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Do You Understand the New Medicare Transitional Care Management Service Codes?

Effective January 1, 2013, Medicare and other payers will pay for two new CPT codes (99495 and 99496) that are used to report physician or qualifying non-physician practitioner transitional care management (TCM) service for patients, following a discharge from a:

  • Hospital
  • Skilled Nursing Facility (SNF)
  • Community Mental Health Center (CMHC)
  • Outpatient observation
  • Partial hospitalization

Using Transitional Health Codes in Your Practice

and including a transition to:

  • Home
  • Domiciliary
  • Rest Home
  • Assisted Living

These two codes require the medical decision-making to be of moderate to high complexity. Each code encompasses one face-to-face visit and non face-to-face services, for instance, arranging home health agencies for patient care.

Codes are selected based on medical decision-making associated with the patient’s condition, the time when the communication is initiated with the patient, and the time when the face-to-face encounter occurs following discharge. The first face-to-face encounter is included. The codes may be reported only once per 30 calendar days. See the full code description at the end of this article.

The following are FAQs on the codes with answers provided by CMS.

Q: What date of service should be used on the claim?
A: The 30-day period for the TCM service begins on the day of discharge and continues for the next 29 days. The reported date of service should be the 30th day.

Q: What place of service should be used on the claim?
A: The place of service reported on the claim should correspond to the place of service of the required face-to-face visit.

Q: If the codes became effective on Jan. 1 and, in general, cannot be billed until 29 days past discharge, will claims submitted before January 29th with the TCM codes be denied?
A: Because the TCM codes describe 30 days of services and because the TCM codes are new codes beginning on January 1, 2013, only 30-day periods beginning on or after January 1, 2013 are payable. Thus, the first payable date of service for TCM services is January 30, 2013.

Q: The CPT book describes services by the physician’s staff as “and/or licensed clinical staff under his or her direction.” Does this mean only RNs and LPNs, or may medical assistants also provide some parts of the TCM services?
A: Medicare encourages practitioners to follow CPT guidance in reporting TCM services. Medicare requires that when a practitioner bills Medicare for services and supplies commonly furnished in physician offices, the practitioner must meet the “incident to” requirements described in Chapter 15 Section 60 of the Benefit Policy Manual 100-02.

Q: Can the services be provided in a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC)?
A: While FQHCs and RHCs are not paid separately by Medicare under the Physician Fee Schedule (PFS), the face-to-face visit component of TCM services could qualify as a billable visit in an FQHC or RHC. Additionally, physicians or other qualified providers who have a separate fee-for-service practice when not working at the RHC or FQHC may bill the CPT TCM codes, subject to the other existing requirements for billing under the MPFS.

Q: If the patient is readmitted in the 30-day period, can TCM still be reported?
A: Yes, TCM services can still be reported as long as the services described by the code are furnished by the practitioner during the 30-day period, including the time following the second discharge. Alternatively, the practitioner can bill for TCM services following the second discharge for a full 30-day period as long as no other provider bills the service for the first discharge. CPT guidance for TCM services states that only one individual may report TCM services and only once per patient within 30 days of discharge. Another TCM may not be reported by the same individual or group for any subsequent discharge(s) within 30 days.

Q: Can TCM services be reported if the beneficiary dies prior the 30th day following discharge?
A: Because the TCM codes describe 30 days of care, in cases when the beneficiary dies prior to the 30th day, practitioners should not report TCM services but may report any face-to-face visits that occurred under the appropriate evaluation and management code.

Q: Medicare will only pay one physician or qualified practitioner for TCM services per beneficiary per 30 day period following a discharge. If more than one practitioner reports TCM services for a beneficiary, how will Medicare determine which practitioner to pay?
A: Medicare will only pay the first eligible claim submitted during the 30 day period that commences with the day of discharge. Other practitioners may continue to report other reasonable and necessary services, including other E/M services, to beneficiaries during those 30 days.

Open Door Forum Call Including TCM Code Information

CMS is holding a Open Door Forum on Tuesday, March 12, 2013, at 2:00 p.m. Eastern (ET) which will include some information about TCM codes, and an opportunity for listeners to ask individual questions of the presenters.

CALL AGENDA: (subject to change)

I. Opening Remarks

  • Chair – Stewart Streimer (CM)
  • Co-Chair – Dr. William Rogers (OPE)
  • Moderator – Barbara Cebuhar (in lieu of Matthew Brown, OPE)

II. Announcements & Updates

  • Physician Compare Website Redesign
  • DMEPOS Competitive Bidding
  • Ordering & Referring
  • Transitional Care Management:
  • Health Insurance Marketplace

III. Open Q&A

Open Door Participation Instructions:

To participate by phone:

Dial: 1-800-837-1935 & Reference Conference ID: 78871126. Call in 15 minutes before the start of the call.

Persons participating by phone do not need to RSVP

TTY Communications Relay Services are available for the Hearing Impaired.  For TTY services dial 7-1-1 or 1-800-855-2880. A Relay Communications Assistant will help.

Encore: 1-855-859-2056; Conference ID: 78871126.

Encore is an audio recording of this call that can be accessed by dialing 1-855-859-2056 and entering the Conference ID. This recording will be accessible beginning 2 hours after the ODF and expires after 3 business days.

99495 – 99496 Management Of Transitional Care Services

These codes include:

  • Moderate to high complexity medical decision making needs during care transition
  • First interaction (can be face-to-face, by telephone, or electronic) with patient or his/her caregiver and must be done within 2 working days of discharge. If two separate attempts are made in a timely manner, but are unsuccessful and other TCM criteria are met, the service may be reported. Medicare, however, expects attempts to communicate to continue until they are successful.
  • Initial face-to-face interaction within described time frame (99495 = 14 days and 99496 = 7 days) and include medication management
  • All services  from the discharge day up to 29 days post-discharge

Examples of non face-to-face services provided by physicians and non-physician providers included in TCM codes are:

  • Arrangement of follow-up and referrals with community resources and providers
  • Contacting qualified health care professionals for specific problems of patient
  • Review of discharge information
  • Need for follow-up care review based on tests and treatments
  • Patient, family and caregiver education

Note that the non-physicians who may bill TCM codes are Nurse Practitioners (NPs), Physician Assistants (PAs), Clinical Nurse Specialists (CNSs), and Certified Nurse Midwives (CNMs), unless they are otherwise limited by their state scope of practice.

Physicians reporting TCM codes are most likely to be primary care physicians, however other specialties may report them. Both CPT and Medicare prohibit a physician who reports a service with a global period of 10 or 90 days from also reporting the TCM service.

Examples of non face-to-face services provided by staff under the guidance of physicians and non-physician providers included in TCM codes are:

  • Caregiver education to family or patient, addressing independent living and self-management
  • Communication with patient and all caregivers and professionals regarding care
  • Determining which community and health resources would benefit the patient
  • Providing communication with home health and other patient-utilized services
  • Support for treatment and medication adherence
  • The facilitation of services and care

These TCM codes do not include (and may be billed separately):

  • E/M services after the first face-to-face visit
  • Tests and procedures

The following services cannot be billed during the time period covered by transitional care:

  • care plan oversight services (99339, 99340, 99374 – 99380)
  • prolonged services without direct patient contact (99358, 99359)
  • medical team conferences (99366 – 99368)
  • end stage renal disease services (90951 – 90970)
  • online medical evaluation services (98969, 99444)
  • education and training (98960 – 98962, 99071, 99078)
  • anticoagulant management (99363, 99364)
  • telephone services (98966 – 98968, 99441 – 99443)
  • preparation of special reports (99080)
  • analysis of data (99090, 99091)
  • complex chronic care coordination services (99481X – 99483X)
  • medication therapy management services (99605 – 99607)

99495 – Transitional Care Management Services (Medicare reimburses $163.99 for non-facility) with the following required elements:

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge.
  • Medical decision making of at least moderate complexity during the service period
  • Face-to-face visit within 14 calendar days of discharge

99496 – Transitional Care Management Services (Medicare reimburses $231.36 for non-facility) with the following required elements:

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge.
  • Medical decision making of high complexity during the service period
  • Face-to-face visit within 7 calendar days of discharge (note that discharge and TCM may not be billed on the same day.)

What questions do you need to answer in your practice to insure you are correctly using the TCM codes?

  1. Have you spoken with all payers to determine which ones will reimburse you for TCM codes?
  2. If you do not see your patient in the hospital, how will you know your patient is in the hospital? Most hospitals/facilities should call you to schedule a follow-up visit for the patient, triggering a TCM event. If this is not being done, how will you know your patient has been discharged? Hospitals have a vested interest in making this work as they want to prevent readmissions, so they should be helpful in working on a communication plan.
  3. Who in your practice has primary responsibility for managing the discharged patients and triggering the first contact and face-to-face visit within the time frames? What manual or electronic tickler system will be used to alert staff?
  4. What forms for a paper chart or templates for an EMR will be needed for documentation of all services provided?
  5. Do your providers know the difference between moderate and high complexity medical decision making? If not, get them up to speed.
  6. Will your billing system flag the claim with the TCM code to be dropped at 30 days, or will you need an alert system to be sure the claim is dropped appropriately? Can your billing system be programmed to hold charges to review for TCM patients that will not be paid during the TCM period in addition to the TCM code? If not, what’s your plan?



Collections Basics – Part 1: Know Your Payers

In a traditional healthcare setting, the revenue cycle begins with the insurance companies who pay the majority of the bill. There are multitudes of payers and each payer can have many plans.  How can a healthcare organization catalog this information, keep this information updated and make this information easily accessible to staff so they can discuss payments with patients in an informed and confident way?

Start by breaking your payers into five main categories as a logical way to organize the data.

  1. Payers with whom you have a contract
  2. Payers with whom you do not have a contract
  3. State and Federal government payers (Medicare, Medicaid, TriCare)
  4. Medicare Advantage payers
  5. Patients

Payers with whom you have a contract

Your organization has signed a contract with a payer and you have agreed to accept a discounted fee called an allowable, and to abide by their rules.  What is the information you need to collect?

  • A copy of the contract
  • A detailed fee schedule, or a basis for the fees, such as “150% of the 2008 Medicare fee schedule.”
  • Any information about the fees being increased periodically based on economic indicators, or rules (notification, timeline, appeals) on how the payer can change the fee schedule.
  • The process and a contact name for appealing incorrect payments.
  • Information on what can be collected at time of service.  Hopefully your contract does not have any language that prohibits collections at time of service, but you must know what the contract states.
  • Process for checking on patients’ eligibility and benefits: representative by phone, interactive voice response (IVR), website or third-party access.

The contract allowables should be loaded into your practice management system so you can calculate the patient’s responsibility at check-out and you can identify incorrect payments at the time of check-posting.  If your practice management system does not have this feature, you will need a cheat sheet for each contracted payer, showing the most common services, the allowables, and the percentages of the allowables for fast calculation of the patient’s portion at check-out.  The same or a modified cheat sheet will work for the check posters so they can verify the payer is reimbursing according to the contract.

Your cheat sheet should look like this:

Plan A
Service Allowable 20% 40% 50% 60% 80% 90%
99213 75.00 15.00 30.00 37.50 45.00 60.00 67.50

The check-out staff will write the patient’s portion on the encounter form (you may call it a charge ticket, fee ticket, rounding slip, or superbill), add the numbers together and give the patient the total.  Alternately, the computer system will total the patient’s portion based on the payer and the plan for the check-out person.

The balance of the information collected will be used to develop a payer matrix that might look something like this:

 

Payer

 

Employers

Collectible 

At TOS

Elig/Benefit 

Verification

Plan Year Contract 

Dates

How to Notify
XYZ WalMart Deductible & Co-Pay website July-June – Exp Dec 2013, must neg. <Aug1, 2012 Call June Jones at 1-800-555-1212
State Employees Deductible & Co-Ins. Website 

 

Jan –Dec 

 

same same

Another excellent way your organization can catalog payer and plan information is electronically in a document management system such as FileConnect, which I use and recommend.

FileConnect is an electronic filing cabinet with many great attributes, one of which is particularly helpful in this scenario. Every time there is a change in a payer contract, or a new plan is added by a local employer, you can update the staff’s spreadsheet tools simultaneously and the newest version will be instantly available on their desktops.

Payers with whom you do not have a contract

Your primary payers in your community or region will most likely offer you a contract.  Payers with less covered lives will not find it worthwhile to contract with healthcare providers, so you must decide how you will work with these companies and with these patients.

You are not required to file claims with payers that you are not contracted with.  Most healthcare providers do file claims with non-contracted payers to ensure patient satisfaction.   Where providers may differ, however, is whether or not they will ask patients with non-contracted payers to pay in full at time of service, and assign the payment to the patient OR ask the patient to pay only the expected patient portion at time of service and assign the payment to the provider.  This decision will be made as part of your Financial Policy (covered in Part 2.)

State and Federal government payers (Medicare, Medicaid, TriCare)

There has been a tremendous discussion in healthcare for the last several years about physicians limiting how many Medicare patients they will see, or even discontinuing to see Medicare patients completely.  The rate at which Medicare pays is not enough to support the provision of services in most ambulatory practices, so some physicians do not participate in the Medicare program but still see Medicare patients (the fee they can charge Medicare patients is federally controlled and is called the “limiting” charge) or have opted out of the Medicare program altogether and will see Medicare patients on a cash basis only.

If a practice does accept Medicare patients, whether participating or not, there are set amounts to be collected from patients with Medicare – deductibles and co-insurance, as well as services that are never covered by Medicare.

Make sure that current Medicare allowables for your locality are loaded into your computer to do the math for you.  You can use the same type of spreadsheet shown above to develop a cheat sheet of 80% of the Medicare allowable.

Service Medicare Allowable 20% Owed by Patient
99213 66.74 13.34

What is confusing to most providers is what an insurance that is secondary to Medicare will pay.  Many providers do not collect any fees at time of service for Medicare patients with a secondary payer, as there may or may not be any balance left that is the patient’s responsibility.

Medicaid pays less than Medicare does, and based on the very low fee schedule, many ambulatory providers will not accept Medicaid patients.  Many Medicaid patients must depend on health departments, hospital clinics, federally-qualified health centers (FQHCs) and rural health clinics (RHCs) for care.

Tricare may be accepted on a case-by-case basis.  A healthcare provider does not need to accept the health insurance for retired military across the board, and may decide individually whether to accept a Tricare patient or not.

Medicare Advantage

Medicare Advantage Plans, formerly called Medicare Choice + and now called Medicare replacement plans or Medicare Part C, are plans offered by non-government payers which replicate Medicare benefits for seniors, sometimes offering enhanced benefits as part of the package.  There are several types of Medicare Advantage Plans, but the main types are local or regional HMO plans which require you to sign a contract, and the Private Fee For Service Plans (PFFS), for which no contract is required.  If you see a Medicare Advantage PFFS patient, you have in essence agreed to accept their terms.  The one thing you should ask prior to accepting a Medicare Advantage PFFS plan/patient, is what percentage and what year of Medicare rates are they paying.

Patients

So we finally arrive at the payer with whom most healthcare entities have the most difficulties – the patient.  Why is it so difficult to collect from patients?

First, as we have seen throughout this article, insurance can be very confusing.  Without a plan for organizing and sharing information, a healthcare provider may have significant difficulty assessing the patient’s payment responsibility.

Second, it has been a cultural norm until recently that patients do not have to pay at time of service, with the exception of their co-pay, and will be billed for their portion after insurance pays.

We know now that we must collect the correct payment at time of service.  This is the only way to reduce the administrative expense of billing the patient for the balance and/or refunding the patient if too much has been collected.  This is also the only way to maintain adequate cash flow as much of what used to be paid to the providers from insurance companies has now become the responsibility of the patient.  Higher co-pays, higher co-insurance and most of all, extremely high deductible plans have left patients owing much more out-of-pocket and largely being unprepared to pay it at time of service.

In the next part of this series, Collections Basics Part 2: Develop Your Financial Policy, we will discuss setting up your financial policy so both patients and your staff can understand it, and how to collect from patients according to your policy.




Robert Anthony from CMS Takes Questions on Stage One Meaningful Use in PhysiciansPractice Webinar

Today, PhysiciansPractice sponsored a webinar with CMS’s Robert Anthony on the topic of “Meaningful Use Stage 1.” Robert Anthony is a Health Insurance Specialist in the Office of E-Health Standards and Services (OESS) at the Centers for Medicare & Medicaid Services (CMS), where he focuses on the EHR Incentive Programs. Robert had a very pleasant voice to listen to, and he gets my vote for the best CMS Employee Speaker that I’ve heard!

I was not familiar with the OESS before, so I looked it up and found out what they do: Provide the overall leadership for and coordinate the implementation of Title IV of the HITECH Act. (Title IV = Medicare and Medicaid Health Information Technology)

Robert briefly reviewed what has happened to date with the EHR Incentive Program and the terms of the Medicare and Medicaid programs. The three main differences in the two programs are:

  1. The types of providers that are eligible for each program – information here.
  2. The volume of each type of patient needed to participate: no volume needed to participate in the Medicare program and 30% Medicaid patients for all eligible practitioners except pediatricians who only need 20% Medicaid patients.
  3. The tasks in year one in which the certified EHR is adopted. For Medicaid the practice only needs to attest that they have adopted, implemented or upgraded an EHR. In year one for Medicare the practice needs to attest to meaningful use for 90 days, which means data is collected and input into the attestation system.

The majority of the webinar was devoted to FAQs (my favorite part of any CMS-related education session!)

FAQs

Q: Can entities participate in the Medicare EHR Demonstration Project, and the Medicare or Medicaid EHR Incentive programs too?

A: Yes. The demonstration projects are about to be sunsetted (completed.)

Q: What information must be provided to patients to meet the requirement for a clinical summary at the end of each visit?

A: If system is certified, it will automatically provide the appropriate information for the clinical summary, which includes the patient’s problem list, medication list, medication allergy list, and diagnostic test results.

Robert suggested looking at the answer online at the CMS FAQ which I posted below:

In our final rule, we defined “clinical summary” as: an after-visit summary that provides a patient with relevant and actionable information and instructions containing, but not limited to, the patient name, provider’s office contact information, date and location of visit, an updated medication list, updated vitals, reason(s) for visit, procedures and other instructions based on clinical discussions that took place during the office visit, any updates to a problem list, immunizations or medications administered during visit, summary of topics covered/considered during visit, time and location of next appointment/testing if scheduled, or a recommended appointment time if not scheduled, list of other appointments and tests that the patient needs to schedule with contact information, recommended patient decision aids, laboratory and other diagnostic test orders, test/laboratory results (if received before 24 hours after visit), and symptoms.

The EP must include all of the above that can be populated into the clinical summary by certified EHR technology. If the EP’s certified EHR technology cannot populate all of the above fields, then at a minimum the EP must provide in a clinical summary the data elements for which all EHR technology is certified for the purposes of this program (according to §170.304(h)):

  • Problem List
  • Diagnostic Test Results
  • Medication List
  • Medication Allergy List

Q: How and when are incentive payments made?

A: After the online attestation is made (attestation thresholds must be attained), provider information is verified, then in 6 to 8 weeks a payment is generated. Payments are made in whatever way the entity typically gets CMS payments.

Q: What if patients do not routinely receive prescriptions during an office visit? How can the threshold be met? (Referring to computerized provider order entry (CPOE) for medication orders.)

A: For attestation, practices need to do this for 30% or more of all unique patients with at least one medication in their medication list. Note that patients with no medications in their medication list are excluded, so CMS believes this core initiative is realistic.

Q: For the Medicaid program, do you count the patient visit or the number of services (e.g. patient visit plus two tests equals three patient ticks) during the visit?

A: This question needs follow-up and if you send an email to editor@physicianspractice.com, they will be sent to CMS for the answer. Here is additional information from the CMS FAQ:

When calculating Medicaid patient volume or needy patient volume for the Medicaid EHR Incentive Program, are eligible professionals (EPs) required to use visits, or unique patients?

There are multiple definitions of encounter in terms of how it applies to the various requirements for patient volume.  Generally stated, a patient encounter is any one day where Medicaid paid for all or part of the service or Medicaid paid the co-pays, cost-sharing, or premiums for the service.  The requirements differ for EPs and hospitals.  In general, the same concept applies to needy individuals.  Please contact your State Medicaid agency for more information on which types of encounters qualify as Medicaid/needy individual patient volume.

Q: We are a new practice and plan on getting an EMR in the next 3 months. Can you walk me through the time lines?

A: If you haven’t chosen an EMR yet, your first year in either program will probably be 2012. In the first year of Medicare participation, you will need to use the EMR meaningfully for 90 days during calendar year 2012, and you have up to 60 days after the close of the calendar year to attest to your use. In the first year of Medicaid participation, you will need to adopt (acquire, install), implement (commence utilization of EHR such as train, data entry), or upgrade (expand) a certified EHR and attest to your activity at any time during the calendar year.

Q: What validation or oversight will CMS provide for the attestation process?

A: Before any payment is made, checks of provider eligibility and information will be done. Keep in mind that attestation is a legal process. Random audits will be put in place in the near future.

Q: Should a practice register if we don’t know which program we are going to use?

A: You can register at any time, and you can change from one program to the other prior to attesting, so you can register for one program and change before you begin the attestation.

Q: If your first year of attestation is in 2012, can you get the full 44K over the course of the program?

A: Yes.

Q: Can you verify if Physician Assistants are eligible for one of the programs?

A: Physician Assistants (PAs) are only eligible under the Medicaid program and must be the lead provider for a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) to qualify.

Q: Does a radiology practice have to provide a clinical summary for patients?

A: No practice type is excluded from clinical summary mandate. CMS has not heard of any practice type having a problem with this so far. Remember, to achieve meaningful use, you must provide clinical summaries to patients for more than 50 percent of office visits within three business days. Exclusion: Any EP who has no office visits during the period of EHR reporting.

Q: Is the problem list supposed to be related to the chief compliant of the office visit?

A: Not necessarily. Practices are required to maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT (Systematized Nomenclature of Medicine – Clinical Terms) codes. To comply, at least 80 percent of all unique patients seen by eligible providers must have at least one entry (or an indication of none) recorded as structured data.

Q: What if questions were not able to be answered during the webinar?

A: Please e-mail Physicians Practice and we’ll get your answers from CMS. This could take several days, so please be patient. We will post your answers and all post-webinar questions at http://www.physicianspractice.com and notify you via e-mail as well.

Resources

A great list of additional resources were provided by Robert Anthony and Physicians Practice:

Resources from CMS

Resources from PhysiciansPractice.com

 

Other Posts I have written on this topic:

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

CMS Holds National Provider Calls for the Medicare EHR Incentive Program and EHR Attestation Q & A

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

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

How My Practice Knew We Were Ready for EMR

10 Ways to Get More Out of Your PM, EMR or Any Medical Software




My Notes on Today’s CMS Call on the Initial Preventive Physical Exam (Not a Physical Exam) and the Annual Wellness Visit

Today’s CMS call reviewed the guidelines for the IPPE (Initial Preventive Physical Exam) and the AWV (Annual Wellness Visit), what they include and how to code for them.

What is the IPPE (also called the “Welcome to Medicare Visit”)?

The IPPE is a one-time visit, covered within 12 months after the effective date of Part B coverage and including:

  • Review of medical and social history.
  • Review of risk factors for depression.
  • Review of functional ability and level of safety.
  • Measurement of height, weight, body mass index, blood pressure, visual acuity, and other factors deemed appropriate.
  • Discussion of end-of-life planning, if agreed upon by the patient.
  • Education, counseling and referrals based on results of review and evaluation services performed during the visit, including a brief written plan such as a checklist, and if appropriate, education, counseling and referral for obtaining an electrocardiogram (a/k/a EKG, ECG).
  • Note that although the IPPE has the word “exam” in it, there is NO physical exam associated with it. Most practices attempt to call it the Welcome to Medicare Visit and try never to use the word “exam” in association with it.

Who can provide the IPPE?

  • Physician (doctor of medicine or osteopathy)
  • Qualified non-physician practitioner including nurse practitioner physician assistant or Clinical nurse specialist

How is the IPPE Billed?

G0402
Initial preventive physical examination (not really an examination); face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment, plus ONE of the following if a electrocardiogram is done.

G0403
Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report.
G0404
Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination.
G0405
Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination.

What if the IPPE is provided in a facility?

These services typically are provided in a physician office, however, when the services are provided in a facility, the following institutions can bill as follows:

  • Hospitals for inpatients (TOB 12X) and outpatients (TOB 13x)
  • Skilled Nursing Facilities for inpatients (TOB 22X)
  • Rural Health Centers (TOB 71X)
  • Federally Qualified Health centers (TOB 77X)
  • Critical Access Hospitals (TOB 85X)

What diagnosis code should be used?

Although a diagnosis code must be reported on the claim, there are no specific International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes that are required for the IPPE; therefore, Medicare providers should chose an appropriate ICD-9-CM diagnosis code.

How often can the IPPE and the screening EKG be performed?

The IPPE (G0402) is a one-time benefit that must be provided within 12 months of the effective date of a beneficiary’s Medicare Part B coverage.  The screening EKG (G0403, G0404, G0405), when done as a referral from an IPPE, is also only covered once during a beneficiary’s lifetime.

How does the provider collect for the IPPE at time of service?

Effective for dates of services on or after January 1, 2011, the coinsurance or copayment and deductible are waived for the IPPE (G0402) only. The deductible and coinsurance still applies to the screening EKG.

What about screening for the abdominal aortic aneurysm (AAA)?

A one-time only ultrasound screening for an Abdominal Aortic Aneurysm (AAA) can be done as the result of a referral from an IPPE for Medicare beneficiaries with certain risk factors. The code for billing the AAA ultrasound screening is:

G0389

Ultrasound, B-scan and or real time with image documentation;  AAA screening

Effective for dates of services on or after January 1, 2011, the co-insurance or co-payment and deductible are waived for the AAA ultrasound screening (G0389). For more information on the AAA ultrasound screening done as the result of a referral from an IPPE, please see the CMS Internet-Only Manual Pub. 100-04, chapter 18, section 110 on the CMS web site.

Please Note!
• The IPPE is a preventive wellness visit and not a routine physical examination.
• Medicare does not provide coverage for routine physical exams.

What if other services are provided during the IPPE?

If other evaluation and management services are provided in conjunction with the IPPE, use CPT  Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) as follows:

  • Append to the additional E & M service denoting a separate Evaluation and Management (E/M) service furnished with an IPPE.
  • Cost sharing (coinsurance, copayment and deductible) applies to the additional (E/M) service.
  • CPT codes 99201 –99215 may be reported depending on the clinical appropriateness of the circumstances.
  • Preventive services identified in CPT code range 99381 through 99397 are not covered by Medicare.
  • CMS speakers noted that they hoped physician offices would let patients know when they could incur out-of-pocket expenses.

NOTE: Some of the components of a medically necessary E/M service (e.g., a portion of history or physical exam portion) may have been part of the IPPE and should not be included when determining the most appropriate level of E/M service to be billed for the medically necessary, separately identifiable, E/M service.

What is the patient’s role in preparing for the IPPE?

Providers should encourage patient to come prepared with the following information:

  • Medical records, including immunization records if the provider doesn’t already have them;
  • Family health history in as much detail as possible; and
  • A full list of medications and supplements, including calcium and vitamins –how often and how much of each is taken. (Many providers ask patients to bring their actual medication and supplement bottles to every visit so a medication reconciliation can take place and improved communication about medication can take place.)

What is the AWV?

The Annual Wellness Visit (AWV) was created by the Affordable Care Act (ACA) and is a new benefit for 2011. Medicare beneficiaries are eligible for one AWV every 12 months after they have had Medicare Part B for more than 12 months. This is a “visit” and not a physical examination. Patients have a tendency to hear the word “Annual” and think they are getting an annual physical.

The beneficiary does not need to receive an IPPE to be eligible for an AWV.  However, if the beneficiary did receive an IPPE, –s/he is eligible for an AWV 12 months following the IPPE.

What is included in the AWV?

Medical/family history

  • List of current providers/supplier.
  • Blood pressure, height, weight, and other routine measurements.
  • Detection of any cognitive impairment.
  • Review (potential) risk factors for depression, functional ability, and level of safety.
  • A written screening schedule (such as a checklist) for next 5-10 years.
  • Documentation of risk factors and conditions where interventions are recommended.
  • Personalized health advice and referrals for health education and preventive counseling.

Subsequent AWVs:

  • Update of medical/family history.
  • Update of list of current providers/suppliers.
  • Measurement of weight, blood pressure, and other routine measurements.
  • Detection of any cognitive impairment.
  • Update to the written screening schedule.
  • Update to the list of risk factors and conditions where interventions have been recommended.
  • Update to the personalized health advice and referrals for health education and preventive counseling

Who can provide an AWV?

A “health professional” meaning a:

  • Physician
  • Physician assistant
  • Nurse practitioner
  • Clinical nurse specialist
  • Medical professional (including a health educator, a registered dietitian, or nutrition professional, or other licensed practitioner) or a team of such medical professionals, working under the direct supervision of a physician

How should the AWV be coded?

The following G-codes identify the AWV for Medicare payment:
G0438

Annual wellness visit, including Personalized Prevention Plan Service, first visit
G0439

Annual wellness visit, including Personalized Prevention Plan Service, subsequent visit

Who can bill for the AWV?

These services typically are provided in a physician office. When the services are provided in a facility, the following institutions can bill:

  • Hospital inpatients (TOB 12X) and outpatients (TOB 13x)
  • Skilled Nursing Facilities inpatients (TOB 22X) and outpatients (23X)
  • Rural Health Centers (TOB 71X)
  • Federally Qualified Health centers (TOB 77X)
  • Critical Access Hospitals (TOB 85X)

Note: Medicare makes a single fee schedule payment for a beneficiary’s AWV when provided in a physician office or hospital outpatient department.

What diagnosis should be used for the AWV?

Although a diagnosis code must be reported on the claim, there are no specific International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes that are required for the AWV; therefore, Medicare providers should chose an appropriate ICD-9-CM diagnosis code or contact the local Medicare contractor for guidance.

How often can the AWV be performed

  • First visit (G0438) – once in a lifetime
  • Subsequent (G0439)-annually (after 12 full months have passed since the last AWV)

What should be collected at the time of service?

Effective for dates of services on or after January 1, 2011 co-payment or co-insurance and the Medicare Part B deductible are waived.

Please Note! AWV is a preventive wellness visit and not a routine physical examination. Medicare does not provide coverage for routine physical exams.

What if additional services are provided at the same time as the AWV:

If other evaluation and management services are provided in conjunction with the AWV, use CPT  Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) as follows:

  • Append to the additional E & M service denoting a separate Evaluation and Management (E/M) service furnished with an IPPE.
  • Cost sharing (co-insurance, co-payment and deductible) applies to the additional (E/M) service.
  • CPT codes 99201 –99215 may be reported depending on the clinical appropriateness of the circumstances.
  • Preventive services identified in CPT code range 99381 through 99397 are not covered by Medicare,
  • CMS speakers noted that they hoped physician offices would let patients know when they could incur out-of-pocket expenses.

NOTE: Some of the components of a medically necessary E/M service (e.g., a portion of history or physical exam portion) may have been part of the AWV and should not be included when determining the most appropriate level of E/M service to be billed for the medically necessary, separately identifiable, E/M service.

What is the patient’s role in preparing for the AWV?

Providers should encourage patient to come prepared with the following information:

  • Medical records, including immunization records if the provider doesn’t already have it;
  • Family health history in as much detail as possible; and
  • A full list of medications and supplements, including calcium and vitamins –how often and how much of each is taken. (Many providers ask patients to bring their actual medication and supplement bottles to every visit so a medication reconciliation can take place and improved communication about medication can take place.)

What is the proposed refinement to the AWV?

Medicare Physician Fee Schedule CY 2012 Proposed Rule suggests incorporating the use and results of a Health Risk Assessment into the provision of personalized prevention plan services during the AWV.

  • The proposed rule text is available here.
  • We welcome public comments before 5pm on August 30, 2011.
  • Electronically through www.regulations.gov
  • Hard copy (see instructions in the proposed rule)
  • CMS staff cannot discuss this topic on today’s call.

 

Q & A From the listeners (my favorite!)

Q: As a RHC, we usually submit one line item for all services provided on a UB92. How are we supposed to bill this if we are providing both a preventive service and an E & M on the same day?

A: This question was not able to be answered. The listener was asked to send the question to the following email nationalprovidercall@cms.hhs.gov with the subject line reading “IPPE/AWV Call Question.”

Q: We are an Article 28 Institution (place of service 22) – do we still bill the APC separately from the facility?

A: There is not a separate facility payment available, so a single payment is made to the physician or the facility.

Q: We are a Critical Access Hospital – when we receive an order for an EKG or ultrasound AAA, what diagnosis is supposed to come from the physician so that it will pass muster in a review?

A: The initial answer said the EKG should have a screening diagnosis and the AAA should have a risk factor diagnosis, but after a discussion, the listener was asked to send the question to the following email: nationalprovidercall@cms.hhs.gov with the subject line reading “IPPE/AWV Call Question.”

Q: Does the IPPE have a physical exam as a component? If a physical exam is provided, should it be billed as a separate E & M?

A: No physical examination is included. If it is provided, it should be coded separately.

Q: Are there specific identified screening tools that must be used for the depression or mental acuity screening?

A: The physician may choose the screening tool for depression or mental acuity.

Q: We do provider-based billing and our system automatically splits the G code  between facility and professional fees. How will we recoup the facility portion?

A: Only one payment is made based on the physician fee schedule.

Q: If Physician Assistants can perform IPPEs and AWVs, does this mean that the patient must be established since mid-level providers cannot care for new Medicare patients?

A: This question was not able to be answered. The listener was asked to send the question to the following email nationalprovidercall@cms.hhs.gov with the subject line reading “IPPE/AWV Call Question.”

Q: Is the EKG and AAA screening benefits on the IPPE visit only? Will CMS ever add the EKG and AAA screening benefits to the AWV since so many patients don’t take advantage of the IPPE?

A: We will take this under advisement.

Q: Can G0102 (digital rectal exam) be billed with an AWV?

A: Yes.

Q: RE: Referrals to personalized health advice, health education, etc? Are these services covered under Medicare or would these be out-of-pocket expenses for Medicare patients?

A: Would be out-of-pocket unless a covered service.

Q: Will mid-level providers performing AWVs be reimbursed the same as a physician providing the service?

A: This question was not able to be answered. The listener was asked to send the question to the following email nationalprovidercall@cms.hhs.gov with the subject line reading “IPPE/AWV Call Question.”

Q: Will everyone get the answers that were not provided today or just the person who sent the email?

A: CMS will not be compiling the answers, but will post frequently asked questions on their website.

Q: We are getting edits when billing the EKG with the IPPE and the EKG is being denied.

A.This question was not able to be answered. The listener was asked to send the question to the following email nationalprovidercall@cms.hhs.gov with the subject line reading “IPPE/AWV Call Question.”

Q: Can V70.5 (unspecified health examination) be used as a diagnosis for IPPE or AWV?

A: Yes, any diagnosis can be used.

Q: Can a medically-necessary EKG (93000) be billed with a IPPE or AWV?

A: Yes.

Q: What should we do when a Medicare patient refuses the AWV and wants a traditional preventive visit? Do we get an ABN signed and charge the 99397 per the patient’s request?

A: Yes. Treat the preventive service the way you would any other non-covered service.

Q: Can an IPPE be provided with a pap and pelvic?

A: Yes.

Q: If providing an IPPE, pap and pelvic, breast exam and a physical examination to a Medicare beneficiary, can the physician choose NOT to bill the patient for the physical exam?

A: This question was not able to be answered. The listener was asked to send the question to the following email nationalprovidercall@cms.hhs.gov with the subject line reading “IPPE/AWV Call Question.”

Q: We are having problems with Medicare beneficiaries turning down the IPPE or AWV, asking for an annual physical examination (preventive service), then getting a bill, then calling Medicare and the Medicare rep telling the patient that they should never have been charged.

A: The speakers asked for details about the caller’s experience in an email to: nationalprovidercall@cms.hhs.gov with the subject line reading “IPPE/AWV Call Question.”

Q: On the Medicare Preventive Physical Exam form, what is the “Up and Go” test?

A: This question was not able to be answered due to the form not being recognized. The listener was asked to send the form to the following email nationalprovidercall@cms.hhs.gov with the subject line reading “IPPE/AWV Call Question.”

Q: We are having problems with patients asking for the AWV, but presenting with medical issues. The patients want the service without having to pay the deductible or co-insurance.

A: You can bill for an E & M in addition to the AWV, but the deductible and co-insurance will apply.

Note: if you have a question that was not answered today, you can send it to the following email nationalprovidercall@cms.hhs.gov with the subject line reading “IPPE/AWV Call Question.” Every question will not be able to be answered, but they will try to answer as many as possible.

Mary Pat’s Suggestions to CMS for future calls:

  1. Don’t make presenters with laryngitis participate.
  2. Coach all presenters in speaking for an audio presentation – speak slowly, speak loudly, don’t move your head around (causes volume spikes and dips) and be cautious of the auditory disruption turning papers and coughing causes, OR
  3. Have a professional or experienced speaker present the slides – no commentary is being given so the CMS experts aren’t needed to speak through the slides.
  4. Have one facilitator delegating each question to a specific expert to answer it.



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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The Dog Days of PECOS: CMS Publishes the Short Form (Paper) for PECOS, plus Consultant David Zetter Walks You Through It Online

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

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Many managers have told me they know their providers are in PECOS but they’re not on the list OR they never enrolled their providers but they are on the list OR they’ve sent their paperwork and have not heard back for 2, 4, 6 weeks – should they be worried?  The CMS website says “It is possible that it could take 45-60 days, sometimes longer, for Medicare enrollment contractors to process enrollment applications,” so I guess we all need to chill out a little.

The massive undertaking of qualifying every single healthcare professional who refers/orders or provides medical services to Medicare patients in order to sift out those who would lie about providing goods and services is fraught with confusion, miscommunication and misunderstanding.  That’s okay, though, because CMS says no checks for services or goods will be withheld due to providers not being listed in PECOS, at this time. They know it’s a mess and it will take quite a while to get everyone straightened out, on the list and able to get checks from CMS if and only if their name is on the list.

Below is the CMS fact sheet published last week.

The Doctor, by Sir Luke Fildes (1891)

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Medicare Enrollment Guidance for Physicians that Infrequently Receive Reimbursement from the Medicare Program

Traditionally, most physicians have enrolled in the Medicare program to furnish covered services to Medicare beneficiaries.  However, with the implementation of Section 6405 of the Affordable Care Act, some physicians will need to enroll in the Medicare program for the sole purpose of certifying or ordering services for Medicare beneficiaries. These physicians do not send claims to a Medicare contractor for the services they furnish.

In the process of implementing the provisions contained in the Affordable Care Act, we have become aware of several unique enrollment issues for certain types of physicians or practitioners. Specifically, we have modified the process of enrollment to accommodate the special circumstances of the following individual physicians and practitioners:

  • Physicians employed by the Department of Veterans Affairs
  • Physicians employed by the Public Health Service
  • Physicians employed by the Department of Defense Tricare program
  • Physicians employed by Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs) or Critical Access Hospitals (CAHs)
  • Physicians in a Fellowship
  • Dentists, including oral surgeons

This document provides guidance to those practitioners.

Q: How can I verify whether I am already enrolled in PECOS?

A: If a physician is concerned or uncertain about whether s/he is actually enrolled in the Provider Enrollment, Chain and Ownership System (PECOS), s/he can  review the Ordering and Referring file found in the download section of the “OrderingReferringReport” tab (click here) on the Medicare Provider and Supplier Web Site.

Providers and suppliers can check with the ordering or referring physician to see if the physician is currently seeing Medicare patients and the physician’s claims are being paid. Until we advise otherwise, your orders and referrals will not be rejected due to the lack of an approved enrollment record in PECOS.

Q: I am a physician employed by the Department of Veterans Affairs, Department of Defense Tricare program, by the Public Health Service, an FQHC, an RHC, or a CAH.  Do I need to enroll in PECOS to order and refer items or services for Medicare beneficiaries?

A: Yes, but we have abbreviated the enrollment process and documents for physicians employed by the Department of Veterans Affairs, the Public Health Service, the Department of Defense Tricare program, an FQHC, an RHC, or a CAH. However, because this is a unique solution to enrollment for a specific set of physicians, our systems will not accommodate the abbreviated forms on-line. Therefore, any physician employed by the Department of Veterans Affairs, the Public Health Service, the Department of Defense Tricare program, an FQHC, an RHC, or a CAH, who is not already enrolled in PECOS, must use the paper enrollment application process
and do the following:

Complete the following sections of the paper CMS-855I, “Medicare Enrollment Application for Physicians and Non-Physician Practitioners” and mail the completed form to the designated Medicare enrollment contractor:

  • Section 1  Basic Information (they would be a new enrollee)
  • Section 2  Identifying Information (section 2A, 2B, 2D and if appropriate 2H and 2K)
  • Section 3  Final Adverse Actions/Convictions
  • Section 4C/4E  Practice Location Information (same as section 2B)
  • Section 13  Contact Person
  • Section 15  Certification Statement (must be signed and dated””blue ink recommended)
  • Section 17  Supporting Documentation (cover letter stating the provider is only enrolling to order and refer services to a beneficiary)

Note: Physicians who are employed by the Department of Veterans Affairs, the Public Health Service, the Department of Defense Tricare program, an RHC, FQHC, or CAH are not required to include the Electronic Funds Authorization Agreement (CMS-588) or the Medicare Physician and Supplier Agreement (CMS-460) with the enrollment form.

Q: I am a  physician in a fellowship program.  Do I need to enroll in PECOS?

A: If you are a physician in a fellowship, and licensed in the State, you can enroll in Medicare for the sole purpose of ordering or referring items or services for Medicare beneficiaries. To enroll as a “referring and ordering physician-only” you would need to complete the abbreviated enrollment application form in the same way as other physicians (VA, DoD, PHS, FQHC, RHC CAH) who are enrolling to order and refer only (see previous question.) If you elect to enroll to order and refer only, you would not be enrolled in Medicare for the purpose of providing Medicare services to Medicare beneficiaries. In order to provide covered services to Medicare beneficiaries, a physician would need to complete the full enrollment application either on-line or in hard copy.

Q: I am an Oral Surgeon or Dentist. How do I Enroll in PECOS?

A: Dentists, including oral surgeons, must enroll in the Medicare program to receive reimbursement for services furnished to Medicare beneficiaries or to order covered items or services for Medicare beneficiaries. Oral surgeons would complete the same paper forms, or on-line application, as any other practitioner enrolling in PECOS.
If you elect to enroll as a “referring and ordering physician-only”, you would need to complete the abbreviated enrollment application form in the same way as other physicians (VA, DoD, PHS, FQHC, RHC CAH) who are enrolling to order and refer only (see previous two questions.)  If you elect to enroll to order and refer only, you would not be enrolled in Medicare for the purpose of providing Medicare services to Medicare beneficiaries.

In order to provide covered services to Medicare beneficiaries, a dentist, including oral surgeons, would need to complete the full enrollment application either on-line or in hard copy.

Note:  In completing the enrollment application portion dealing with specialty, oral surgeons would check the “oral surgery (dentist only)” box found in section 2 of the Medicare enrollment application and any other dentist would check the box titled, “Undefined Physician Type” and specify that they are a dentist in the space provided.  In the near future, we will revise the Medicare enrollment application to add “Dentist” as a physician specialty.

Internet-based PECOS

Physicians and practitioners who are employed by the Department of Veterans Affairs, the Defense Department, the Public Health Service, an RHC, FQHC, or CAH must complete the paper enrollment application that has been modified and shortened to accommodate the special situation of these professionals. All other physicians and practitioners who furnish services to Medicare beneficiaries must enroll in the Medicare program to receive reimbursement and order/refer in the Medicare program.  For those physicians and practitioners using the on-line process, we have developed a document that will help you through the PECOS enrollment process.   It will be easier to complete the process if you review this document before you begin the enrollment process.

  • The document titled, “Internet-based PECOS — Getting Started Guide for Physicians and Non-Physician Practitioners” can be found here.
  • Although you are permitted to complete your enrollment application in hard copy, it will be easier and quicker if you use the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) to complete the Medicare enrollment process.  The Internet-based PECOS application is completed via the web here.
  • After submitting an enrollment application via Internet-based PECOS, you must:
    • Print, sign and date (blue ink recommend) the Certification Statement(s), and
    • Mail the Certification Statement(s) and applicable supporting documentation to the designated Medicare contractor (no later than 7 days after you complete the online portion.)
    • NOTE: The Medicare contractor will not be able to begin to process your enrollment application until it receives a signed and dated Certification Statement.

 

Additional Medicare Enrollment Information

To ask a provider enrollment question, contact the Medicare contractor for your State. Medicare provider enrollment contact information for each State can be found here.

To report Internet-based PECOS navigation, access, or printing problem with Internet-based PECOS, contact the EUS Help Desk at 1-866-484-8049 or send an e-mail to the EUS Help Desk to EUSSupport@cgi.com

For additional information regarding the Medicare enrollment process, visit the website here. Of course, if you have any additional questions about the Medicare enrollment process, you can contact the designated Medicare contractor for your state.

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If you haven’t started yet but plan to use the online process to enroll your providers or yourself, here’s a really excellent SlideShare presentation by David Zetter that steps you through the enrollment process by showing screen shots of each step.  You can contact David Zetter here.

PECOS Enrollment Process 




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

Note: read my latest post on getting the EHR Incentives here.

Medicare Definition of Eligible Provider (EP)

For Medicare, physicians and some hospitals are eligible providers. “Physicians” includes doctors of medicine (MD) or osteopathy (DO), dentists or dental surgeons (DDS or DMD), podiatric medicine (DPM), and optometry (OD) and chiropractors (DC).

For providers, their annual payment will be equal to 75 percent of Medicare allowable charges for covered services in a year, not to exceed the incentives in the table below.  Payments will be made as additions to claims payments.

Hospitals include quick-care hospitals (subsection-d) and critical access hospitals  and only includes hospitals in the 50 States or the District of Columbia.

Medicaid Definition of Eligible Provider (EP)

Medicaid takes the Medicare definition of eligible providers (physicians) and adds nurse practitioners, certified nurse midwives and physician assistants, however, physician assistants are only eligible when they are employed at a federally qualified health center (FQHC) or rural health clinic (RHC) that is led by a Physician Assistant.  Eligible hospitals include quick care hospitals and children’s hospitals.

At minimum, 30 percent of an EP’s patient encounters must be attributable to Medicaid over any continuous 90-day period within the most recent calendar year. For pediatricians, however, this threshold is lowered to 20 percent.

The first year of payment the Medicaid provider must demonstrate that he is engaged in efforts to adopt, implement, or upgrade certified EHR technology.  For years of payment after year 1, the Medicaid provider must demonstrate meaningful use of certified EHR technology.

Change 1:

The  definition of “hospital-based physician” was recently clarified to include physicians working in hospital outpatient clinics (employed physicians) as opposed to the inpatient units, surgery suites or emergency departments.  This still excludes pathologists, anesthesiologists, ER physicians, hospitalists and others who see most of their patients in the ER as outpatients or as hospital inpatients.

Possible Change 2:

The Health Information Technology Extension for Behavioral Health Services Act of 2010 (HR 5040)  is a bill in the US Congress originating in the House of Representatives that would amend the Public Health Service Act and the Social Security Act to extend health information technology assistance eligibility to behavioral health, mental health, and substance abuse professionals and facilities, and for other purposes.  You can track the bill here.

For more information on stimulus money for meaningful use of an EMR, read my post here.