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Medicare This Week: Private E/M Billing Reports, Two Free Calls on eRx and 5010, Revised Medicare Conditions of Participation

  • CMS to Start Accepting Suggestions for PQRS Measures and Measure Groups (jump to story)

  • New Rules Finalized by Health and Human Services to Cut Regulations for Hospitals and Health Care Providers  (jump to story)

  • Denise Buenning from CMS Answers the Industry’s Top Questions about the Version 5010 Upgrade (jump to story)

  • Last Chance to Register for National Provider Call – Physician Quality Reporting System & Electronic Prescribing (eRx) (jump to story)

  • CMS to Release a Comparative Billing Report on Evaluation and Management Services (jump to story)

  • May is Hepatitis Awareness Month and May 19 is National Hepatitis Testing Day (jump to story)

CMS to Start Accepting Suggestions For PQRS Measures and Measure Groups

From June 1st, 2012 to 5PM ET on August 1st, 2012, CMS will be accepting suggestions for Measures and/or Measure Groups in the Physicians Quality Reporting System. This is your chance to make your voice heard on the quality measures that will determine performance!

For more information on the PQRS Call for Measures, visit the CMS page here.

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New Rules Finalized by Health and Human Services to Cut Regulations for Hospitals and Health Care Provider

HHS Finalizes New Rules to Cut Regulations for Hospitals and Health Care Providers, Savings More Than $5 Billion

Changes Will Reduce Costs and Allow More Focus on Medical Care

On May 9, HHS Secretary Kathleen Sebelius announced significant steps to reduce unnecessary, obsolete, or burdensome regulations on American hospitals and health care providers. These steps will help achieve the key goal of President Obama’s regulatory reform initiative to reduce unnecessary burdens on business and save nearly $1.1 billion across the health care system in the first year and more than $5 billion over five years.

The new rules were issued on May 9 by CMS. The first rule revises the Medicare Conditions of Participation (CoPs) for hospitals and critical access hospitals (CAHs). CMS estimates that annual savings to hospitals and CAHs will be approximately $940 million per year.

The second, the Medicare Regulatory Reform rule, will produce savings of $200 million in the first year by promoting efficiency. This rule eliminates duplicative, overlapping, and outdated regulatory requirements for health care providers.

Among other changes, the final rules will:

  • Increase flexibility for hospitals by allowing one governing body to oversee multiple hospitals in a single health system;
  • Let CAHs partner with other providers so they can be more efficient and ensure the safe and timely delivery of care to their patients;
  • Require that all eligible candidates, including advanced practice registered nurses and physician assistants, be reviewed by medical staff for potential appointment to the hospital medical staff and then be granted all of the privileges, rights, and responsibilities accorded to appointed medical staff members; and
  • Eliminate obsolete regulations, including outmoded infection control instructions for ambulatory surgical centers; outdated Medicaid qualification standards for physical and occupational therapists; and duplicative requirements for governing bodies of organ procurement organizations.

View the Medicare CoPs final rule and the Medicare Regulatory Reform final rule. For additional information on the Hospital and other CoPs, visit the Conditions for Coverage (CfCs) & Conditions of Participations (CoPs) website.

Full text of this excerpted CMS press release (issued May 9).

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Denise Buenning from CMS Answers the Industry’s Top Questions about the Version 5010 Upgrade

Upgrading to Version 5010 involves significant planning and preparation. The Version 5010/4010A electronic standards upgrade deadline was January 1, 2012. However, CMS enacted an enforcement discretion period through June 30, 2012 for all HIPAA-covered entities. It you haven’t upgraded to Version 5010, it is important to begin testing now.

Denise Buenning, MsM, Acting Deputy Director, Office of E-health Standards & Services (OESS) recently took time to answer some of the industry’s top questions on the Version 5010 upgrade.

Is the industry up to date with the Version 5010 upgrade and taking steps to prepare for the ICD-10 transition?

Yes, we are hearing that the industry is progressing with Version 5010 implementation. We also continue to see from the Medicare Fee-For-service (FFS) group consistent increases across the board for 5010 transaction volumes and number of 5010 submitters. We are also hearing that the industry is continuing to take steps to prepare for ICD-10. ICD-10 is a major undertaking for providers, payers, and vendors. It will drive business and systems changes throughout the health care industry, from large national health plans to smaller provider offices, laboratories, hospitals, and more. The updates will go much more smoothly for organizations that plan ahead and prepare now. A successful upgrade to Version 5010 now and transition to ICD-10 later will be vital to transforming our nation’s health care system.

What steps should I take if I am behind in the upgrade to Version 5010?

There are a number of things that HIPAA-covered entities should do now. Communication among plans, providers, clearinghouses, and vendors, as well as other trading partners, is critical. Below outlines three steps providers can take now:

    • Reach out to clearinghouses for assistance and/or take advantage of any free or low cost software that may be available from payers.
    • Check with payers now to see what plans they will have in place to handle incoming claims, and what interim alternatives are available.
    • Consider contacting financial institutions to establish lines of credit to get through any possible temporary interruptions in claims reimbursement as a result of not being Version 5010 compliant.
    • CMS has developed a fact sheet for health care providers, which discusses the risk mitigation steps in more detail.

How is CMS helping the industry prepare?

o   The Workgroup for Electronic Data Interchange (WEDI) and CMS are holding a webinar on ASCX12 5010 implementation and problem solving on May 23 from 1-2:30pm ET. Registration is free. These online presentations are designed to gather feedback, track challenges and provide guidance to correcting ASC X12 5010 implementation-related issues.

o   WEDI and CMS previously held a webinar on ASCX12 5010 implementation, and a replay of the webinar with the slides presented is located online.

o   Additionally, the CMS website has official resources to help the industry prepare for Version 5010 and ICD-10. CMS will continue to add new tools and information to the site throughout the course of the transition. Sign up for ICD-10 Email Updates and follow @CMSgov on Twitter for the latest news and resources.

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Last Chance to Register for National Provider Call – Physician Quality Reporting System & Electronic Prescribing (eRx)

CMS will host a National Provider Call with question and answer session. CMS subject matter experts will provide an overview of the 2013 Electronic Prescribing Payment Adjustment and an overview of the 2012 Physician Quality Reporting System Medicare EHR Incentive Pilot.

Target Audience:  All Medicare Fee-For-Service Providers, Medical Coders, Physician Office Staff, Provider Billing Staff, Electronic Health Records Staff, and Vendors

Registration Information:  In order to receive call-in information, you must register for the call on the CMS Upcoming National Provider Calls webpage. Registration will close at 12pm on the day of the call or when available space has been filled; no exceptions will be made, so please register early.

Providers and suppliers can now submit their enrollment applications 30 days sooner. CMS-855 enrollment applications and Internet-based PECOS applications may now be submitted 60 days prior to the effective date.

NOTE: This does not apply to providers and suppliers submitting a Form CMS-855A application, Ambulatory Surgical Centers (ASCs), or Portable X-ray Suppliers (PXRSs).

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CMS to Release a Comparative Billing Report on Evaluation and Management Services

On June 4, CMS will release a national provider Comparative Billing Report (CBR) addressing Evaluation and Management Services.

CBRs produced by SafeGuard Services under contract with CMS, contain actual data-driven tables and graphs with an explanation of findings that compare provider’s billing and payment patterns to those of their peers located in the state and across the nation.

These reports are not available to anyone except the providers who receive them. To ensure privacy, CMS presents only summary billing information. No patient or case-specific data is included. These reports are an example of a tool that helps providers better understand applicable Medicare billing rules and improve the level of care they furnish to their Medicare patients. CMS has received feedback from a number of providers that this kind of data is very helpful to them and encouraged us to produce more CBRs and make them available to providers.

For more information and to review a sample of the Evaluation and Management Services CBR, please visit the CBR Services website  or call the SafeGuard Services’ Provider Help Desk, CBR Support Team at 530-896-7080.

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New and Revised Articles Posted to MLN Matters

Examining the Difference between a National Provider Identifier (NPI) and a Provider Transaction Access Number (PTAN) http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1216.pdf

Negative Pressure Wound Therapy Interpretive Guidelines

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1222.pdf

Assigned Codes for Home Oxygen Use for Cluster Headache (CH) in a Clinical Trial (ICD-10)

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7820.pdf

July 2012 Integrated Outpatient Code Editor (I/OCE) Specifications Version 13.2

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7841.pdf

July Quarterly Update for 2012 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7822.pdf

Calendar Year 2013 and After Payments to Home Health Agencies That Do Not Submit Required Quality Data

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7833.pdf

Revised: Reporting of Recoupment for Overpayment on the Remittance Advice (RA) with Patient Control Number

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7499.pdfs

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Updates from the Medicare Learning Network

From the MLN: New Fast Fact and Archive on MLN Provider Compliance Webpage – A new fast fact is now available on the MLN Provider Compliance webpage.  This webpage provides the latest Medicare Learning Network® (MLN) products designed to help Medicare Fee-For-Service providers understand – and avoid – common billing errors and other improper activities. You can now view previous fast facts on the MLN Provider Compliance Fast Fact Archive page. Please bookmark this page and check back often as a new fast fact is added each month.

From the MLN: “Negative Pressure Wound Therapy Interpretive Guidelines” MLN Matters® Article Released MLN Matters® Special Edition Article #SE1222, “Negative Pressure Wound Therapy Interpretive Guidelines” has been released and is now available in downloadable format. This article is designed to provide education on CMS-approved guidelines that accrediting organizations can use to accredit suppliers that provide Negative Pressure Wound Therapy (NPWT) equipment to Medicare beneficiaries.  It includes a list of relevant local coverage determinations and standards to help DMEPOS suppliers comply with standards and guidelines for NPWT equipment.

From the MLN:  “Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Quality Standards” Booklet Revised Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Quality Standards Booklet (ICN 905700) has been revised and is now available in downloadable and hard copy format. This booklet is designed to provide education on durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). It includes DMEPOS quality standards as well as information on Medicare deemed Accreditation Organizations (AOs) for DMEPOS suppliers.

From the MLN: “Quick Reference Information: Preventive Services” and “Quick Reference Information: Medicare Immunization Billing” Revised – The MLN has revised the recently updated Quick Reference Information: Preventive Services (ICN 006559) and Quick Reference Information: Medicare Immunization Billing (ICN 006799) educational tools.  We have updated these charts to include the recently released flu code Q2034.  All other information remains the same.

From the MLN: “Medicare Fraud & Abuse: Prevention, Detection, and Reporting” Web-Based Training — New – This Web-Based Training (WBT) course is designed to provide education on how to identify Medicare fraud and abuse and understand the related laws and penalties. It includes information on what entities and safeguards protect against and detect fraud and abuse, as well as how you can help prevent and report it. Continuing education credit is available for this course.  To access a new or revised WBT course, visit the MLN Products webpage and click on “Web-Based Training (WBT) Courses” under “Related Links” at the bottom of the webpage.

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May is Hepatitis Awareness Month and May 19 is National Hepatitis Testing Day

The month of May has been designated Hepatitis Awareness Month and May 19 is the first ever National Hepatitis Testing Day. Every year, approximately 15,000 Americans die from liver cancer or chronic liver disease associated with viral hepatitis. Despite this, viral hepatitis is not well known. In fact, as many as 75 percent of the millions of Americans with chronic viral hepatitis don’t know they’re infected. Please join CMS in support of the Centers for Disease Control and Prevention’s “Know More Hepatitis” national education initiative aimed to decrease the burden of chronic viral hepatitis by increasing awareness about this hidden epidemic and encouraging people who may be chronically infected to get tested.

Medicare provides coverage of the hepatitis B vaccine and its administration for certain individuals at high or intermediate risk.

Increased provider knowledge has been shown to improve delivery of preventive services, including those for viral hepatitis. By educating yourself on this hidden epidemic, you can help save lives and decrease this epidemic’s burden. As a healthcare provider for people with Medicare, discuss with eligible patients who may be at high or intermediate risk, whether the hepatitis B vaccine is appropriate.

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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.

The two primary steps to obtaining incentive payments are:

  1. Register for the EHR Incentive Program
  2. Attest to meeting all the incentive payment eligibility criteria

Let’s start with information on the two different incentive programs. Remember that an eligible professional (EP) is defined differently for Medicare than it is for Medicaid.

Step One: Are You Eligible for the EHR Incentive Programs?

Medicare Eligible Professionals:

  • Must be a physician (defined as MD, DO, DDM/DDS, optometrist, podiatrist, or chiropractor) – mid-levels do not qualify
  • Must have Pa rt B Medicare allowed charges
  • Must not be hospital-based which is defined as having 90% or more of their covered
    professional services in either an inpatient (POS 21) or emergency room (POS 23) of a hospital
  • Must be enrolled in PECOS
  • Must be living (Social Security records are examined)

Medicaid Eligible Professionals:

  • Must be a MD, DO, DDM/DDS or a Nurse Practitioner, a Certified Nurse Midwife, OR a Physician Assistant who is the lead provider for a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC).
  • Must either have 30% or more Medicaid patient volume (pediatricians must have 20% or more Medicaid patient volume) OR must practice predominantly in a FQHC or RHC
    with 30% or more needy individual patient volume. Needy is defined as patients who are Medicaid, Medicare, uninsured, under-insured, charity care and indigent care.
  • Must be licensed and credentialed
  • Must have no OIG exclusions
  • Must be living (Social Security records are examined)
  • Must not be hospital-based, which is defined as having 90% or more of their covered
    professional services in either an inpatient (POS 21) or emergency room (POS 23) of a hospital

Step Two: How much EHR Incentive Money is Available From the Two Programs?

Medicare Incentive Payments:

  • First eligible year for the program is 2011.
  • Incentive amounts are based on the EP’s Medicare Fee-for-Service allowable charges.
  • Maximum incentives are $44,000 over 5 years.
  • Incentives decrease if the EP does not start until after 2012.
  • EPs must begin using an EHR by 2014 to receive incentive payments.
  • Last payment year is 2016.
  • An extra 10% bonus amount based on actual payments from Medicare, not allowables, is available for EPs practicing predominantly in a Health Professional Shortage Area (HPSA). Go here to see if you practice in a HPSA.
  • EPs will receive only 1 incentive payment per year.

Medicaid Incentive Payments:

  • First eligible year for the program is 2011.
  • Maximum incentives are $63,750 over 6 years.
  • Incentives are the same regardless of the year started.
  • The first year’s payment is $21,250.
  • Must begin by 2016 to receive incentive payments.
  • No extra bonus for health professional shortage areas.
  • Incentives are available through 2021.
  • EPs will receive only 1 incentive payment per year.

How Do You Choose Which Program to Qualify For?

  1. First, determine which programs you can qualify for based on the type of eligible professional you are.
  2. Then, determine which programs you can qualify for based on your patient population.
  3. Next, review the requirements and potential payments and/or reductions for each program – get your calculator out!
    • Once an eligible professional has demonstrated meaningful use in the first participation year, they may receive an incentive payment equal to 75% of Medicare allowable charges for covered professional services furnished by the eligible professional in a payment year VERSUS Once an eligible professional has demonstrated adoption, implementation, upgrading, or meaningful use of certified EHR technology in the first participation year, they may receive an incentive payment of $21,250 from Medicaid. Remember the payments are for each provider. Don’t forget the 10% HPSA bonus if you participate in  the Medicare program.
    • Medicare requires EPs to escalate meaningful use participation and reporting and ultimately plans to impose payment reductions for EPs not engaged in using a certified EHR and implementing meaningful use. For Medicaid, each state has some leeway is defining the criteria for eligibility for incentives and there are no plans for payment reductions as a part of the program.
  4. If you not up to speed on meaningful use and want to collect incentive money for 2011, it will be easier to you to meet the requirements of the Medicaid program than the Medicare program, if you are eligible for the Medicaid program and there is one offered in your state.
  5. Remember that EPs can switch programs once after their first year in either program.

Getting Ready for the Registration Process

  1. Make sure you have your provider’s National Plan and Provider Enumeration System (NPPES) User ID and Password. If the provider does not know this information, s/he will have to call and get the information. The NPI, NPPES User ID and password are the basis for everything else. While you’re in that record, make sure all the provider’s information is correct and completely up-to-date. You’ll have an opportunity to update this information during the registration process, but it will not backfill the NPPES record.
  2. Make sure your provider’s enrollment record in the Provider Enrollment, Chain and Ownership System (PECOS). You can see if s/he has a record in PECOS here – scroll down this page to “OrderingReferringReport”. This is a 16,000+ page pdf file and as of this post it was updated June 27, 2011. (Note: Eligible professionals who are only participating in the Medicaid EHR Incentive Program are not required to be enrolled in PECOS.)
  3. If you do not have an active User ID and Password for NPPES or PECOS, request them via Identity & Access Management. You will need your type 2 NPI, your Taxpayer Identification Number (TIN), and your address from IRS Form CP-575. You will also need to mail a copy of IRS Form CP-575 as directed.
  4. Payee Tax Identification Number (if you are reassigning your benefits to a group or a hospital).
  5. Payee National Provider Identifier (NPI) if you are reassigning your benefits. Note that many independent physicians are reassigning their benefits to their practice and almost all hospital-sponsored physicians are reassigning their benefits to the hospital.

Step by Step Directions to Register for the Medicare/Medicaid EHR Incentive Programs

NOTE! You can register before you have a certified EHR. Register even if you do not have an enrollment record in PECOS which is required for all Medicare eligible professionals. If you plan to register for the Medicaid program, your state’s Medicaid program must be up and running. Check to see if your state has launched a Medicaid EHR Incentive Program here.

  1. Go to the registration site here. The Login page instructs the user on what is required for a valid User ID and Password combination.  EPs are required to have an active NPI and must have a National Plan and Provider Enumeration System (NPPES) user account to login. For users who do not have either of these requirements, click on the link provided to you in the program.
  2. A link to the Identity and Access Management System, I&A, is also provided. The I&A system allows EP users use to reset their passwords and edit their account information. Any additional login issues can be resolved by contacting the help desk (see info at the bottom of this post.) At the bottom of the page the user enters their User ID and Password combination.  Please keep in mind that both of the fields are case-sensitive.
  3. Once the user has logged into the system, the links and tabs displayed in the top right hand corner are shown on every page.
    • The Home hyperlink navigates the user to the Welcome page.
    • The Help hyperlink opens a PDF User Manual that assists the user throughout the Registration process.
    • If at anytime you wish to logout of the system, click the Log Out link and select yes in the pop-up window.
    • The Instructions section on the Welcome page describes the actions that can be performed under each of the tabs.  The EP submits and maintains their registration under the Registration tab and completes their Attestation under the Attestation tab.
    • The Status Tab provides a snapshot of the user’s current standing in the EHR Incentive Program. This includes the status of their registration and any attestations and payments associated with their account.
    • The Account Management tab allows the user to proceed to the I&A system in order to change their account information.
    • Clicking the Registration tab will reveal a set of instructions about the actions that can be performed. These options will differ depending on the status of the registration.
  4. The EP’s name, social security number, and NPI are retrieved from their NPPES account.  If they have not started their registration, the status will be blank and Register will be the only available action.
  5. Select the Register link to begin.
  6. The Registration ID is displayed on the “Topics for this Registration” page. Write this number down for tracking purposes.
  7. There are three topics that an Eligible Professional must complete before submitting their Registration.  They are EHR Incentive Program, Personal Information, and Business Address and Phone. The “Begin Submission” button cannot be selected until all of the topics are complete.  Select the “Start Registration” button to navigate to the first topic.
  8. On the EHR Incentive Program page, EPs are given the option to receive either a Medicare or Medicaid EHR Incentive Payment.  For additional information about the two EHR Incentive Programs select the link that is provided. By selecting the Medicare option and clicking the “Apply” button, the EP type field page cursor moves across screen to highlight information. Provider Types that are eligible in the Medicare EHR Incentive Program are displayed in the dropdown. Selecting the Medicaid option and then the “Apply” button refreshes the page with two fields, Medicaid State/Territory and Eligible Professional Type. Only those states and territories participating in the Medicaid EHR Incentive Program are displayed in the Medicaid State/Territory dropdown. Provider types that are eligible for the Medicaid EHR Incentive Program are displayed in the dropdown.
  9. Two additional links on the EHR Incentive Program page provide the user with information on certified EHRs and the EHR Certification Number. The Eligible
    Professional is required to indicate whether they are currently using a certified EHR.
    A provider’s EHR system is not required to be certified prior to registration; however, an EHR Certification Number will be required at the time of attestation. See the Certified Health IT Product List (CHPL) for a listing of “certified” EHR products and to identify a product’s corresponding certification number.Select the “Save and Continue”
    button to navigate to the next topic.
  10. The Name and Identifiers displayed on the Personal Information page are retrieved from the user’s NPI record on the NPPES system. These fields cannot be modified in the EHR Incentive Program System. The Payee TIN Type field provides the user with two options in terms of who receives the EHR Incentive Payments.  If the payments should be sent directly to the Eligible Professional, the SSN tab should be selected in the Payee TIN Type field. If the payments should be sent to a group associated with the Eligible Professional, the user should select E-I-N in the Payee TIN Type field and then select the “Apply” button. After the page is refreshed, three additional fields are displayed.
  11. The next step is to select the Group that should receive the payments.  A Group Name will only appear in the dropdown if the EP’s Medicare enrollment in the Provider Enrollment, Chain, and Ownership System, or PECOS, has reassigned benefits to the Group. After the Group Name is selected, the Group’s TIN is retrieved from PECOS and displayed in the Payee TIN field.  It is also required that the user enters the NPI associated with the Group in the Payee NPI field. If the user had selected to register for the Medicaid EHR Incentive Program, the system requires the user to manually enter the Group Name, Payee TIN, and Payee NPI. A dropdown list of Group Names would not be provided. Select the “Save and Continue” button to navigate to the next topic.
  12. The address and phone number displayed on the Business Address and Phone page is consistent with the Practice Location on the Eligible Professional’s NPI record. Unlike the Personal Information page, the address and phone number fields can be modified here. However, if changes are made to the address and phone number in the EHR Incentive Program System, the changes will not be reflected on the Eligible Professional’s NPI record.  E-mail Address is also a required field and must be entered with the correct email address format. Select the “Save and Continue” button to complete the last topic.
  13. Once the user has entered the required registration information, all three of the topics are marked as completed.  To initiate the submission process, select the “Begin Submission” button.
  14. The Verify Registration page displays a summary of the registration information.  It displays Personal Information, Business Address, as well as the Incentive Program that was chosen for this registration. The “Reason for Submission” section describes the action that the user is currently performing on the registration. If any of the information on this page is incorrect, the user should select the “Previous Page” button and make the appropriate modification.
  15. After verifying that all of the information is correct, please select the “Submit” button to proceed. Before the registration can be submitted, the user must review and agree to the Registration Disclaimer.  Agreeing to the legal notice means that the EP is certifying that the information provided in the registration is true and accurate.  Please take the time to review each line of the disclaimer.  Select the “Agree” button to proceed.
  16. If the registration passes all validations, the submission will be successful. Please keep in mind that things like a non-approved Medicare enrollment in PECOS or OIG Exclusions can result in registration failure. Contact the help desk
    to resolve any of these issues.
  17. The Submission Receipt page reminds users that they will not receive an e-mail confirmation and that attestation information must be submitted in order to qualify for an incentive payment. Print the Submission Receipt page by selecting the “Print” button at the bottom of the page.  Select the “Return to Home” button to proceed.
  18. A registration must be Active in order to proceed with Attestation and Payment.  If any changes need to be made to the registration, the user would select the Modify link and navigate back to the topics page.  The registration can also be cancelled, which would end the Eligible Professional’s participation in the EHR Incentive Program.
  19. Selecting the Status tab navigates the user to the Status Summary page.  The Select link navigates to the Status Detail page which displays all of the registration information in one location. The Additional Information link expands to display more registration information and the status of validations that are performed during submission.

Q & A from the listeners (always the best part!)

Q: Do you have to have paid for an EHR to receive the money? Can you use a Free EHR and still receive the incentive money?

A: Yes, you can use a free EHR and still receive the incentive money. The incentive money is to assist EPs implement EHRs and is not intended to be used only to purchase the software. Remember that the EHR must be certified by one of the certifying bodies and must be certified for ambulatory care.

Q: Is there a certain amount of time after registering that an EP must attest for Medicaid?

A: Once an EP registers, there is no deadline for attesting. Once an EP has attested, payment will be received in 45 days or less.

Q: Is the denominator for the meaningful use measures all patients that an EP sees, or just all Medicare or Medicaid patients seen during a specific period?

A: The denominator is all patients that the EP sees during the applicable period.

Q: Are radiologists eligible?

A: Yes. The radiologist must use a certified ambulatory care EHR. There is no guideline as to where the information going into the EMR comes from, with the exception of the CPOE measure. Many radiologists have expressed concerns as they do not actually “see” patients – CMS will be addressing this in the future.

Q: Where does the certification number needed for the EHR Incentive Program registration come from?

A: The certification number comes from the CHPL website. Get the EHR Vendor’s certification number, enter that number into the CHPL site and a registration/attestation number will be provided from the CHPL program to enter into the registration/certification program.

nursing home visits

Q: Is attestation the last step after completing the 90-day reporting period and collecting the data for the Medicare meaningful use program?

A: Yes.

Q: Do visits count if an EP sees patients in nursing homes?

A. Nursing home visits can count if a certified ambulatory EHR is being used, for instance if the EP carries a laptop with him, or if the visit information is later entered into the EP’s EHR.

Q: Can an administrator or other third party complete the registration and attestation?

A: Yes, if the third party goes through the Identity and Authority Management system, they can register and attest. The system will ask for the third party’s social security number as they will be legally attesting to the information entered.

Q: What is the latest 90-day period an EP can use a certified EHR to receive an incentive payment for 2011?

A: October 1, 2011 – December 31, 2011 is the latest 90-day period. EPs must start using a certified EHR by October 1, 2011 and must demonstrate meaningful use by providing data via the attestation process before 60 days after the close of the 2011 calendar year.

Q: What if due to the EP’s specialty none of the meaningful use measures can be met?

A: The EP must exhaust all core, alternate and menu measures by answering “0”, exhausting all 38 of the measures by attesting “0” to all 38.

Q: If state does not accept any electronic submission of public health information, is the EP excluded from having to meet this requirement?

A: Yes.

Resources:

EHR Information Center

Hours of Operation: 7:30 a.m. – 6:30 p.m. (Central Time)
Monday through Friday, except federal holidays.
1-888-734-6433 (primary number) or 888-734-6563 (TTY number)

 

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How Do You Get That Stimulus Money for Using an Electronic Medical Record? (You Register!)

20 Dollars art2

Image via Wikipedia

Note: see my latest post on registering and attesting for the EHR Incentive Program here.

Registration opens on January 3, 2011 for the Medicare and Medicaid EHR Incentive Programs

  1. Register as soon as possible after January 3, 2011.
  2. You can register before you have a certified EHR, but you will have to have an EHR when you attest.
  3. You can register even if you do not have an enrollment record in PECOS.
  4. A link to the Incentive Registration will be available here when it is published.
  5. Not all states will be ready to participate in the Medicaid program on January 3rd.  Information by state is here.

What do you have to have to register?

  1. A National Provider Identifier (NPI) All eligible professionals, eligible hospitals, and critical access hospitals (CAHs) must have a National Provider Identifier (NPI) to participate in the Medicare and Medicaid EHR Incentive Programs.
  2. An enrollment record in the Provider Enrollment, Chain and Ownership System (PECOS) All eligible hospitals and Medicare eligible professionals must have an enrollment record in PECOS to participate in the EHR Incentive Programs. Eligible professionals who are only participating in the Medicaid EHR Incentive Program are not required to be enrolled in PECOS. If you do not have an enrollment record in PECOS, you should still register for the Medicare and Medicaid EHR Incentive Programs.
  3. CMS Identity and Access Management (I&A) User ID and Password
    • Eligible Professionals: Eligible professionals can use the same User ID and Password they use for the National Plan and Provider Enumeration System (NPPES). This is also the same User ID and Password that is used to access PECOS.  If you do not have an active User ID and Password for NPPES or PECOS, request them here. You will need your type 2 NPI, your Taxpayer Identification Number (TIN), and your address from IRS Form CP-575. You will also need to mail a copy of IRS Form CP-575 as directed.
    • Hospitals/Critical Access Hospitals: Authorized Officials can use the same User ID and Password they use to access PECOS.  If you do not have an Authorized Official with access to PECOS, request a User ID and Password here. You will need your type 2 NPI, your Taxpayer Identification Number (TIN), and your address from the IRS Form CP-575. You will need to mail a copy of the IRS Form CP-575 as directed.  Additional hospital staff will need to request access to the “EHR Incentive Programs” application here and be approved by the Hospital’s Authorized Official.

What else do you need to know about registration?

Hospitals:

  1. Hospitals that are eligible for EHR incentive payments under both Medicare and Medicaid should select “Both Medicare and Medicaid” during the registration process, even if they plan to apply only for a Medicaid EHR incentive payment by adopting, implementing, or upgrading certified EHR technology. Dually-eligible hospitals can then attest through CMS for their Medicare EHR incentive payment at a later date, if they so desire. It is important for a dually-eligible hospital to select “Both Medicare and Medicaid” from the start of registration in order to maintain this option.
  2. Hospitals that register only for the Medicaid program (or only the Medicare program) will not be able to manually change their registration (i.e., change to “Both Medicare and Medicaid” or from one program to the other) after a payment is initiated and this may cause significant delays in receiving a Medicare EHR incentive payment.

Eligible Professionals:

  1. Eligible professionals eligible for both the Medicare and Medicaid EHR Incentive Programs must choose which incentive program they wish to participate in when they register.
  2. Before 2015, an eligible professional may switch programs only once after the first incentive payment is initiated. Most eligible professionals will maximize their incentive payments by participating in the Medicaid EHR Incentive Program.

The Electronic Health Record (EHR) Information Center is open to assist the EHR Provider Community with inquiries.

Hours of operation are:
8:30 a.m. ”“ 4:30 p.m. (Central Time) Monday through Friday (except federal holidays)
1-888-734-6433 (primary number) or 888-734-6563 (TTY number)

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When, If Ever, Do You Get a New NPI Number and Other NPI Questions

Questions

Image by Oberazzi via Flickr

What is a NPI again?

The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions.

As outlined in the Federal Regulation, The Health Insurance Portability and Accountability Act of 1996 (HIPAA), covered providers must also share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes.

When should you get a new NPI?

The National Provider Identifier (NPI) is meant to be a lasting identifier, and is expected to remain unchanged even if a health care provider changes his or her name, address, provider taxonomy, or other information that was furnished as part of the original NPI application process. There are some situations, however, in which an NPI may change such as when health care provider organizations determine they may need a new NPI due to, for example, certain changes of ownership, the conditions of a purchase, or a new owner’s subpart strategies. There also may be situations where a new NPI is necessary because the current NPI was used for fraudulent purposes.

A health care provider (or the trustee/legal representative of a health care provider) should deactivate its NPI in certain situations, such as retirement or death of an individual, disbandment of an organization, or fraudulent use of the NPI. To deactivate an NPI, a health care provider (or the trustee/legal representative of a health care provider) must complete a CMS-10114 and mail it to the NPI Enumerator.

Does the NPI replace the tax ID number?

The billing provider’s tax ID number and NPI are always required on claims. Any other providers identified on the claim, such as rendering provider or service facility, must be identified with their NPI only. Their tax ID number should not be included.

For eligibility, claim status inquiry, referral and precertification, only the NPI (no tax ID number) is used.

How does a rendering physician report their National Provider Identifier (NPI) on a claim that includes Physician Quality Reporting Initiative (PQRI) or Electronic Prescribing Incentive Program (eRx) quality-data codes (QDCs)? What if he/she is part of a group and the group NPI is used on the claim?

Your individual National Provider Identifier (NPI) must be included on the claim line items for the quality-data codes (QDCs) you submit as well as the line items for the services to which the QDC is applicable. The PQRI/eRx QDC must be included on the same claim that is submitted for payment at the time the claim is initially submitted in order to be included in PQRI analysis.

If a group NPI is used at the claim level, the individual rendering physician’s NPI must be placed on each line item, including all allowed-charge and quality-data line items. See the PQRI Implementation Guide for a sample CMS-1500 claim. This is available as a download from the Measures/Codes section of the CMS PQRI website. For eRx, see the Claims-Based Reporting Principles for eRx, available on the CMS eRx website.

If a health care provider with a National Provider Identifier (NPI) moves to a new location, must the health care provider notify the National Plan and Provider Enumeration System (NPPES) of its new address?

Yes.  A covered health care provider must notify the NPPES of the address change within 30 days of the effective date of the change. We encourage health care providers who have been assigned NPIs, but who are not covered entities, to do the same. A health care provider may submit the change to NPPES via the web or by paper. If paper is preferred, the health care provider may download the NPI Application/Update Form (CMS-10114) from the Centers for Medicare & Medicaid Services’ forms page or may call the NPI Enumerator (1-800-465-3203) and request a form.

What happens when you join a group?

In Section 4B of the CMS-855I, the NPI of the Group should be entered if it has been issued to the Group. If you are joining a group, the group is responsible for providing you with their current Provider Identification Number (PIN) and the NPI, if they have been issued.

If you are a solo physician with an incorporated practice, how many NPIs should you have?

An individual is eligible for only one NPI. In the above example, there are two health care providers: the physician and the corporation. The physician would obtain an NPI (Entity Type Code 1, Individual). The corporation would obtain an NPI (Entity Type Code 2, Organization). Generally, the corporation’s NPI would represent the Billing and Pay-to Providers and the physician’s NPI would represent the Rendering, Referring/Ordering, Attending, Operating and/or Other Providers. These physicians should ensure that their enrollment records with the health plans to whom they will be sending claims are up to date, that those health plans are aware of the assigned NPIs, and that the NPIs are used in a way that is compatible with their enrollment.

I do not submit healthcare claims to Medicare; do I need a National Provider Identifier (NPI)?

Yes. NPIs are required by the NPI Final Rule to be used to identify health care providers in HIPAA standard transactions (including claims) that are conducted with any health plan, not just with Medicare. So even if you do not submit claims to Medicare, but submit HIPAA standard claims transactions to some other health plan, you are required to use an NPI in those transactions, and should be doing so as of May 23, 2007. Additionally, many health plans are requiring that providers use NPIs on paper claims. Providers should check with any health plan with whom they conduct business to determine their policy on the use of the NPI for paper claims.
*Questions and Answers excerpted from the CMS website.

Where can you look up NPIs?

https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do
http://nynpi.com/
http://www.npinumberlookup.org/
http://www.npinumberlookup.org
http://www.npivalidator.com/
http://npidb.org/
http://www.hmedata.com/npi.asp
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Providers Without a PECOS Record Will Receive a Letter From Their Medicare Administrative Contractor (MAC)

Note: MLN Matters published this link on June 9th that was inadvertently left out of the June 8th notice: http://www.cms.gov/MLNMattersArticles/downloads/MM6842.pdf

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On May 28, 2010, CMS in Change Request 6842 notified Medicare Part A & B Administrative Contractors (A/B MACs) of their responsibility to facilitate a “One-Time Mailing” to all physicians and non-physicians who are currently enrolled in Medicare but who do not have an enrollment record in PECOS.

Centers for Medicare and Medicaid Services (Me...

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This mailing is to take place no later than 30 days after the date of the issuance (May 28th), therefore no later than June 28, 2010, leaving only six business days before the July 6 date for PECOS enrollment.

Additionally, the Change Request states:

A provider education article related to this instruction will be available at http://www.cms.hhs.gov/MLNMattersArticles/ shortly after this CR is released.  You will receive notification of the article release via the established “MLN Matters” listserv.  Contractors shall post this article, or a direct link to this article, on their Web site and include information about it in a listserv message within one week of the availability of the provider education article.  In addition, the provider education article shall be included in your next regularly scheduled bulletin.  Contractors are free to supplement MLN Matters articles with localized information that would benefit their provider community in maintaining Medicare provider enrollment data correctly.

As of Tuesday evening when I posted this article, the MLN Matters article referred to had not been published.

Interestingly, there is no mention of the July 6, 2010 date that is the so-called compliance date for all providers to have an enrollment record in PECOS.  As of the last CMS open door forum (my notes here) there was a lack of clarity surrounding the July 6, 2010 date versus the original January 1, 2011 date. The speaker would not definitively say that providers without a PECOS enrollment record as of July 6, 2010 would not receive Medicare payments.  Given the short time frame between the MAC letters and the July 6 date, one would assume providers will have a grace period before CMS shuts off reimbursement for services rendered and/or refuses stimulus money for meaningful use of an EMR.

More information on the Stimulus Money here:

FAQ on HITECH, Meaningful Use, Eligible Providers, and the Stimulus Money

ARRA Eligible Providers: Who Is Eligible to Receive Stimulus Money and How Much is Available Per Provider?

If you are not enrolled in PECOS,

this is what your letter will look like:


[DATE]

[Physician/Non-Physician Practitioner Name and Correspondence Address]

Dear Physician/Non-Physician Practitioner:

Our records indicate that you do not have an enrollment record in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) because you enrolled in Medicare prior to the implementation of PECOS and you have not submitted any updates to your Medicare enrollment information in the past 6 (or more) years.  PECOS is the enrollment system for Medicare providers and suppliers.

There are three important reasons why you should take the necessary action to establish an enrollment record in PECOS as soon as possible.  First, updating your Medicare enrollment record will assist us in ensuring payment accuracy for the services you furnish to Medicare beneficiaries.  Second, you will need an approved enrollment record in PECOS to continue to order or refer items or services for Medicare beneficiaries.  Finally, in accordance with the American Recovery and Reinvestment Act of 2009, Title XIII, known as the “HITECH Act,” incentive payments may be made by Medicare and Medicaid to enrolled “eligible professionals” and certain hospitals that meet the HITECH requirements.  More information on Medicare HITECH incentive payments can be found at http://www.cms.hhs.gov/Recovery/11_HealthIT.asp under “Related Links Outside CMS” on the CMS web site.  The Centers for Medicare & Medicaid Services (CMS) will use the PECOS enrollment records to verify Medicare enrollment for HITECH incentive payments.  Therefore, you will not be eligible to receive incentive payments from Medicare for meaningful use of certified electronic health records if your enrollment information is not maintained in PECOS by CMS.

Since you do not have a current Medicare enrollment record, it is imperative that you immediately begin the process to establish your enrollment record in PECOS.  CMS expects you to do this as soon as possible after receiving this letter.  If you have already submitted an enrollment application within the last 60 days, and your enrollment application has been accepted for processing by the carrier or A/B MAC, you need not take any additional actions based on this letter.

You can submit your enrollment application in one of two ways:

(1) Use Internet-based PECOS

”¢ Step 1.  Before you begin, be sure you have a National Provider Identifier (NPI) and have created a User ID and password in the National Plan and Provider Enumeration System (NPPES).  You will need the NPPES User ID and password in order to access Internet-based PECOS.  If you need help creating an NPPES User ID and password, or if you are not sure you ever created them or cannot remember what they are, you may contact the NPI Enumerator for assistance at 1-800-465-3203.

”¢ Step 2.  Read the documents that are available about Internet-based PECOS on the CMS Provider/Supplier Enrollment web page www.cms.hhs.gov/MedicareProviderSupEnroll/

”¢ Step 3.  Once you have completed and submitted your enrollment application using Internet-based PECOS, be sure to print the Certification Statement, sign and date it, and mail it, along with any required supporting documentation, to the carrier or A/B MAC whose name and mailing address will be displayed to you by the system.

Note:  If you reassign some or all of your Medicare benefits to a group practice, there will be two Certification Statements to print, sign and date, and one of them will also need to be signed and dated by an Authorized Official of the group practice.  The carrier or A/B MAC cannot process your web-submitted enrollment application without having the signed and dated Certification Statement(s) in hand.

(2) Complete the paper Medicare enrollment application (CMS-855I) as an initial application.

”¢ Step 1.  Complete the CMS-855I (if you reassign benefits to a clinic or group practice other than your own, complete a CMS-855R as well), sign and date (blue ink recommended) and mail the application(s), along with any required additional supporting documentation, to the Medicare carrier or A/B MAC.  These forms are downloadable from the CMS Provider/Supplier Enrollment web page (shown above) or the CMS forms page www.cms.hhs.gov/cmsforms or you may request the necessary forms from the carrier or A/B MAC.

”¢ Step 2.  Once the paper application has been received by the carrier or A/B MAC, the carrier or A/B MAC will begin to process your enrollment application.  If additional information is needed by the carrier or A/B MAC to complete the processing of your enrollment application, they will contact you.

You are strongly urged not to delay in establishing your Medicare enrollment record within PECOS, especially if you plan on applying for incentive payments under the HITECH program. The carriers and A/B MACs are expected to process your enrollment application within 60 days as long as you submit your enrollment application before September 1, 2010.

If you need information about Medicare enrollment or how to use Internet-based PECOS, visit the
CMS Provider/Supplier Enrollment web page at: www.cms.hhs.gov/MedicareProviderSupEnroll/

If you need assistance with your NPPES User ID and password, contact the NPI Enumerator at 1-800-465-3203.

If you have questions about this letter, contact [carrier or A/B MAC phone number/contact person].

Sincerely,

[Name of carrier or A/B MAC]




My Notes from the CMS Open Door Forum on May 19, 2010: PECOS, DMEPOS and Blue Ink on Paper Forms

CMS held a two-hour Open Door Forum today and there was so much good information shared that I thought I’d pass my notes from the call along to you.

New EFT Form

The revised EFT (Electronic Funds Transfer) authorization form 588 is available here (pdf.) The old form will still work for a few months longer before it becomes invalid.

Changes to the Medicare Program Integrity Manual

The Program Integrity Manual (publication 100-08) will have revisions related to the changes in provider enrollment.  The online-only manual here will have content moved from Chapter 10 to Chapter 15 and the provider enrollment information will be easier to understand. 🙂

The Question on Everyone’s Lips

How do I know if I’m listed in PECOS (Provider Enrollment and Chain/Ownership System) and how do I know if others are listed in PECOS?  A new downloadable file is now available here (12,000 pages!) and everyone listed in this Ordering/Referring file has approved enrollment status.  Anyone not appearing on this list is not in approved status, or has opted completely out of the Medicare program.

Advanced Diagnostic Imaging

Beginning in January 2012, all diagnostic magnetic resonance imaging (MRI), computed tomography (CT), and nuclear medicine imaging such as positron emission tomography (PET) must be performed in a facility accredited by the American College of Radiology (ACR), The Joint Commission (TJC) or the Intersocietal Accreditation Commission (IAC) for the technical component of the test to be reimbursed by Medicare.  This rule does not apply to x-rays, ultrasound, fluoroscopy, mammography or DEXA scans and does not apply to any professional component.

Hospital Revalidations

Hospitals not enrolled in PECOS or not receiving EFT (Electronic Funds Transfer) will be contacted by CMS in an attempt to get all hospitals revalidated.

PECOS (pronounced “pay-cose”)

CMS recommends that anyone with questions or just getting started in PECOS read the “Getting Started Guide”, of which there are two versions, both available here in pdf form.  One is for providers and one is for suppliers of DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies.) You need to know your corporate structure before getting started because the business must enroll before the providers can assign benefits to the business.  The 855I is for individual/solos providers and the 855B is for non-individuals (multiple owners) billing Medicare Part B and assigning benefits to a legal entity/corporation.  Dentists and pediatricians who order or refer services for Medicare patients are required to have an enrollment record in the PECOS. Residents and interns are exempt from the enrollment requirement, but an attending physician needs to be identified on the claim when a service is ordered or referred. The main page for enrollment is https://www.cms.gov/MedicareProviderSupEnroll/

Two Ways to Get Into PECOS

One is to complete the paper form in BLUE INK (and if time is of the essence CMS suggests that you use the paper form) and let the MAC enter it into PECOS for you.  The other is to use the internet-PECOS system directly, and sign, date and mail the certification statement to complete the process.  Submit the participation form or EFT form if required.  The certification form for the paper process is NOT the same as the certification from for the internet-PECOS process.

What is the 30-day rule?

The 30-day rule states that you can bill for services provided to Medicare patients up to 30 days prior to your filing date.  The filing date is the date your enrollment is accepted, not the date you mailed it.  Online it will say “Status Approved”, and you will receive an email, and then a letter confirming it. You will appear on the Ordering/Referring file on the CMS website.

What happens to payments for patients that were referred by a provider not enrolled on PECOS?

Even though you are enrolled, if the referring physician is not enrolled, you will not be paid for that patient’s services.  However, if that referrer becomes enrolled, you can resubmit the claim and it will be paid.

What happens on July 6, 2010? When does this happen?

July 6, 2010 The compliance date for Part A providers (hospitals, skilled nursing homes and home health agencies) and Part B providers (physicians, ambulance) must be enrolled in PECOS as ordering/referring physicians for payments to be made has been delayed indefinitely!

What happens on July 13, 2010?

DMEPOS (pronounced “demmy-pos”) providers must be enrolled in PECOS to receive Medicare payments.

What should be done if a provider leaves a group?

The provider or his Authorized Official (CEO, CFO, Manager) should file a 855R or make the change in PECOS as soon as possible.

Why do provider offices still request UPINs from our office?

Unclear.  UPINs were no longer required as of May 23, 2008.  The NPI is the only number accepted on Medicare claims.

Should the information submitted on a 855 be the same information in PECOS?

Yes, if it isn’t, contact the Help Desk.  Their toll-free number is 1-866-484-8049 and their e-mail address is eussupport@cgi.com.

For more information on the nuts and bolts of PECOS, see my post here.




What Health Care Providers Need To Know About Medicare and the RAC

Carla Hannibal

By Carla Hannibal, CMM,CPM,CIMBS

Recovery Audit Contractors (RACs) will pursue corrections of Medicare claims by auditing for overpayments and underpayments under Part A or B of the title XVIII of the Social Security Act.  Health care providers will be affected as Medicare has recently contracted with RACs for 2009 and beyond.  RACs will audit every United States and Peurto Rico health care provider who files with Medicare.  The audit and recovery plan is expected to be in place by 2010 in all 50 states and Puerto Rico on a permanent basis. Based on findings, if compliance with Medicare billing rules is not up to standard, penalties may be assessed including fines and in severe cases, the loss of Medicare billing privileges.

What should providers do?
Health care providers would be wise to ensure their offices are in compliance because Medicare will not provide any specific guidance to the physician or provider of care outside of basic written guidelines.  RAC contracts fees are contingency-based which means they will have every incentive to find errors.  It should be noted that each RAC’s contingency fee is established during contract negotiations with CMS and varies for each RAC.

Region A: 12.45%
Region B: 12.50%
Region C: 9.00%
Region D: 9.49%

For practices, internal changes need to be established to monitor documentation and coding for compliance as well as establishing a framework to track RAC requests.  These are not new requirements to providers.  The provider application and contract clearly states that it is the sole responsibility of the Physician to follow all documentation rules and regulations, coding and billing rules 100% of the time.  Offices setting up compliance guidelines should appoint someone who will be responsible for monitoring compliance within the practice.

Is there a limit to what records RACs will audit?

Yes there is a medical records limit, established by NPI, of records the RAC will audit.

Ӣ Solo Practitioner
Limit = 10 medical records/45 days

Ӣ Partnership of 2-5 individuals
Limit = 20 medical records/45 days

Ӣ Group of 6-15 individuals
Limit = 30 medical records/45 days

Ӣ Large Group (16+ individuals)
Limit = 50 medical records/45 days

What are the RACs focusing on?

Under the program, RACs will focus on CMS-established payment criteria and will consist of both automated claims history reviews from the CMS database as well as complex clinical reviews of patient medical records.   Specific areas of concentration include “not medically necessary services” (or those not meeting the established CMS clinical payment criteria), non-covered services, incorrectly coded claims, duplicate services and incorrect payment amounts.

What is involved in the RAC claims audit process?

The Process consists of six phases.

I.     Data Screening & Claim Selection

II.    Medical Record Request

III.  Record Review and Status Determination

IV.  Post Review Notification

V.    Overpayment Recoupment

VI.   Post Determination- Other Provider Options and Data Tracking

Does the RAC program cover Medicare Replacement policies?

No the RAC program does not detect or correct payments for Medicare Advantage or the Medicare prescription drug benefit.

What happens after a RAC audit?

In those cases of overpayments, the physicians may choose to send a rebuttal of the findings directly to the RAC within 15 days of receiving the RAC’s letter identifying an overpayment.  However this does not stop the clock on the 120-day time period during which you can request a redetermination (first level appeal) from your Medicare contractor or on the interest accrued when money is not refunded to CMS within 30 days of request.  If the RAC discovers that an underpayment has been made to the provider then the RAC will inform the carrier or intermediary who will proceed with the claim adjustment and payment to the provider.

When does all this begin?

Implementation will take place on a rolling basis in 3 phases which began 10/1/08.  The schedule for the program rollout can be found here.


Will your practice be ready?


Carla Hannibal, CMM, CPM, CIMBS is President of Hannibal Professional Services, LLC (HPS).  HPS is a practice management company that provides services for small to medium-sized physician groups.  Carla is a writer, speaker, trainer and highly skilled manager with 27 years of clinical and administrative experience in the healthcare industry.  Her experience in the healthcare industry ranges from claims processing to practice management.  If you need more information on RAC, or help in implementing a compliance process in your practice, Carla can be reached at 623- 204-8992.




Monday Special: Interview with NPIdentify’s Marti Jensen

Note: Here is an updated (October 2010) list where you can find NPIs.


https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do
http://nynpi.com/
http://www.npinumberlookup.org/
http://www.npinumberlookup.org
http://www.npivalidator.com/
http://npidb.org/
http://www.hmedata.com/npi.asp
Also, click here for more answers about NPIs.

———————————————————————

UPDATE on July 4, 2009: I’ve been having problems with the links in this article and I’ve found that the HITTG website has vanished!  I’ve not been able to find out where it went.  If anyone has any information, please let me know.

Until recently you could download one directory during every update cycle completely free of charge.

I wish we could keep doing that, but here’s what happened:

  • Literally hundreds of downloads were being taken “against the rules,” that is, people were creating multiple accounts and downloading multiple states every month. That cost us serious bandwidth problems, and slowed down our site for everyone. Eventually, it crashed our site, broke some stuff, and threw us offline for quite awhile.
  • We put about 45 hours of work each month into processing the data, turning it into software, and uploading it so you can access it. Unfortunately, so few people were buying our non-free products that we were frankly losing money.

Those two things, taken together, meant that if we were going to keep doing NPIdentify Desktop — the best NPI directory on the planet — we would have to start charging a little bit for it, both to prevent the download avalanche, and to hopefully at least break even.

We’re truly sorry! But the good news is that we’ve reduced the price, so for those of you that have been paying for multiple states, now you’ll be paying far less! For those who were, well, shall we say “fibbing,” you’ll be paying a little bit more. It’s still the best NPI directory out there, and it’s still the least expensive, with all of the others running at least $39 per state!

Here’s my original article:

I had the pleasure of interviewing Marti Jensen of HITTG Consulting recently.  Marti was kind enough to answer lots of questions about himself, the company, and their new product NPIdentify.


As most of you know, the transition to requiring NPIs on claims last year was one of the more chaotic and troublesome times for medical practices in recent memory.  To lay the foundation for understanding the NPI (National Provider Identifier), and what NPIdentify does, here’s what the 2006 CMS NPI Fact Sheet states:

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires the adoption of a standard unique identifier for health care providers. The NPI Final Rule issued January 23, 2004 adopted the NPI as this standard.

Describing the NPI, the fact sheet goes on to say:
The NPI is a 10-digit, intelligence free numeric identifier (10 digit number). Intelligence free means that the numbers do not carry information about health care providers, such as the state in which they practice or their provider type or specialization. The provider’s NPI will not change and will remain with the provider regardless of job or location changes.

Marti Jensen is HITTG’s Chief Operating Officer and has an impressive list of accomplishments.  Marti describes himself as a “student of the Internet,” and his group as one that takes resources and makes them more accessible to users.  In the case of NPIdentify, users are typically physician offices, billers and billing companies, software vendors and healthplans.  Creating this product, Marti explained that CMS provides the NPI information for free, so HITTG’s job was to fashion the information into a database that is easy to search.  This is especially helpful as the entire CMS file cannot be imported into Excel due to its size.
NPIdentify not only provides NPIs, it also provides UPINs and:
  • Provider name, including AKA
  • Type of provider (organization, male, female)
  • Practice location address
  • Mailing address
  • Zip code, 3, 5 or 9 digits
  • State License Code and licensing state
  • Taxonomy Code (the 9-digit numbers assigned under the HIPAA provisions to health care providers, to digitally encode their specialty in order to facilitate electronic billing) and specialty/subspecialty description
  • Other Identifiers, including:
    • Medicare NSC (National Supplier Clearinghouse for DME)
    • Medicare PIN
    • Other Medicare IDs
    • Medicaid Number
  • Date provider updated the information
Marti’s group HITTG (Healthcare IT Transition Group, Inc.) describes itself like this:
HITTG was originally formed in 1993 as Computer Quality Associates, Inc., and, from its first day, worked almost exclusively in healthcare information technology. Ten years later, its HIPAA Transition Weblog became a respected independent voice amidst the difficulties of implementing the HIPAA standards. HITTG now publishes theHIT Transition Weblog and HITSync eMagazine, devotes substantial resources to healthcare IT standards development on the national level, and serves clients in varied capacities within healthcare IT.

I have to tell you that one of the things I really like about HITTG is their mission, which says the group “…works with organizations to reduce the cost and improve the quality of healthcare through the development and implementation of robust IT standards.”

I do not, however, care for their acronym.  I just can’t remember it!  I’m sure they’d rather we all just remember NPIdentify and find them from there, but I’d rather they do something interesting by calling themselves  something like Shaboom!, HealthLookup or NeedGovNum.


Now that I’ve criticized their name, where could they take their gig from here?
  1. All practice management and billing software should integrate HITTG products as standard issue.
  2. One of the most hit and miss mailing lists ever are those for doctors – how about a “Where are they now?” ability to get a fast mailing list customizable by specialty, location, etc.  I don’t know of a list that keeps up with docs moving locations and practices. (I do believe Marti told me they could produce mailing lists for specific needs for a reasonable price, but you’ll have to speak with him about that.)
  3. How about a list from the insurance department by state of all plans operating in a state and any other gritty information we could could get about them?