Posts Tagged HPSA

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12 Ways to Supercharge Your Practice in 2012: #12 – 9 Ways to Maximize Your Medicare Payments

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Medicare has so many programs that have the potential to increase or decrease your payments that practices need a list to keep them straight.

Here’s your list with information on which programs are mutually exclusive and which can be combined.

 

1. Electronic Health Records (EHR) Incentive Program

  • You must be an eligible provider to participate.
  • You must be the owner of the EHR, although you do not need to have paid for the EHR.
  • The EHR must be certified.
  • You can choose to participate in Medicare (federally administered) or Medicaid (state administered) program.
  • You must register for the programs.
  • You must attest or document that you have adopted, implemented, upgraded or demonstrate meaningful use.
  • Eligible professionals choosing to participate the Medicare program can each earn up to $44K over 5 years, and eligible professionals choosing to participate in the Medicaid program can each earn up to $63,750 over 6 years.

2. ePrescribing Incentive Program

  • Eligible professionals do not need to register for the program.
  • You can participate in one of three ways: via submitting codes on claim forms, via an EHR or via a registry
  • Each professional needs to report 10 eRx events for Medicare patients for dates of service before June 30, 2012 OR apply for one of five exclusions or four exemptions.
  • EPs who are successful e-prescribers can qualify to earn an incentive payment based on a percentage of their total estimated Medicare PFS allowed charges processed not later than 2 months after the end of the reporting period. For reporting year 2012, EPs who are successful e-prescribers can qualify to earn an incentive payment equal to 1.0 percent of allowed charges. For reporting year 2013, EPs can qualify to earn an incentive payment of 0.5 percent of allowed charges. Beginning in 2012, EPs who are not successful e-prescribers in 2011 and do not qualify for a hardship exception will be subject to a payment adjustment equal to 1.0 percent of their Medicare PFS allowed charges. The payment adjustment increases to 1.5 percent in 2013 and 2.0 percent in 2014.

3. PQRS (Physician Quality Reporting System)

  • Originally called PQRI (Physician Quality Reporting Initiative) is the basis for pay-for-performance models.
  • Physicians may report individually or practices may choose a set of three measures that relate to the type of patients they see. Measures are  performed and modifiers are attached to claims.
  • Bonuses are available until 2014; starting in 2015 practices not participating in PQRS will receive a negative payment adjustment.
  • For reporting years 2012 through 2014, EPs who satisfactorily report Physician Quality Reporting System measures will earn an incentive payment equal to 0.5 percent of allowed charges. Additionally, for reporting years 2011 through 2014, EPs who satisfactorily report Physician Quality Reporting System measures can qualify to earn an additional 0.5 percent incentive payment by, more frequently than is required to qualify for or maintain board certification status, participating in a maintenance of certification program and successfully completing a qualified maintenance of certification program practice assessment. Beginning in 2015, EPs who do not satisfactorily report under the Physician Quality Reporting System will be subject to a payment adjustment equal to 1.5 percent of their Medicare PFS allowed charges. The payment adjustment increases to 2.0 percent in 2016 and beyond.

4. Medicare Wellness Visits

  • Many practices are losing money due to the confusion over what Medicare pays for and what Medicare doesn’t pay for.  Medicare introduced three new visits in 2010 and many providers continue to have trouble understanding and providing them correctly.
  • The “Welcome to Medicare” visit is technically called the “Initial Patient Physical Examination” (IPPE), but to everyone’s dismay, it is not a physical examination at all, with the exception of basic visits such as height, weight, BMI, blood pressure and pulse, and the potential for an EKG and an Abdominal Aortic Aneurysm screening. The Annual Wellness Visit (AWV) and the Subsequent Annual Wellness Visit are not physical examinations either, yet almost ALL patients believe that Medicare now gives free annual physicals.
  • Practices must train all staff and physicians to use the correct terminology first. I suggest everyone stop using the phrases “annual physical” or “complete physical” with Medicare patients. Patients can request and receive:
    • A Welcome to Medicare Visit with no exam (no deductible, no co-insurance)
    • A first annual Wellness Visit with no exam  (no deductible, no co-insurance)
    • A Subsequent Annual Wellness Visit with no exam every year thereafter (no deductible, no co-insurance)
  • What patients think they want is either a preventive visit, which Medicare will NOT pay for, or a standard Evaluation & Management (E/M) visit, which their deductible and co-insurance will apply to.
  • The only way the practice can win is by driving home to patients what Medicare does pay for and doesn’t pay for and making sure your documentation matches the code you submit to Medicare.

 

5. The ABN (Advance Beneficiary Notice)

  • Many practices miss revenue when they provide services to Medicare patients that are statutorily excluded from Medicare benefits.
  • These may be services that do not meet the Medicare definition of medical necessity or are provided at more frequent intervals than Medicare approves.
  • Identifying these non-covered services is the hard thing, however, unless your EMR can alert you to a service that will not be paid by Medicare, and if the patient requests the service and signs an ABN prior to the provision of the service  In this case, the practice may collect the full fee from the patient.

6. Primary Care Incentive Payment Program (PCIP)

  • Eligible Providers (Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, and Physicians who have their primary specialty designation in family medicine, internal medicine, geriatric medicine or pediatric medicine) can receive a 10% incentive payment for services under Part B.
  • The PCIP program, which was created by the Patient Protection and Affordable Care Act, requires Medicare to pay primary care providers, whose primary care billings comprise at least 60 percent of their total Medicare allowed charges, a quarterly 10-percent bonus from Jan. 1, 2011, until the end of December 2015.
  • Eligible primary care physicians furnishing a primary care service in a Health Professional Shortage Area (HPSA) area may receive both a HPSA and a PCIP payment.

7. HPSA (Health Professional Shortage Area)

  • Medicare makes bonus payments annually of 10% to physicians who provide medical care services in geographic areas that lack sufficient health care providers to meet the needs of the population.
  • Payments are automatic; there is no need to register or report anything on the claim for
  • If services are provided in ZIP code areas that do not fall entirely within a full county HPSA or partial county HPSA, the AQ modifier must be entered on the claim to receive the bonus.

 

8. HPSA (Health Professional Shortage Area ) Surgical Incentive Payment (HSIP)

  • The Affordable Care Act of 2010, Section 5501 (b)(4) expands bonus payments for general surgeons in HPSAs.  Effective January 1, 2011 through December 31, 2015, physicians serving in designated HPSAs will receive an additional 10% bonus for major surgical procedures with a 10 or 90 day global period.
  • Payments are automatic; there is no need to register or report anything on the claim form.
  • If services are provided in ZIP code areas that do not fall entirely within a full county HPSA or partial county HPSA, the AQ modifier must be entered on the claim to receive the bonus.

9. NEW! Comprehensive Primary Care Initiative (CPCi)

  • Payment model per beneficiary per month (PBPM) for care management of Medicaid and Medicare patients
  • Markets in Arkansas, Colorado, New jersey, New York, Ohio/Kentucky, Oklahoma and Oregon for Medicaid patients
  • Arkansas, Colorado, Ohio and Oregon are the four states for Medicaid pilots.
  • Multiple payers, including CMS, will be paying a monthly care management fee to support the 5 primary care functions of:
    • Risk-stratified care management
    • Access and continuity
    • Planned care for chronic care & preventive care
    • Patient & caregiver engagement
    • Coordination of care across the medical neighborhood
  • Primary care practices in the states and markets can apply from June 15 to July 20, 2012 (application here.)

 

What Medicare Bonus or Incentive Programs Can Be Claimed Together?

  • PQRS can claimed with eRx.
  • PQRS can be claimed with EHR.
  • HPSA and PCIP are automatic and are not affected by any other programs
  • EHR and eRx can both be claimed but you cannot earn both an eRx incentive and an EHR incentive in the same year if you elect to receive the EHR incentive payment through Medicare. NOTE: Just because you cannot claim the eRx bonus in conjunction with EHR incentive, you must still continue to ePrescribe to avoid the eRx penalty!

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Posted in: 12 Ways to Supercharge Your Practice, General

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Everything You Ever Wanted to Know About the Global Surgical Package: Coding and Billing for the GSP

If you do the professional fee (pro-fee) coding or billing for surgeries, you know that the rules surrounding the Global Surgical Package (GSP) are many and can be complex. CMS just published a new fact sheet on the GSP and it’s a great recap for coders and billers.

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

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Step by Step Directions for Getting the EHR Incentive Money: My Notes From Last Week’s CMS Call

First the facts on what has taken place so far in the 2011 EHR Incentive Programs.

  • As of June 30th, the total of Medicare EHR Incentive Program payments is over $94 million.
  • As of June 30th, over $166 million has been paid in Medicaid EHR incentives since the program began in January.  In May and June, four states launched Medicaid EHR Incentive Programs – Indiana, Ohio, Pennsylvania, and Washington, bringing the total states with Medicaid EHR Incentive Programs to 21.  More states will launch in July.
  • There are 68,001 active registrations of eligible professionals and eligible hospitals for the Medicare and Medicaid EHR Incentive Programs.

If your group hasn’t received a check and hasn’t registered for the Medicare or Medicaid Incentive Program, then this blog post is for you! For anyone who is really just beginning their EHR journey, today’s presentation clarified previous information given by CMS, as well as giving listeners new information about the programs.

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

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CMS Roundup of 17 Announcements: More Information Than You Can Shake a Stick At!

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Hospital Wage Index Reform Call

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 1-800-837-1935 Conference 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.
  • Eligible Hospital and CAH Meaningful Use Criteria – Must report on 14 core measures, 5 of 10 menu measures, and 15 clinical quality 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.

Want more information about the EHR Incentive Programs? Make sure to visit the CMS EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs; also read the new EHR Incentive Program FAQs from CMS.

Preventive Services, Preventive Physical Examinations and Annual Wellness Visits Quick Reference Charts

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.

IMPORTANT 5010/D.0 IMPLEMENTATION ITEMS

REMINDER  – 5010/D.0 Errata requirements and testing schedule can be found here

REMINDER  – Contact your MAC for their testing schedule

READINESS ASSESSMENT  – Have you done the following to be ready for 5010/D.0?

READINESS ASSESSMENT  – What do you need to have in place to test with your MAC?

READINESS ASSESSMENT  – Do you know the implications of not being ready?

New Mental Health Services Booklet

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.

 

Medicare Disproportionate Share Hospital Fact Sheet Revised

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.

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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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