Below is an e-mail from Jurisdiction B DME titled "Face-to-Face Requirements for Orders Used to Obtain Medicare Payment on ACA items.  It is self-explanatory.

Debra Farley
Billing Director
BILLPro Management Systems
12-1-14

    From: Jurisdiction B DME MAC [mailto:dmemaclistserve@anthem.com]
    To: debra@billpro.net
    Sent: Wed, 26 Nov 2014 15:30:55 -0500
    Subject: Face-to-Face Requirements for Orders Used to Obtain Medicare Payment on ACA Items


          
    Face-to-Face Requirements for Orders Used to Obtain Medicare Payment on ACA Items

    Joint DME MAC Publication   

    The Affordable Care Act (ACA) Section 6407 requires a face-to-face encounter to occur within six months prior to the written order prior to delivery (WOPD) for certain DME items listed within it (see "MM8304 Revised - Detailed Written Orders and Face-to-Face Encounters" ). This requirement applies any time a new order has been obtained for
       
       [All-About-NGS_RBoxBG]
       
       
    the purposes of Medicare payment. The only exception to the requirement for a face-to-face encounter within six months is when a new order is obtained due to state law, and the order is not being used as documentation to support a claim for Medicare payment.  If the order is being used to meet a Medicare requirement, a new face-to-face must be conducted.

    If a new order is being used as documentation to support continued medical need or to fulfill any other documentation requirement for Medicare payment, then a face-to-face encounter within 6 months prior would be required.  One way to determine whether or not a new face-to-face encounter is required is to determine if the order obtained/required will be used to support Medicare payment of the claim.  If the answer is "yes" then a face-to-face encounter is required within six months of the date prior to that order.

    The face-to-face requirement became effective 7/1/2013 for all ACA items and a delay in enforcement has been made by the DME MACs. Other auditing entities may enforce this requirement at this time.

     

Below is an e-mail from Jurisdiction B DME titled "Face-to-Face Requirements for Orders Used to Obtain Medicare Payment on ACA items.  It is self-explanatory.

Debra Farley
Billing Director
BILLPro Management Systems
12-1-14

    From: Jurisdiction B DME MAC [mailto:dmemaclistserve@anthem.com]
    To: debra@billpro.net
    Sent: Wed, 26 Nov 2014 15:30:55 -0500
    Subject: Face-to-Face Requirements for Orders Used to Obtain Medicare Payment on ACA Items

          
    Face-to-Face Requirements for Orders Used to Obtain Medicare Payment on ACA Items

    Joint DME MAC Publication   

    The Affordable Care Act (ACA) Section 6407 requires a face-to-face encounter to occur within six months prior to the written order prior to delivery (WOPD) for certain DME items listed within it (see "MM8304 Revised - Detailed Written Orders and Face-to-Face Encounters" ). This requirement applies any time a new order has been obtained for
       
       [All-About-NGS_RBoxBG]
       
       
    the purposes of Medicare payment. The only exception to the requirement for a face-to-face encounter within six months is when a new order is obtained due to state law, and the order is not being used as documentation to support a claim for Medicare payment.  If the order is being used to meet a Medicare requirement, a new face-to-face must be conducted.

    If a new order is being used as documentation to support continued medical need or to fulfill any other documentation requirement for Medicare payment, then a face-to-face encounter within 6 months prior would be required.  One way to determine whether or not a new face-to-face encounter is required is to determine if the order obtained/required will be used to support Medicare payment of the claim.  If the answer is "yes" then a face-to-face encounter is required within six months of the date prior to that order.

    The face-to-face requirement became effective 7/1/2013 for all ACA items and a delay in enforcement has been made by the DME MACs. Other auditing entities may enforce this requirement at this time.

     

Below is an e-mail from CMS yesterday publishing the article "Calendar Year (CY) 2015 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule." The link is provided to access the article.

From: CMS MLNMatters-L [mailto:MedlearnMatters-L@CMS.HHS.GOV]
To: MLNMATTERS-L@LIST.NIH.GOV
Sent: Tue, 25 Nov 2014 06:47:32 -0500

 New
 

MM8999 – Calendar Year (CY) 2015 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule


http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8999.pdf

 
Please do take the time to read the entire article.

The "2015 Fee Schedule Update Factor of 1.5 Percent" is addressed on page 4.

Attention podiatrists:  Please pay particular attention to "Specific Coding and Pricing Issues" on the top of the third page as it addresses revised payment amounts for shoe modification codes A5503 through A5507  effective 1-1-2015.   It also discusses therapeutic shoe insert codes A5512 and A5513.


The DMEPOS fee schedule file is available at:

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule-Items/DME15-A.html?DLPage=1&DLSort=2&DLSortDir=descending


Debra Farley
Billing Director
BILLPro Management Systems
11-25-14

Below is a self-explanatory e-mail from Jurisdictin B DME MAC

Debra Farley
Billing Director
BILLPro Management Systems
11-25-14

From: Jurisdiction B DME MAC <dmemaclistserve@anthem.com>
To: debra@billpro.net
Date: 11/24/2014 04:24 PM
      
Prohibited Unsolicited Contact to Medicare Beneficiaries - Supplier Standard #11

Medicare regulations have defined standards suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) must meet in order to receive and maintain billing privileges. These DMEPOS Supplier Enrollment Standards can be found on the National Supplier Clearinghouse (NSC) website. The standards are also listed in their entirety in 42 CFR 424.57(c). All Medicare-enrolled suppliers are required to abide by these
   
   [All-About-NGS_RBoxBG]
   
   
DMEPOS supplier standards. Failure to comply with the supplier standards may result in the supplier's Medicare billing privileges being revoked.

Supplier standard #11 specifically states a supplier must agree not to contact a beneficiary by telephone when supplying a Medicare-covered item unless one of the following applies:

 -  The individual has given written permission to the supplier to contact them by telephone concerning the furnishing of a
    Medicare-covered item that is to be rented or purchased.
 -  The supplier has furnished a Medicare-covered item to the individual and the supplier is contacting the individual to
     coordinate the delivery of the item.
 -   If the contact concerns the furnishing of a Medicare-covered item other than a covered item already furnished to the
     individual, the supplier has furnished at least one covered item to the individual during the 15-month period preceding
     the date on which the supplier makes such contact.

As a condition of payment, Medicare requires that a supplier have an order from the treating physician before dispensing any DMEPOS item to a beneficiary. Additionally, there must be documentation in the beneficiary's medical record that supports the medical necessity of the DMEPOS item. For all DMEPOS items, the initial justification for medical need is established at the time the item(s) is first ordered; therefore, beneficiary medical records demonstrating that the item is reasonable and necessary are created just prior to, or at the time of, the creation of the initial prescription. For purchased items, initial months of a rental item or for initial months of ongoing supplies or drugs, information justifying reimbursement will come from this initial time period. Entries in the beneficiary's medical record must have been created prior to, or at the time of, the initial date of service (DOS) to establish whether the initial reimbursement was justified based upon the applicable coverage policy. This documentation must be available upon request. If this documentation is not made available to the contractor upon request, the claim will be denied.

If anyone has knowledge of a potential marketing violation by a DMEPOS supplier, he or she may call and report the violation to 1-800-MEDICARE or 1-800-HHS-TIPS.

If you have any questions regarding supplier standard #11 or any of the supplier standards, please contact the National Supplier Clearinghouse.

Related Content

     -  42 CFR 424.57 - Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing
        privileges at http://www.law.cornell.edu/cfr/text/42/424.57
   
     -   National Supplier Clearinghouse (Abbreviated) Medicare Durable Medical Equipment, Prosthetics, Orthotics and
         Supplies (DMEPOS) Supplier Standards at http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~National%20Supplier%20Clearinghouse~Supplier%20Enrollment~Standards%20Compliance~DMEPOS%20Supplier%20Standards~7GLS7Z1267?open&navmenu=||

Clients:

We are attaching a document prepared by BILLPro addressing the major changes in CPT 2015 (effective with 1-1-2015 date of service) affecting our client base.  This shall also be posted on our informational forum, the MESSAGE BOARD.

The document does not encompass all additions/deletions/revisions as the number of changes is too vast and specialties are so varied.  It must necessarily be the responsibility of each client to review the changes.  As all are aware, the provider of service holds the ultimate responsibility for the correct coding of his/her services.  Nothing takes the place of reviewing each code that you currently bill against the 2015 CPT code book.  One must code based on the services provided.

Reminder:  Whenever billing a time-based code, documentation must be maintained in the medical record about the duration and content of the service meaning you MUST document the start and end times of the service along with the date of service and who provided the service.

If a 2015 CPT book has not been procured by your office, we urge that it be obtained as soon as possible as it is an invaluable source of information.  One is unable to fully understand the codes unless the preface to a section is read.   The "Introduction" section of the CPT is so insightful.  We know that in the AMA edition of the CPT book, available at https://commerce.ama-assn.org/store/, there is an "Appendix B" which is a "Summary of Additions, Deletions, and Revisions."  Another source for the book is from PMIC, a leading independent distributor of coding books, located at http://www.medicalcodingbooks.com/category/publishers-pmic.

Please do share this with your office staff.

Debra Farley
Billing Director
BILLPro Management Systems
11-21-14

CLIENTS:

This is an update to my 9-2-14 email which is included -- please scroll down.  As promised, directly below is information copied from the CMS website today which contains the 2014-2015 flu vaccine pricing.  Please do review your pricing and modify as warranted.   If you find your fee(s)  have been less than the payment allowance, please so inform your account manager as she can request a "mass adjustment" to those claims previously processed.  Do remember the pricing below is for dos 8-1-14 thru 7-31-2015 dates of service.

Payment Allowances and Effective Dates of for the 2014-2015 Flu Season:

    CPT 90654 Payment allowance is $18.918. Effective dates: 8/1/2014-7/31/2015
    CPT 90655 Payment allowance is pending. Effective dates: 8/1/2014-7/31/2015
    CPT 90656 Payment allowance is $14.096. Effective dates: 8/1/2014-7/31/2015
    CPT 90657 Payment allowance is $6.022. Effective dates: 8/1/2014-7/31/2015
    CPT 90661 Payment allowance is $21.666. Effective dates: 8/1/2014-7/31/2015
    CPT 90662 Payment allowance is $33.374. Effective dates: 8/1/2014-7/31/2015
    CPT 90672 Payment allowance is $25.736. Effective dates: 8/1/2014-7/31/2015
    CPT 90673 Payment allowance is $37.193 Effective dates: 9/26/2014-7/31/2015
    CPT 90685 Payment allowance is $23.900. Effective dates: 8/1/2014-7/31/2015
    CPT 90686 Payment allowance is $17.984. Effective dates: 8/1/2014-7/31/2015
    CPT 90687 Payment allowance is $9.134. Effective dates: 8/1/2014-7/31/2015
    CPT 90688 Payment allowance is $16.844. Effective dates: 8/1/2014-7/31/2015
    HCPCS Q2035 Payment allowance is $11.885. Effective dates: 8/1/2014-7/31/2015
    HCPCS Q2036 Payment allowance is $8.579. Effective dates: 8/1/2014-7/31/2015
    HCPCS Q2037 Payment allowance is $15.396. Effective dates: 8/1/2014-7/31/2015
    HCPCS Q2038 Payment allowance is $12.044. Effective dates: 8/1/2014-7/31/2015
    HCPCS Q2039 Flu Vaccine Adult - Not Otherwise Classified payment allowance is to be determined by the local claims processing contractor with effective dates of 8/1/2014-7/31/2015.



Debra Farley
Billing Director
BILLPro Management Systems
11-17-14

    From: Debra [mailto:debra@billpro.net]
    To: kerio_bpm [mailto:bpm@billpro.net]
    Sent: Tue, 02 Sep 2014 06:39:24 -0500
    Subject: CMS: New Article: Influenza Vaccine Payment Allowances - Annual Update for 2014-2015 Season


    CLIENTS:

    Please scroll down to the CMS e-mail announcing a new article, number MM8890 titled  "Influenza Vaccine Payment Allowances - Annual Update for 2014-2015 Season."   The allowances would be from 8/1/2014 - 07/31/2015.

    As all the payment allowances are "pending," CMS states "MACs will not search their files either to retract payment for claims already paid or to retroactively pay claims prior to the implementation date of CR8890.   However, they will adjust claims that you bring to their attention."   Please note the implementation date for MM8890 is 11/24/2014.

    Below are the CURRENT payment allowances for the flu vaccines:

    90654 - $18.92
    90655 - $17.24
    90656 - $12.40
    90657 - $ 6.02
    90661 - $20.66
    90662 - $31.82
    90672 - $24.60
    90673 - $36.48
    90685 - $23.23
    90686 - $19.41
    90687 - not posted
    90688 - not posted
    Q2035 - $11.54
    Q2036 - $ 8.58
    Q2037 - $14.96
    Q2038 - $12.04

    When CMS publishes the 2014-2015 payment allowances, and it may not be until November or December 2014, we shall provide that information to you.  If it is then determined that your fee(s) for the flu vaccine(s) was lower than the allowance, BILLPro can request a "mass adjustment" to those claims from CGS Medicare.



    Debra Farley
    Billing Director
    BILLPro Management Systems

        From: CMS MLNMatters-L [mailto:MedlearnMatters-L@CMS.HHS.GOV]
        To: MLNMATTERS-L@LIST.NIH.GOV
        Sent: Thu, 28 Aug 2014 15:28:17 -0500
        Subject: New  Article Posted to MLN Matters

           

         

        New:
         

        MM8890 – Influenza Vaccine Payment Allowances - Annual Update for 2014-2015 Season

        http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8890.pdf

         

Please scroll down for the self-explanatory CMS e-mail below announcing "Important 2015 PQRS Changes."

Do note "there is no incentive for 2015 PQRS reporting."


Debra Farley
Billing Director
BILLPro Management Systems
11-17-14

    From: Centers for Medicare & Medicaid Services [mailto:cmslists@subscriptions.cms.hhs.gov]
    To: debra@billpro.net
    Sent: Fri, 14 Nov 2014 13:29:48 -0500
    Subject: CMS Releases 2015 Physician Fee Schedule Final Rule

    CMS Releases 2015 Physician Fee Schedule Final Rule

    On October 31, 2014, CMS issued the final rule that updates the payment policies and payment rates for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2015. The rule changes several of the quality reporting initiatives associated with PFS payments, including the Physician Quality Reporting System (PQRS).

    Important 2015 PQRS Changes

     The rule includes several changes for the 2015 PQRS program. Major highlights include:

        EPs and group practices that meet the criteria for 2015 PQRS reporting will avoid the negative payment adjustment in 2017
        A total of 255 measures in 2015, including:
            63 outcome-based measures
            19 cross-cutting measures
            Addition of two measures groups
            Removal of five measures groups
        Critical Access Hospitals Method II (CAH-II) may now report PQRS via claims

    Note: There is no incentive for 2015 PQRS reporting.

    The final rule was published in the Federal Register on November 13, 2015.

    More Information

    For more information about participating in PQRS in 2015, visit the CMS PQRS website. 

The CMS e-mail below is self explanatory.

 Debra Farley
 Billing Director
 BILLPro Management Systems
 
        From: Centers for Medicare & Medicaid Services [mailto:cmslists@subscriptions.cms.hhs.gov]
        To: debra@billpro.net
        Sent: Thu, 13 Nov 2014 17:09:38 -0500
        Subject: CMS Announces Distribution of 2012 PQRS Supplemental Incentive Payments has Begun

        CMS Announces Distribution of 2012 PQRS Supplemental Incentive Payments has Begun

        CMS is pleased to announce that the 2012 Physician Quality Reporting System (PQRS) Supplemental Incentives have begun to be distributed to eligible professionals who submitted data for the reporting period of January 1, 2012 through December 31, 2012 and met criteria for satisfactory reporting. 2012 PQRS Supplemental Incentives will be provided to those eligible professionals (EPs) who submitted a PQRS Informal Review (IR) request that was approved by CMS.

        The incentive is 0.5% of total estimated 2012 Medicare Part B Physician Fee Schedule (PFS) allowed charges for covered professional services furnished during reporting period.

            Paid as lump sum to the Taxpayer Identification Number (TIN) under which the eligible professional’s claims were submitted.
            PQRS incentive payments will also include an additional 0.5% for the Maintenance of Certification Program Incentive, if applicable.

        If needed, please contact the QualityNet Help Desk for assistance. They can be reached at 1-866-288-8912 (TTY 1-877-715-6222) or via qnetsupport@hcqis.org from 7:00 a.m. to 7:00 p.m. CST Monday through Friday.

         
        Centers for Medicare & Medicaid Services (CMS) has sent this update. To contact Centers for Medicare & Medicaid Services (CMS) go to our contact us page.

To read the complete final CMS Rule for the Medicare Program for 2015 including revisions to payment policies under the physician fee schedule and clinical lab fee schedule along with other information, please visit

    https://s3.amazonaws.com/public-inspection.federalregister.gov/2014-26183.pdf

Even though the final rule addresses Medicare, we all are aware many other payers soon follow Medicare's rules.

Below is an article of interest published by "Part B Insider."

Part B Insider (Multispecialty) Coding Alert
[Print Friendly and PDF] [More Options]
Part B Payment: Final Fee Schedule Confirms Phasing out of Global Periods
- Published on Fri, Nov 07, 2014

Plus: You will see an extra $40.39 for every month of chronic care management.

When CMS announced on Halloween that it had published the 2015 Physician Fee Schedule Final rule, many practices were a bit spooked to review it—but fortunately, the finalized version of the document doesn’t differ too wildly from the proposal that the agency published earlier this year. Read on to discover several of the most impactful items from the 1,185-page document.


No Negative Conversion Factor—Yet

When it comes to the conversion factor, the fee schedule had some good news. Because the Protecting Access to Medicare Act won’t allow any cuts in the conversion factor through March 31, 2015, CMS has finalized the conversion factor of $35.7977 through that date. Starting April 1, however, you’ll be looking at a conversion factor cut of 21.2 percent through the end of 2015 unless Congress votes to reverse the cut.

“In most prior years, Congress has taken action to avert a large reduction in Physician Fee Schedule rates before they went into effect,” CMS says in a fact sheet about the new fee schedule. “The administration supports legislation to permanently change the sustainable growth rate (SGR) to provide more stability for Medicare beneficiaries and providers while promoting efficient, quality health care.” Of course, whether the SGR does get an overhaul in the near future will be anyone’s guess, but with both physicians and CMS supporting a change to it, something might transpire in the coming months.

In addition to the potential 21.2 percent cut, other specialties may see pay cuts whether or not Congress votes to avert that deep discount. Ophthalmologists and dermatologists in particular are expected to see a two percent cut to their Medicare payments, according to the Final Rule.

Specialties that could see a positive turn include family practitioners, emergency room physicians, infectious disease providers, physical therapists and internists, who are expected to enjoy a one percent raise each.


Chronic Care Pay Will Offer Extra Reimbursement

It makes sense that the primary care doctors will see payment increases, since CMS appears to be following through on its promise to offer separate payment for chronic care management (CCM) services starting in 2015. CMS has confirmed a $40.39 payment rate for the CCM code (99490), which can be billed once a month for qualified patients. The CCM code will be classified as a non-face-to-face service for patients with at least two significant chronic conditions. These services will include “regular development and revision of a plan of care, communication with other treating health professionals and medication management,” CMS says.

Here’s the catch: You’ll soon need an electronic health record (EHR) system “that is in use on December 31 of the prior calendar year for the EHR Incentive Programs to bill for CCM services,” the agency says. This means that if you want to collect for CCM in 2015, you’ll need to have your certified EHR in use by Dec. 31 of this year.


Don’t Get Attached to Global Periods

Following through on suggestions that were in the proposed rule, CMS has confirmed that it will phase out global periods. In 2017, all services with 10-day global periods will be assigned zero-day globals, and by 2018, the 90-day globals will fall to zero days as well.

Because CMS seems to believe that Medicare is wasting cash by paying doctors for global periods that include visits the doctors don’t actually perform, CMS will start evaluating whether a better payment model could be created to reimburse doctors for surgical services “that incentivizes care coordination and care redesign across an episode of care,” CMS says in its fact sheet.


CMS Updates Mammography Rules

Although CMS had proposed eliminating G codes for mammograms, the agency decided to reverse its position on the topic at this point. “We believe it is appropriate to continue to recognize both the CPT® codes and the G codes for mammography for CY 2015, as we consider appropriate valuations now that digital mammography is typical,” CMS says in the Final Rule. “Therefore, we are not finalizing our proposal to delete the G codes. We are, however, making a change in the descriptors to make clear that the G0202, G0204 and G0206 are specific to 2D mammography.” You should report these codes with one of the 3D screening mammography codes when furnished using 3D mammography.

In addition, CMS has debuted new code G2079 (Diagnostic digital breast tomosyntehsis, unilateral or bilateral) as an add-on code to report with the corresponding 2D diagnostic mammography G code when diagnostic breast tomosynthesis is employed. CMS intends to assign the same RVUs to this new code as it has assigned to 3D screening mammography code 77063, which is valued at about $57.00.


Telehealth Payments Could Come Your Way

CMS has added several services as payable under the telehealth benefit effective Jan. 1, including psychoanalysis (90845), family psychotherapy (90846-90847), annual wellness visits (G0438-G0439) and prolonged services (add-on codes 99354-99355).

Keep in mind that a phone call won’t allow you to meet the telehealth requirement—you need a two-way, real-time communication system that includes both audio and video, such as a Skype session. “Telephones, facsimile machines and electronic mail systems do not meet the definition of an interactive telecommunications system,” CMS says in the Final Rule.

                                                     ********************************

In the not too distant future, BILLPro shall be providing the major CPT updates for calendar year 2015.  We believe it an absolute MUST that every practice obtain the 2015 edition which contans an appendix of the "Summary of Additions, Deletions, and Revisions."  This is the only way you will know changes specific to your practice.           

Debra Farley
Billing Director
BILLPro Management Systems
11-13-14

The OIG (Office of Inspector General) recently released its 2015 OIG Work Plan. To read the entire work plan, visit

       http://oig.hhs.gov/reports-and-publications/archives/workplan/2015/FY15-Work-Plan.pdf

Below is an article appearing in a recent edition of the publication "Part B Insider" related to the 2015 Work Plan.

Part B Insider (Multispecialty) Coding Alert
Compliance: OIG Sets Sights on Hospital Admissions, Place of Service Coding
- Published on Fri, Nov 07, 2014

The latest Work Plan focuses on several new areas.

This year, you’ll want to make sure you button up your documentation for inpatient admissions, because the OIG has released its long-awaited 2015 Work Plan -- which includes the agency’s intentions to review Medicare claims for everything from physical therapy to place of service coding and beyond.

What the Work Plan is: The OIG Work Plan details issues that the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General will address during the fiscal year. The agency published its latest document on Oct. 31, which outlines the target areas it will be reviewing in 2015, and we’ve got the highlights below.

Inpatient Admissions Under Fire

    One of the OIG’s 2015 intentions is to evaluate whether hospital admissions were appropriate or not. “Previous OIG work identified millions of dollars in overpayments to hospitals for short inpatient stays that should have been billed as outpatient stays,” the Work Plan notes.

    As most practices know, physicians should only admit Medicare patients who are expected to require at least two nights of hospital care (also referred to as the “two midnight policy.”)

    Translation: The OIG appears to be looking for incidences of inpatient admissions when the patient is actually only expected to be in the hospital for less than two overnight periods, which would constitute a misuse of the admissions policy.

    How to Button up: To ensure that you aren’t vulnerable to this target area, confirm that your physicians are aware of the two midnight rule, and that they strive to treat patients who don’t require two nights in the hospital as outpatients.


Differentiate ‘AA’ From ‘QK’ Modifier

    Another hot spot for the OIG is personally-performed anesthesia services. “We will also determine whether Medicare payments for anesthesiologist services reported on a claim with the ‘AA’ service code modifier met Medicare requirements,” the OIG said in the Work Plan. “Reporting an incorrect service code modifier on the claim as if services were personally performed when they were not will result in Medicare’s paying a higher amount.”

    Translation: The OIG believes that Medicare might be overpaying for anesthesia services due to misuse of the AA modifier (Anesthesia services performed personally by anesthesiologist). If the anesthesiologist does not personally perform the anesthesia, you should not bill as if he did, and you shouldn’t append modifier AA to the service code.

    How to Button up: If the anesthesiologist personally performs a case, you must know where he is for the entire procedure and report modifier AA with the procedure code. The carrier pays him for the entire case.

    Coding gets trickier when the anesthesiologist oversees other members of the team rather than personally performing cases. If he medically directs one CRNA, report modifier QY (Medical direction of one certified registered nurse anesthetist [CRNA] by an anesthesiologist) with the procedure code; if he directs from two to four anesthetists, report modifier QK (Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals) instead. If you report modifier QK, your payment will be limited to 50 percent of the Medicare-allowed amount because you’ll be splitting it with the other anesthetists.


Know Your Place of Service

    If you perform a considerable number of services at ASCs or hospital outpatient departments, double and triple-check your place of service (POS) coding to ensure that you didn’t erroneously lead your payer to believe that you performed the service in your office.

    “Prior OIG reviews determined that physicians did not always correctly code nonfacility places of service on Part B claims submitted to and paid by Medicare contractors,” the OIG says in the Work Plan.

    Translation: Because CMS reimburses more money for procedures performed in your office than those performed in hospitals, you’re getting overpaid for services that you misidentify with POS 11 (Office) if the service actually took place elsewhere.

    How to Button up: If you perform services in an outpatient hospital setting, you should use place of service 22 instead of 11. If the service took place in an ASC, you should instead use POS code 24.

    Remember: Even if your physician performs 80 percent of his procedures in the hospital, it’s possible that a dermatological procedure here or a fracture setting there will take place in the office, so you can never assume that you know the POS when you read a chart. Therefore, you should always be sure to confirm where a procedure was performed before you file the claim with the POS code. 


Physical Therapists Should Confirm Medical Necessity

    Physical therapists who perform a variety of outpatient services will be under the microscope next year, as the OIG scrutinizes whether the claims were in compliance with Medicare rules.

    “Prior OIG work found that claims for therapy services provided by independent physical therapists were not reasonable or were not properly documented or that the therapy services were not medically necessary,” the OIG says in the Work Plan.

    Translation: The OIG only wants to see PTs report services that are reasonable and medically necessary, rather than reviewing claims for services that appear to be at a patient’s request or for conditions that aren’t covered.

    How to button up: Go over your documentation to confirm that a provider has ordered the physical therapy for a valid medical reason and that your services meet CMS’s requirements.


Ophthalmologists, Chiropractors Also Under the Microscope

    The OIG will also be reviewing ophthalmology claims that were submitted in 2012 “to identify potentially inappropriate and questionable billing.” Although the agency hasn’t said which specific services they’re targeting, the Work Plan points out that Medicare paid over $6.8 billion for ophthalmology services in 2010, which is clearly the trigger for this current audit.

    In addition, the OIG will be reviewing Part B payment for chiropractic services to ensure that every Part B claim is solely for the purpose of manual manipulation of the spine to treat a subluxation, since that’s the only chiropractic service that Medicare covers. In the past, the agency identified a chiropractor with a startling 93 percent error rate who overbilled Medicare by about $700,000, so CMS is ensuring that this is not a common practice.


Debra Farley
Billing Director
BILLPro Management Systems
11-13-14
   

Below is a revised article from CMS on "Hospice Related Services - Part B."  Please click on the link for the full article.

    Debra Farley
    Billing Director
    BILLPro Management Systems
    11-12-14

        From: CMS MLNMatters-L [mailto:MedlearnMatters-L@CMS.HHS.GOV]
        To: MLNMATTERS-L@LIST.NIH.GOV
        Sent: Mon, 10 Nov 2014 06:50:42 -0500
        Subject: Revised Article Posted to MLN Matters

     

        Revised:

        SE1321 – Hospice Related Services - Part B

        http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1321.pdf

On November 5, 2014  CMS held a National Provider call on "Transitioning to ICD-10."  The presentation is available at

http://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events.html

      Scroll down and under "Date" click on "2014-11-05" for the presentation

PREVIOUS BILLPRO REMINDERS:

A) As we have previously published when the implementation date was set for 10-1-2014, please ensure your practice has enough
    of a monetary cushion should there be major problems when ICD-10 is implemented which could severely impede cash flow.  If
   you do not have a line of credit with a banking institution or you believe it may not be in a sufficient amount, take steps to   
    seek  same.  Some payers may not permit both ICD-9 and ICD-10 codes on the same claim while others will request that they be
    submitted on the same claim when dates of service span the compliance date.   This could result in a slower cash flow until it is
    determined how carriers want claims submitted!     

B)  The responsibility for ICD-10 education must be the sole responsibility of our clients as this is a MAJOR overhaul!  BILLPro's
     responsibility is education of its employees.  Will we keep you up-to-date on ICD-10?   Yes, as we are provided information.

C)  If you (or members of your office) do not have access to the MESSAGE BOARD, please contact Wendy Erbskorn at BILLPro at
     440-854-0213, 1-800-736-0587 ext 0213 or by e-mail at wxb@billpro.net.  This site holds  vast amounts of information including
     ICD-10 information


Debra Farley
Billing Director
BILLPro Management Systems
11-7-14

The e-mail below is self-explanatory.

Debra Farley
Billing Director
BILLPro Management Systems
11-4-14


From: Jurisdiction B DME MAC <dmemaclistserve@anthem.com>
To: debra@billpro.net
Date: 11/03/2014 03:30 PM
Subject: Jurisdiction B “Tip of the Week” – Items Provided in Anticipation of Discharge from a Hospital or Skilled Nursing Facility

     
      
Jurisdiction B "Tip of the Week" - Items Provided in Anticipation of Discharge from a Hospital or Skilled Nursing Facility

A supplier may deliver a durable medical equipment prosthetics, orthotics and supplies (DMEPOS) item to a patient in a hospital or nursing facility for the purpose of fitting or training the patient in the proper use of the item. This may be done up to two days prior to the patient's anticipated discharge to their home. The supplier should bill the date of service on the claim as the date of discharge and shall use the place of service (POS) as 12 (patient's home). The item must be for subsequent use in the patient's home. No billing may be made for the item on those days the patient was receiving training or fitting in the hospital or nursing facility.

Related Content

    Proof of Delivery Requirements, Chapter 8, JB Supplier Manual  at http://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/Supplier-Manual/chapter%208%20documentation/proof%20of%20delivery%20requirements/!ut/p/a1/1VRNU8IwEP0r9cCxk5RWKMeUoiMfgjIMTS9ObBII06Y1TWHw15si43RUQG-aySFvs_t2sy8JiEEEYkm2YkW0yCVJaxx3njx0N3CcPhzdwlEA0Wi28B_DueN1HLAEMYjH0z7AKE2tuSaalbVpUylRUpHUPAAPG8gK6n25KsfTAOBwMviAX0gSqQu9BtjsZsyEE8WSXGomtWS7FmyYD7ionlOD6iRlC2ZEViQ1i7IqilQw9W5owWRNCs2U5Vs0T6rMsB1CTLzKc26ZSVkqtkztLcVeKqFY7XMoqEgEBZh3PNpzuWvzxO_ZHoHc9qlZ0YS6Puxy3nV67205HjAC2HQRnhgI_qjJTZepO_Uh8m6CMHyYubdB--hwJgU2NXRPJuk5YF5zLPuTp4fF4NF4f9YDn5UUNwXF38iJm3L_oo_n6x50_2fdC--v1j28dBnNZW6rSX-yMrREr20heQ6iE48KRBce1dL8BmNBN3c7UGSZ7x6nHcHNdbFCaHZvE4xQ-MqzDCHku9fpZo-u3gA-Ic_Q/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?LOB=DME&LOC=All%20States&ngsLOB=DME&ngsLOC=All%20States&jurisdiction=Jurisdiction%20B

   

Your attention is directed to the CMS e-mail received today announcing a new article titled "Medicare Coverage of Ultrasound Screening for Abdominal Aortic Aneurysms (AAA) and Screening Fecal-Occult Blood Tests (FOBT)."

It is not only important to read the article, it is important to click on and read the three transmittals located under "Additional Information" on the second page which is the official, detailed instruction.

Debra Farley
Billing Director
BILLPro Management Systems
   
        From: CMS MLNMatters-L [mailto:MedlearnMatters-L@CMS.HHS.GOV]
        To: MLNMATTERS-L@LIST.NIH.GOV
        Sent: Mon, 03 Nov 2014 06:54:32 -0500
        Subject: New Article Posted to MLN Matters

          New:

        MM8881 – Medicare Coverage of Ultrasound Screening for Abdominal Aortic Aneurysms (AAA) and Screening Fecal-Occult Blood Tests (FOBT)

        http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8881.pdf

         

         

Please scroll down to an e-mail from Ohio Medicaid addressing ICD-10 and retain for future reference.  Please share with your office staff.

We suggest bookmarking the Medicaid webpage provided below and visit it frequently.

Debra Farley
Billing Director
BILLPro Management Systems
10-31-14

    From: Day, Douglas [mailto:Douglas.Day@mha.ohio.gov]
    To: Debra _Farley [mailto:debra@billpro.net]
    Sent: Thu, 30 Oct 2014 08:00:46 -0500
    Subject: Ohio Medicaid ICD-10 Billing Guidance


     Several  ICD-10 resources are  available on ODM’s ICD-10 webpage at http://medicaid.ohio.gov/PROVIDERS/Billing/ICD10.aspx. ODM will continue to update the webpage throughout the year and hope it serves as a valuable resource to our providers. If you have any questions on Ohio Medicaid ICD-10 transition, you may send them to ICD10question@medicaid.ohio.gov

     From the webpage is Ohio Medicaid’s first billing guidance document for ICD-10 implementation, entitled ICD-10 TIPS.  It focuses on the compliance date for ICD-10 usage on claims. Going forward, ICD-10 billing guidance will be posted regularly in the ICD-10 TIPS (Billing Guidance) section of Ohio Medicaid’s ICD-10 webpage under the ICD-10 TIPS (Billing Guidance) section.

Douglas L. Day, Chief, Bureau of Health Integration
Ohio Department of Mental Health and Addiction Services (OhioMHAS)
30 East Broad Street, 36th Floor
Columbus, Ohio, 43215