New Medicare Card and Reason Code N793

CMS Rolls Out New Medicare Card

If you’ve seen new reason code N793 on your Medicare remittance advice lately and wonder what it is, you now know it relates to the new Medicare card.

The description for N793 is:

Alert: CMS is changing from the Medicare Health Insurance Claim Number (HICN aka “hickin”) to the new Medicare Beneficiary Identifier (MBI). You can use either the HICN or MBI during this transition period.

You’ve probably been bombarded with Medicare news releases and Open Door Forums describing the change and the timeline, but if not, here are some helpful links:

CMS Page on the New Card here.

FAQs updated April 4th here.

Signs and widgets for your office and website here.

Timeline for state by state rollout here. (Hint: most states are described only as “After June 2018”)

Electronic Remittance Advice Example here.

Important Dates for the New Medicare Card

  • Transition Period ends December 31, 2019.
  • CMS accepts MBIs only regardless of the date of service January 1, 2020



Advance Beneficiary Notice FAQs

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

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

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

Here are some of your most frequently asked ABN questions.

What is the ABN? What does it do?

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

What won’t Medicare pay for?

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

Should we just have everybody sign an ABN?

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

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

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

Are ABNs for Medicare only?

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

 

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




The CMS ICD-10 Announcement: What It Means to Your Practice

The Lion and the Lamb - CMS and the AMA Collaborate on ICD-10 Concessions

First, the game-changing announcement below means that a sigh of relief is in order. Some of the anxiety surrounding potential financial disaster should be abated. CMS announced:

“Medicare review contractors [MACs and RACs] will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.” (see FAQ2 below)

Second, we think it means that the sword rattling coming from the AMA and other individuals should subside. The fact that the CMS changes are based on recommendations from the AMA, which has been adamantly opposed to the ICD-10 mandate for years, is no less unexpected than the lion laying down with the lamb.

Regardless of the changes, the AMA’s previous assertion that ICD-10 “will create significant burdens on the practice of medicine with no direct benefit to individual patients’ care” still stands. The transition is inevitable, in my mind, but the changes will lessen the burden on physicians.

In the announcement from CMS, the clarification was made that

“In accordance with the coming transition, the Medicare claims processing systems will not have the capability to accept ICD-9 codes for dates of services after September 30, 2015, nor will they be able to accept claims for both ICD-9 and ICD-10 codes.”

Third, CMS will name a CMS ICD-10 Ombudsman to triage and answer questions about the submission of claims. The ICD-10 Ombudsman will be located at CMS’s ICD-10 Coordination Center.

Also, mark your calendars! CMS will have a provider call on August 27th to discuss these changes.

See the answers below provided by CMS in their new FAQs published this week.

Q1. What if I run into a problem with the transition to ICD-10 on or after October 1st 2015?

A1. CMS understands that moving to ICD-10 is bringing significant changes to the provider community. CMS will set up a communication and collaboration center for monitoring the implementation of ICD-10. This center will quickly identify and initiate resolution of issues that arise as a result of the transition to ICD-10. As part of the center, CMS will have an ICD-10 Ombudsman to help receive and triage physician and provider issues. The Ombudsman will work closely with representatives in CMS’s regional offices to address physicians’ concerns. As we get closer to the October 1, 2015, compliance date, CMS will issue guidance about how to submit issues to the Ombudsman.

Q2. What happens if I use the wrong ICD-10 code, will my claim be denied?

A1. While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family. However, a valid ICD-10 code will be required on all claims starting on October 1, 2015. It is possible a claim could be chosen for review for reasons other than the specificity of the ICD-10 code and the claim would continue to be reviewed for these reasons. This policy will be adopted by the Medicare Administrative Contractors, the Recovery Audit Contractors, the Zone Program Integrity Contractors, and the Supplemental Medical Review Contractor.

Q3. What happens if I use the wrong ICD-10 code for quality reporting? Will Medicare deny an informal review request?

A3. For all quality reporting completed for program year 2015 Medicare clinical quality data review contractors will not subject physicians or other Eligible Professionals (EP) to the Physician Quality Reporting System (PQRS), Value Based Modifier (VBM), or Meaningful Use 2 (MU) penalty during primary source verification or auditing related to the additional specificity of the ICD-10 diagnosis code, as long as the physician/EP used a code from the correct family of codes. Furthermore, an EP will not be subjected to a penalty if CMS experiences difficulty calculating the quality scores for PQRS, VBM, or MU due to the transition to ICD-10 codes. CMS will not deny any informal review request based on 2015 quality measures if it is found that the EP submitted the requisite number/type of measures and appropriate domains on the specified number/percentage of patients, and the EP’s only error(s) is/are related to the specificity of the ICD-10 diagnosis code (as long as the physician/EP used a code from the correct family of codes). CMS will continue to monitor the implementation and adjust the timeframe if needed.

Q4. What is advanced payment and how can I access this if needed?

A4. When the Part B Medicare Contractors are unable to process claims within established time limits because of administrative problems, such as contractor system malfunction or implementation problems, an advance payment may be available. An advance payment is a conditional partial payment, which requires repayment, and may be issued when the conditions described in CMS regulations at 42 CFR Section 421.214 are met. To apply for an advance payment, the Medicare physician/supplier is required to submit the request to their appropriate Medicare Administrative Contractor (MAC). Should there be Medicare systems issues that interfere with claims processing, CMS and the MACs will post information on how to access advance payments. CMS does not have the authority to make advance payments in the case where a physician is unable to submit a valid claim for services rendered.

NOTE: Watch for upcoming posts on ICD-10 websites and apps that I am rating for their usefulness. We will also be producing free webinars on translating the diagnoses on your superbills, picklists and cheat sheets for ICD-10 – stay tuned!

Photo Credit: Tojosan via Compfight cc




Before and After: How the Sequester’s Cut will Change Your Medicare Reimbursement

Medicare Sequester Cut Provider ReactionThis is no April Fool’s Joke for medical practices and providers: starting Monday, April 1st, we will face a 2% cut in reimbursement for services due to the “sequester.” The sequester is the other half of the “fiscal cliff” that we reported on back in January. Although not too long ago, all the conventional wisdom was dead set against the government “going over the cliff,” and here we are with both automatic tax hikes and spending cuts now a reality.

Managers might  find themselves giving the same explanations about gridlock to the doctors that you gave your employees when their first paycheck of 2013 was lower than usual.

Although the cut is only 2%, it comes entirely from the 80% of the allowable that the government reimburses, as opposed to the 20% patient responsibility. The cut does not affect the Medicare patient’s co-insurance, not does it affect the 2013 Medicare Part B deductible.

To give medical practice managers an idea of what that cut will look like, here are some sample numbers.

Let’s Assume: a solo primary care physician sees roughly 500 patients a month, 30% of whom are Medicare-enrolled. Of the 150 Medicare patients seen per month, a quarter of them are new patient visits. Let’s also assume that about 40% of your Medicare visits are coded as level 3 office visit, with the remaining 60% coded as a level 4 visit. If these numbers seem oversimplified – they are, but I’m hoping to keep the math a little under control. Using the unadjusted, national reimbursement of these four basic CPT codes from the AMA, here’s how the sequester would affect a practice.

Medicare Sequester Cut ExampleIn this scenario then, pre-sequester, the physician would be reimbursed a total of $12,629.18 for the month. With the 2% cut taken on the federal government’s portion starting April 1st, 2013 that number would shrink to $12,376.60 – a difference of $252.58 a month.

The beginning of the calendar year is already tough on many practice’s cash flow because of deductibles restarting. A 2% cut in Medicare reimbursements from Uncle Sam is not going to help. As for the future outlook of the sequester cuts, there has been no real movement on the part of the Democrats or the Republicans to replace the cuts now that they have happened. For the time being, they seem here to stay.

We are advising our clients to take a look at their financial policies and collection procedures in the wake of these changes. Collecting patient-responsible co-pays, co-insurance and deductibles on the front end is more important than ever. One idea that we recommend every practice take a look at is starting a credit card on file program in your practice to cut collection costs, increase front-end collections, and reduce days in accounts receivable (A/R.)

Our next webinar – “Starting a Credit Card on File Program in Your Practice” will be Tuesday, April 2nd, 2013, and is a 60-minute program designed to give you all the tools you need to start a program in your practice. We’ll hope you’ll join us. Register Today!




RAC Alert: How to Bill Medicare for Hospice Patients When You Are Not the Hospice Provider

Hospice Care

What is Hospice?

Hospice care focuses on improving the quality of life for persons and their families faced with a life-limiting illness. The primary goals of hospice care are to provide comfort, relieve physical, emotional, and spiritual suffering, and promote the dignity of terminally ill persons. Hospice care neither prolongs nor hastens the dying process. As such, it is palliative not curative. Hospice care is a philosophy or approach to care rather than a place. Care may be provided in a person’s home, nursing home, hospital, or independent facility devoted to end-of-life care.

How is Medicare Hospice Care Paid?

When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for services that are related to the treatment and management of his/her terminal illness during any period his/her hospice benefit election is in force, except for professional services of an attending physician, which may include a nurse practitioner. If the attending physician, who may be a nurse practitioner, is an employee of the designated hospice, he or she may not receive compensation from the hospice for those services under Part B. These physician professional services are billed to Medicare Part A by the hospice.

What is the RAC Issue?

Recovery Auditors recently reported a billing issue for physicians providing services unrelated to a Hospice terminal diagnosis provided during a Hospice period. Hospice claims are filed under Part A, while services not related to a Hospice diagnosis are filed under Part B. In these cases, unrelated care was billed without the accompanying GW modifier. All services related to a Hospice terminal diagnosis are included in the Hospice payment and are not paid separately.

For beneficiaries enrolled in Hospice, Medicare Administrative Contractors (MACs) and/or Medicare Carriers must deny any service furnished on or after January 1, 2002, that are submitted without either GV or GW modifier.

GV Modifier = Attending physician treating a patient with a Hospice related terminal diagnosis, but not employed or paid under arrangement by the patient’s hospice provider

GW Modifier = Service not related to the Hospice patient’s terminal condition

Recovery Auditor Finding

In this audit, the recovery auditors conducted an automated review of claims for physician services. A significant number were deemed to contain improper billing resulting in overpayment.

Claim Example 1: A patient is enrolled in Hospice and goes to a physician’s office for open treatment of a femoral fracture, with internal fixation or prosthetic replacement, CPT code 27236.

Finding: If the procedure is unrelated to the terminal diagnosis (Non-Hospice related), the physician’s bill should contain modifier GW. If this modifier is not appended, the procedure is related to the terminal diagnosis and should not be reimbursed under the part B benefit, instead paid under the hospice benefit.

Claim Example 2: The patient is shown as being on hospice starting August 1, 2010, through August 31, 2010. A provider billed CPT code 45378, Colonoscopy, with no modifiers to Part B on August 3, 2010.

Finding: The billing of code 45378 would be incorrect since the beneficiary was enrolled in hospice. There can be no separate reimbursement unless the service was unrelated to the terminal diagnosis, which has to be reflected by the proper modifier.

How to Capture Medicare Hospice Information

  • Identify patients enrolled in Hospice, and document in your system the Hospice in which they are enrolled.
  • If you have referred a patient to Hospice, flag their account in the computer so anyone performing coding or billing can investigate the of use appropriate modifiers.
  • If you have received correspondence notifying you of a patient’s enrollment in Hospice, notify staff and make sure the billing record is flagged for appropriate coding.
  • If you become aware during the patient’s care that the patient you are treating is in Hospice, document the name of the Hospice and notify staff, making sure the billing record is flagged.
  • Patients sometimes dis-enroll or are discharged from Hospice, so do not assume a patient is continuing care under Hospice. When in doubt, contact the patient’s Hospice to clarify if the patient is or is not enrolled.
  • A little extra leg work will not only cause your claim to be paid on time and properly, it will also keep you from having to pay back any money if improperly paid to you.

 




The Big Idea for 2013: Show Me Your Fees

Transparency in HealthcarePrivate practices, hospital-owned practices and affiliated group practices are facing big changes from healthcare reform, demographic shifts, and economic and reimbursement pressure. The industry is re-evaluating itself from top to bottom and looking for new business models, ideas and opportunities to make medical practice feasible. Health insurance is changing as employers and payers are reducing benefits and shifting costs to patients. High deductible health plans (HDHPs) are becoming more popular, and with that patients are thinking more like customers, and making their healthcare decisions based on out-of-pocket costs.

Patients want access to pricing info, and are not satisfied with “it’s complicated” as an answer. The industry as a whole is moving towards rewarding performance over volume, and patients will also be armed with more publicly available performance and safety data.

In short, bedside manner and reputation are not enough anymore: practices now have to compete on price and quality in a more explicit way than ever before. We are advising our medical practice clients to take a long hard look at how they set their prices. Setting your prices does not have to be a complicated exercise when you have a basic understanding of your overhead. If you understand what it costs to produce each RVU of service to your patients, than you can understand what a self-pay or high-deductible patient needs to pay in costs and margin. Then tell your customers what your services cost. This is what other businesses do.

Price transparency improves patient satisfaction and trust because patients can relate what they are paying for to the value they are getting. It eases conversations about patient financial responsibility. Patients want to understand the money behind the treatment they are getting, because they have more financial “skin in the game” than ever before. Engage your patients in this process immediately by publishing your fees!

For almost as long as I’ve been in healthcare, telling patients what services cost has been an issue and here’s why –

Fee schedules are set for insurance companies, not for patients. When a practice signs a contract with an insurance company, the assumption is that in exchange for the insurance company delivering volume (lots of patients) the practice can afford to deeply discount their fees. The practice supplies their fee schedule and the insurance company cuts it down. The practice wants to start with a high enough fee schedule that a significantly cut schedule will still be much better than Medicare. This is what is referred to as “not leaving any money on the table” – setting your fee schedule high enough to capture everything an insurance company will potentially pay.

Medicare and Medicaid don’t pay physicians enough to cover expenses. To make up for this, practices charge commercial payers more to cover what government payers don’t pay.

Every payer/insurance company negotiates a different rate. Unless the practice has negotiating power, the physicians are usually forced to take what the insurance company is offering. Especially if the insurance company has a strong presence in the community, the physician may feel s/he has no choice but to take what is offered. This is why many physicians are opting to join megapractices or hospital organizations.

The rise of uninsured patients and high-deductible insurance plans has changed the number of patients paying 100% for their healthcare. For the past 5 years, the payment for healthcare has dramatically shifted and medical practices and patients have not been ready. Against rising healthcare costs, insurance plans and employers have shifted payment to patients in the way of increased cost-sharing, increased deductibles, increased co-pays and co-insurance and decreased benefits. Patients have often been the only ones paying the full retail cost for healthcare – the full fee schedule.

How do you place a price on healthcare services?

  1. Calculate what your services really cost. One way is to take the last 12 months of practice expenses and divide them by the work Relative Value Units (wRVUs) you produced over the same period. This will tell you what it costs you to produce each unit of work. Look at it with the physician’s pay included and without the physician’s pay included.
  2. Calculate what portion of your expense is related to filing and collecting insurance payment. This is primarily your coding, billing and insurance staff, their workspace and equipment and everything related to filing insurance and collecting. Reduce your fees by this cost for uninsured patients.

 

Why should you take this radical advice?

  1. Consumers deserve to know what your service costs. Why would anyone buy anything without knowing what it costs? Consumers should know both the value of the service as well as knowing what is their personal responsibility to pay. Does the fact that healthcare sets their prices above what the market can bear mean we are part of the healthcare problem?
  2. Publishing fees makes you justify them. Medical practices may not want to post their fees if they aren’t sure what their services truly cost. Other businesses charge what their services or goods cost plus a profit, why don’t we?
  3. You will find out if your prices are not competitive in the market. Patients will tell you. Then you will have to decide if you want to be competitive. If you are worried you can’t compete with a hospital-sponsored practice if they know your prices, stop worrying. The hospitals already know your prices.
  4. Publishing your prices will open the door for things to be simpler. Publishing fees will liberate you and your staff to talk much more openly with patients about their financial responsibility.

 Part of this post was originally published under “The Big Idea: Healthcare Price Transparency” on LinkedIn.




Your Health Insurance Deal in 2014: Calculate Your Cost

CalculatorMost people think they know the basics about health insurance reform in 2014: If they do not have access to medical insurance, they will be required to purchase insurance (costly) or they will be taxed (also costly.)

What many people don’t know is that based on their income, age and family size, they may be eligible for a subsidy to help defray the cost of health insurance.

Here’s a handy calculator from the Kaiser Family Foundation that will help you see your healthcare insurance deal if you are without insurance now, or might be without insurance in 2014. The calculator site says:

“This tool illustrates premiums and government assistance under the health reform law signed by the President. Beginning in 2014, tax credits will be available for people under age 65 who purchase coverage on their own in a health insurance Exchange and are not covered through their employer, Medicare or Medicaid. The tool allows the user to examine the impact at different income levels, ages, family sizes, and regional costs.

Premium calculations are consistent with estimates of premiums under reform prepared by the Congressional Budget Office. CBO projects that average premiums under reform for the same level of coverage for a given group of enrollees would be 7-10% lower than under the status quo. However, in many cases coverage will be more comprehensive and accessible than what is typically available today in the non-group market. As a result, 2014 premiums in the calculator cannot necessarily be compared to what people buying insurance on their own are paying in 2010.

The calculator does not apply to people with coverage available through an employer, where the firm is generally paying for a substantial portion of the insurance premium.”

The calculator (see screen shot below) is simple to use and helps you to understand what your healthcare future might be in 12 months. Click here to go to the calculator.

Kaiser Family Foundation Insurance Cost Tool

 

 

 

 

 

 

 

 

 

 

 




Medicare News This Week: The 27.5% Cut, Meaningful Use Stage 2 Specifications, and Upcoming Webinars

This Week’s Medicare News for Medical Practice Managers

  • Vice Chair Gingrey (R-GA) “Confident” of SGR Fix Passing in Lame Duck Congress Session (jump to story)

  • CMS Releases Stage 2 Meaningful Use Specification Sheets with Details on Each Measure  (jump to story)

  • Information on Upcoming Webinars  (jump to story)

Logo for the Centers For Medicare and Medicaid Services

Gingrey “Confident” Lame Duck Congress Will Pass SGR Fix.

Modern Healthcare (11/15, Subscription Publication) reports that Representative Phil Gingrey (R-GA), vice chair of the House Doctors Caucus said Wednesday that he is “pretty confident” Congress will “approve a one-year freeze in Medicare physician pay rates” during the lame duck session. This so-called “SGR patch” would put off a slated 27.5% cut to Medicare reimbursement rates. He said he believed “Congress would find the $18 billion needed to offset the cost of a one-year payment freeze,” adding that “his caucus plans to focus next year on finding a replacement t the SGR and a way to pay the $300 billion cost of permanently replacing it.”
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CMS Releases Stage 2 Meaningful Use Specification Sheets with Details on Each Measure

CMS has added Stage 2 meaningful use specification sheets for both eligible professionals (EPs) and for eligible hospitals and critical access hospitals (CAHs) to help them participate in Stage 2 of meaningful use in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs.

The new specification sheets can be found on the Stage 2 page of the EHR website. Each specification sheet includes the objective, measure, and exclusion for each core and menu objective, as well as a definition of terms, attestation requirements, additional information, and the corresponding standards and certification criteria.

You can view the specification sheets in two ways:

  • Use the Stage 2 Specification Sheet Table of Contents — The Table of Contents lists all the core and menu objectives, with direct links to each individual measure specification sheet. The page contains a Table of Contents for both EPs and for eligible hospitals and CAHs.
  • Download ALL Stage 2 Specification Sheets Zip files containing PDFs of all of the core and menu objectives for EPs and for eligible hospitals and CAHs are available for download on the page.

Reminder: The earliest that the Stage 2 criteria will be effective is in fiscal year 2014 for eligible hospitals and CAHs or calendar year 2014 for EPs. All providers must achieve meaningful use under the Stage 1 criteria before moving to Stage 2. 

Want more information about the EHR Incentive Programs?
Make sure to visit the Medicare and Medicaid EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.
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Information on Two Upcoming Webinars from CMS

National Medicare Training Program Update Webinar on Tuesday, November 20.

Attendees will hear information on:

  • Flu Vaccine
  • Plan Finder
  • Innovations Center
  • Enrollment Opportunities for People Affected by Hurricane Sandy
  • Pharmacy & Provider Access During Federal Disasters and Other Public Health Emergencies

When: Tuesday, November 20, 2012

Time: 2:30-3:30 p.m., ET

Call-In Number: 877-251-0301

Conference ID: 90024799

Webinar ID: https://webinar.cms.hhs.gov/nmtpnov12/

 

Make Your Community a Source of Health and Wellness – Establishing a Health Ministry in Your Community Webinar on Thursday, November 29.

Sue Heitmuller, Health Ministry Coordinator for Adventist HealthCare, will speak in-depth on how to lead communities through the process of faithfully establishing health ministries.

The presentation will be followed by a Question & Answer session.

When: Thursday, November 29, 2012

Time: 2:00-3:00 p.m., ET
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Medicare Pricing Released for Most Flu Vaccine Codes

Flu Shot ReimbursementMedicare pricing for flu vaccines were released September 28th and appear below for all HCPCS codes which were published with fees. For more information on billing for these vaccines, see our post here.

NEW for 2012-2013! 90653 – Influenza virus vaccine, inactivated, subunit, adjuvanted, for intramuscular use (Medicare reimbursement not yet published)

90654 Influenza virus vaccine, split virus, preservative-free, for intradermal use (Medicare reimbursement $18.91)

90655 Influenza virus vaccine, trivalent, preservative free, when administered to children 6-35 months of age, for intramuscular use (Medicare reimbursement $16.45) single dose syringe

90656 Influenza virus vaccine, trivalent, preservative free, when administered to individuals 3 years and older, for intramuscular use (Use for Medicare flu shots using the vaccine Fluarix) (Medicare reimbursement $12.39) single dose syringe

90657 Influenza virus vaccine, trivalent, when administered to children 6-35 months of age, for intramuscular use (Medicare reimbursement $6.02) multi-dose vial

90658 Influenza virus vaccine, trivalent, when administered to individuals 3 years and older, for intramuscular use (not recognized by Medicare) multi-dose vial

90660 Influenza virus vaccine, live, for intranasal use (Medicare reimbursement $23.45)

90662 Influenza virus vaccine, trivalent, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use (Medicare reimbursement $30.92) high dose

90672 Influenza virus vaccine, quadrivalent, live, for intranasal use (not recognized by Medicare)

90685 Influenza virus vaccine, quadrivalent, preservative free, when administered to children 6-35 months of age, for intramuscular use (not recognized by Medicare)

90686 Influenza virus vaccine, quadrivalent, preservative free, when administered to individuals 3 years and older, for intramuscular use (not recognized by Medicare)

90687 Influenza virus vaccine, quadrivalent, when administered to children 6-35 months of age, for intramuscular use (not recognized by Medicare)

90688 Influenza virus vaccine, quadrivalent, when administered to individuals 3 years and older, for intramuscular use (not recognized by Medicare)

 

Only for Medicare Patients:
NEW for 2012-2013! Q2034 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Agriflu) (Medicare reimbursement not released)

Q2035 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria) (Medicare reimbursement $11.54)

Q2036 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval) (Medicare reimbursement $9.83)

Q2037 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirun) (Medicare reimbursement $14.05)

Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone) (Medicare reimbursement $12.04)

Q2039 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Not Otherwise Specified) (No reimbursement rate specified)




Medicare Place of Service Audits Show “Most” Part B Claims Have Incorrect POS

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You wouldn’t think that a simple thing like the place of service would have the potential to cause a $9.5M overpayment by Medicare. But that is the figure the OIG (Office of the Inspector General) says it estimates that Medicare contractors overpaid physicians for place of service errors in 2009.

The OIG conducted the 2009 audit to determine whether physicians correctly coded non-facility place- of-service on selected part B claims submitted to and paid by Medicare contractors. The audit report, titled “Review of Place-of-Service Coding for Physician Services Processed by Medicare Part B Contractors During Calendar Year 2009” is available at http://oig.hhs.gov/oas/reports/region10/11000516.pdf on the OIG website.

Physicians correctly coded the claims for 17 of the 100 services that the OIG sampled. However, physicians incorrectly coded the claims for 83 sampled services by using non-facility place-of-service codes for services that were actually performed in hospital outpatient departments or ASCs. Based on the sample results, OIG estimated that nationally, Medicare contractors overpaid physicians $9.5 million for incorrectly coded services provided during calendar year 2009. – (MLN Matters®Number: SE1226)

It’s not surprising that physicians might use the wrong place of service. Because of the verbiage used to identify when the physician is providing the space, equipment and overhead versus when he is not, many of us in the field have been confused.

Here’s how CMS describes it:

Physicians may perform services in a facility setting, such as a hospital outpatient department or freestanding Ambulatory Surgical Center (ASC), or in a non-facility setting such as a physician’s office, urgent care center, or independent clinic.

To account for the increased overhead expenses physicians incur by performing these services in non-facility locations, Medicare reimburses physicians based on a fee schedule that may pay a higher rate for individual services provided in these locations. When physicians perform these services in facility settings, such as hospital outpatient departments or ASCs, Medicare reimburses the overhead expenses to the facility and the physician receives a lower reimbursement rate.

It might be a good time to review the POS codes you are using in your practice to make sure you are not running afoul of the law. The two areas practices tend to go astray are:

  • split billing correctly (splitting the professional fee from the facility fee)
  • providing services to patients in one location and describing it as another because the reimbursement is higher

Here’s the complete list below.

 

01
Pharmacy
A facility or location where drugs and other medically related items and services are sold, dispensed, or otherwise provided directly to patients.
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02
Unassigned
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03
School
A facility whose primary purpose is education.
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04
Homeless Shelter

A facility or location whose primary purpose is to provide temporary housing to homeless individuals (e.g., emergency shelters, individual or family shelters).
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05
Indian Health Service
Free-standing Facility

A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to American Indians and Alaska Natives who do not require hospitalization.
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06
Indian Health Service
Provider-based Facility
A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services rendered by, or under the supervision of, physicians to American Indians and Alaska Natives admitted as inpatients or outpatients.
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07
Tribal 638
Free-standing Facility
A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to tribal members who do not require hospitalization.
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08
Tribal 638
Provider-based Facility
A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to tribal members admitted as inpatients or outpatients.
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09
Prison/Correctional Facility
A prison, jail, reformatory, work farm, detention center, or any other similar facility maintained by either Federal, State or local authorities for the purpose of confinement or rehabilitation of adult or juvenile criminal offenders.
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10
Unassigned

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11
Office
Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.
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12
Home
Location, other than a hospital or other facility, where the patient receives care in a private residence.
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13
Assisted Living Facility
Congregate residential facility with self-contained living units providing assessment of each resident’s needs and on-site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services.
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14
Group Home
A residence, with shared living areas, where clients receive supervision and other services such as social and/or behavioral services, custodial service, and minimal services (e.g., medication administration).
____________________
15
Mobile Unit
A facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and/or treatment services.

____________________

16
Temporary Lodging
A short term accommodation such as a hotel, camp ground, hostel, cruise ship or resort where the patient receives care, and which is not identified by any other POS code.
____________________
17
Walk-in Retail Health Clinic
A walk-in health clinic, other than an office, urgent care facility, pharmacy or independent clinic and not described by any other Place of Service code, that is located within a retail operation and provides, on an ambulatory basis, preventive and primary care services.  (This code is available for use immediately with a final effective date of May 1, 2010)

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18-19
Unassigned
____________________
20
Urgent Care Facility
Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.
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21
Inpatient Hospital
A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.
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22
Outpatient Hospital
A portion of a hospital which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
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23
Emergency Room – Hospital
A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.
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24
Ambulatory Surgical Center
A freestanding facility, other than a physician’s office, where surgical and diagnostic services are provided on an ambulatory basis.

____________________

25
Birthing Center
A facility, other than a hospital’s maternity facilities or a physician’s office, which provides a setting for labor, delivery, and immediate post-partum care as well as immediate care of new born infants.
____________________
26
Military Treatment Facility
A medical facility operated by one or more of the Uniformed Services. Military Treatment Facility (MTF) also refers to certain former U.S. Public Health Service (USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF).
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27-30
Unassigned
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31
Skilled Nursing Facility
A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.

____________________
32
Nursing Facility
A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals.
____________________
33
Custodial Care Facility
A facility which provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component.
____________________
34
Hospice
A facility, other than a patient’s home, in which palliative and supportive care for terminally ill patients and their families are provided.
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35-40
Unassigned
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41
Ambulance – Land
A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.
____________________
42
Ambulance – Air or Water
An air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.
____________________
43-48
Unassigned
____________________
49
Independent Clinic
A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only.  (effective 10/1/03)
____________________
50
Federally Qualified Health Center
A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under the general direction of a physician.

____________________

51
Inpatient Psychiatric Facility
A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician.
____________________
52
Psychiatric Facility-Partial Hospitalization
A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or hospital-affiliated facility.
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53
Community Mental Health Center
A facility that provides the following services: outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC’s mental health services area who have been discharged from inpatient treatment at a mental health facility; 24 hour a day emergency care services; day treatment, other partial hospitalization services, or psychosocial rehabilitation services; screening for patients being considered for admission to State mental health facilities to determine the appropriateness of such admission; and consultation and education services.
____________________
54
Intermediate Care Facility/Mentally Retarded
A facility which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals but does not provide the level of care or treatment available in a hospital or SNF.
____________________
55
Residential Substance Abuse Treatment Facility
A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board.
____________________
56
Psychiatric Residential Treatment Center
A facility or distinct part of a facility for psychiatric care which provides a total 24-hour therapeutically planned and professionally staffed group living and learning environment.

____________________

57
Non-residential Substance Abuse Treatment Facility
A location which provides treatment for substance (alcohol and drug) abuse on an ambulatory basis.  Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing.
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58-59
Unassigned
____________________
60
Mass Immunization Center
A location where providers administer pneumococcal pneumonia and influenza virus vaccinations and submit these services as electronic media claims, paper claims, or using the roster billing method. This generally takes place in a mass immunization setting, such as, a public health center, pharmacy, or mall but may include a physician office setting.

____________________

61
Comprehensive Inpatient Rehabilitation Facility
A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services.
____________________
62
Comprehensive Outpatient Rehabilitation Facility
A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services.
____________________
63-64
Unassigned
____________________
65
End-Stage Renal Disease Treatment Facility
A facility other than a hospital, which provides dialysis treatment, maintenance, and/or training to patients or caregivers on an ambulatory or home-care basis.
____________________
66-70
Unassigned
____________________
71
Public Health Clinic
A facility maintained by either State or local health departments that provides ambulatory primary medical care under the general direction of a physician.
____________________
72
Rural Health Clinic
A certified facility which is located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician.
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73-80
Unassigned
____________________
81
Independent Laboratory
A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician’s office.
____________________
82-98
Unassigned
___________________
99
Other Place of Service
Other place of service not identified above.