of a recall.)
  4. The next decision is disbursement.  Do you have a flu shot clinic and have people get in line for the flu shot, or do you take flu shot appointments, do you give flu shots during regular appointments, or some combination thereof? What about drive-through flu clinics?  Do people sit in the parking lot for 15 minutes to make sure there are no bad after-effects?  How do you let patients know about your flu shot plans without costly postcards or advertisements?
  5. Then, there is policy setting for patients whose insurance covers the flu shot and for patients whose insurance does not.  Do you collect and refund if necessary, or do you not collect and bill the patient after insurance responds (Jaws theme music here, please.)

Does Medicare pay for flu shots?

Medicare pays 100% of the allowable for influenza vaccine (and pneumococcal vaccines) and the administration of the vaccines without any out-of-pocket costs to the patient.  One flu vaccine is allowable per flu season, but Medicare will pay for a second flu shot if a physician determines and documents the medical necessity.  A physician’s order is not necessary and a physician’s supervision is not necessary – that’s why patients are able to get a flu shot at the drugstore.  A patient can receive a flu shot twice in one calendar year by getting a flu shot late in one season and getting a flu shot early in the next season.

How should a provider that is not enrolled in Medicare bill for the flu vaccine?

CMS typically does not allow non-enrolled providers to treat Medicare beneficiaries, however, CMS is allowing them to give flu shots this year.  Beneficiaries can receive a flu vaccine from any licensed physician or provider. However, the billing procedure will vary depending on whether the physician or provider is enrolled in the Medicare Program.

If you are not a Medicare-enrolled physician or provider who gives a flu vaccine to a Medicare beneficiary, you can ask the beneficiary for payment at the time of service. The beneficiary can then request Medicare reimbursement. Medicare reimbursement will be approximately $18 for each flu vaccine.

Public health poster from Spanish flu era.
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To request reimbursement, the beneficiary will need to obtain and complete form CMS 1490S.  So the beneficiary may receive reimbursement, you will need to provide the beneficiary with a receipt for the flu vaccine that has the following information written or printed on it:
”¢    The doctor’s or provider’s name and address
”¢    Service provided (“flu vaccine”)
”¢    Date flu vaccine received
”¢    Amount paid

What codes are used for flu shots?

For flu vaccine and vaccine administration, the following codes are used.

Effective September 1, 2009, (no 2010 changes have been announced) the Medicare Part B payment allowances for influenza vaccines are as follows:

  • For HCPCS 90655, the payment will be  $15.447:  Influenza virus vaccine, split virus, preservative free, for children 6- 35 months of age, for intramuscular use
  • For HCPCS code 90656, the payment will be  $12.541: Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years and above, for intramuscular use
  • For HCPCS code 90657, the payment will be  $15.684:  Influenza virus vaccine, split virus, for children 6-35 months of age, for intramuscular use;
  • For HCPCS code 90658, the payment will be  $11.368:  Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use
  • HCPCS 90660 (FluMist, a nasal influenza vaccine) may be covered if the local Medicare contractor determines its use is medically reasonable and necessary for the beneficiary. When payment is based on 95 percent of the Average Wholesale Price (AWP), the Medicare Part B payment allowance for CPT 90660 is $22.316 (effective September 1, 2009).

G0008 is the Medicare HCPCS for Administration of influenza virus vaccine, including FluMist.  Other payers usually require use of 90465, 90466, 90467, 90468, 90471, 90472, 90473 or 90474 for administration of the vaccine.

The associated ICD-9 codes for flu shots are:

V04.81    Influenza
V06.6      Pneumococcus and Influenza (both vaccines at one visit)

Other resources:

  • Get your practice and your staff ready for flu season by following the guidelines I write about here.
  • Free downloads from the CDC here.
  • MedLine Plus Articles, Downloads and Resources here
  • Article: Mandating Influenza Vaccine – One Hospital’s Experience (MedScape free account required)
  • National Foundation for Infectious Diseases: Influenza
  • National Influenza Vaccine Summit: Prevent Influenza
  • Vaccine Education Center at Children’s Hospital of Philadelphia (CHOP) -Influenza: What You Should Know (pdf)   EnglishSpanish
  • Medicare Preventive Services Quick Reference Information Chart: Medicare Part B Immunization Billing (Influenza, Pneumococcal, and Hepatitis B) is available here (pdf.)
  • For information on roster billing (billing for many patients at one time) see the Medicare Claims Processing Manual for Preventive and Screening Services (Chapter 18) here (pdf) Section 10-3.

NOTE: Beneficiaries have been advised to contact the Inspector General hotline at 1-800-HHS-TIPS (1-800-447-8477) to file a complaint if they believe their physician or provider charged an unfair amount for a flu vaccine.

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Posted in: Collections, Billing & Coding, Medicare & Reimbursement

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New Medicare Waived CLIA Laboratory Tests Published

The CLIA regulations require a facility to be appropriately certified for each test performed. To ensure that the Medicare and Medicaid programs only pay for laboratory tests categorized as waived complexity under CLIA in facilities with a CLIA certificate of waiver, laboratory claims are currently edited at the CLIA
certificate level.

New test list here (pdf.)

All CLIA waived tests here (pdf.) – updated July 6, 2010

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The Cohen Report: Medicare Part B NCCI Update 16.2 for Providers Effective July 1, 2010

Here’s your pop quiz:

The NCCI edits are:

A.  pairs of services that should not be billed by the same physician for the same patient on the same day.

B.  definition refinements for HCPCS codes.

C.  diagnosis codes (ICD-9) that cannot be billed together on a CMS 1500 claim.

The answer is below the picture.

Doctor's Office (Tools of The Trade)

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If you answered “A”, you’re on top of your game!  The King of the National Correct Coding Initiative (NCCI) quarterly analysis is Mr. Frank Cohen and he provides that analysis free of charge for all.  Thank you, Frank!  With his analysis, you have the opportunity to see what’s changed and what’s new, to tweak your system to catch the pairs, and to make sure you are providing the right care at the right time as well as maximizing your reimbursement.

The Cohen Report:

In summary, there are 16,843 new edit pairs, bringing the total number of active edit pairs to 653,718. Six of these are backdated to an effective date of January 1, 2010. The majority of these (75.17%)  are associated to the edit policy “Misuse of column two code with column one code” with 12.82% associated to “Standard preparation / monitoring services for anesthesia”. There are 6,042 unique Column 1 codes and 274 unique Column 2 Codes within the new edits.

There are 36 new terminated edit pairs with 12 backdated to January 1, 2010 and two backdated to April 1, 2010. The edit policies associated to these edit pairs are distributed between “Misuse of column two code with column one code” (44.4%), “CPT Manual and CMS coding manual instructions” (33.3%) and “More extensive procedure” (22.2%).
There were 413 edit pairs with modifier changes. Of these, 387 went from 0 (no modifier permitted) to 1 (modifier permitted) and 26 went from an indicator of 0 to an indicator of 1.
There are currently 1,336 duplicate entries; codes that were activated at one point then terminated and then re-activated. There are 5,318 swapped edit pairs; situations where the edit pair was introduced at one point in a specific order (column 1 and column 2), terminated and then re-activated with the edit pair in the opposite order.

I have posted my analysis worksheets for those interested in the details. Go to www.frankcohen.com and click on the Download tab.

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Posted in: Medicare & Reimbursement, The Cohen Report (NCCI & RVUs)

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Deja Vu All Over Again: The Medicare Fee Cut is Pushed Back to November 30, 2010

I don’t know about you but I am emotionally exhausted thinking about and worrying about the on-again off-again cuts in Medicare fees for physicians.

Here’s the scoop: late Thursday evening, June 24, 2010, the House of Representatives passed the ” Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 (H.R. 3962)” which includes a delay in the 21+% fee cut. Because the same legislation was already passed by the Senate, it now goes to the President for his signature and it becomes law.  It is anticipated that this will happen quickly and CMS will have the MACs start processing new claims with dates of service of June 1, 2010 and later at the 2009 fee schedule plus a 2.2% increase.  The MACs will also have to reprocess the claims already paid for dates of service June 1, 2010 and later that were processed with 2010 fee schedule and that big fat cut.

Q: What should we be doing for the next 5 months and 6 days?

WASHINGTON - SEPTEMBER 10:  Doctors and other ...

Image by Getty Images via @daylife

A: Have someone in your practice take a video of your providers introducing themselves, telling how many Medicare patients they have and how they can’t afford to see Medicare patients unless the SGR formula is replaced with something that works. The video doesn’t have to be slick – just real.  Send it to your senators and representatives.  Send it your local TV news.  Post it on YouTube.  Imagine hundreds of thousands of providers introducing themselves and talking about their patients.  It would be powerful.

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Posted in: Headlines, Leadership, Medicare & Reimbursement

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Congress Expected to Further Delay SGR Cut to Medicare Physician Fee Schedule

UPDATE: On June 24, 2010 the House and Senate passed legislation to further delay the Medicare cuts until November 30, 2010. More here.

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Congress has yet to pass a bill delaying the June 1, 2010 21.2% reduction in physician reimbursement, but most believe it will happen and be effective retroactively.

CMS has said it is anticipating a further delay in Medicare fee schedule cuts, so they have “instructed contractors to hold claims containing services paid under the MPFS for the first 10 business days of June.”

More information on my post here.

Stay tuned!

Posted in: Headlines, Medicare & Reimbursement

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