Please see the CMS e-mail below which is self-explanatory.

Debra Farley
Billing Director
BILLPro Management Systems
4-10-14

From: Centers for Medicare & Medicaid Services <cmslists@subscriptions.cms.hhs.gov>
To: debra@billpro.net
Date: 04/09/2014 10:04 AM
Subject: HHS News: Historic release of data gives consumers unprecedented transparency on the medical services physicians provide and how much they are paid
[Centers for Medicare &amp; Medicaid Services]
 

 

Historic release of data gives consumers unprecedented transparency on the medical services physicians provide and how much they are paid

Today, as part of the Obama administration’s work to make our health care system more transparent, affordable, and accountable, Health and Human Services (HHS) Secretary Kathleen Sebelius announced the release of new, privacy-protected data on services and procedures provided to Medicare beneficiaries by physicians and other health care professionals. The new data also show payment and submitted charges, or bills, for those services and procedures by provider.

“Currently, consumers have limited information about how physicians and other health care professionals practice medicine,” said Secretary Sebelius “This data will help fill that gap by offering insight into the Medicare portion of a physician’s practice. The data released today afford researchers, policymakers and the public a new window into health care spending and physician practice patterns.”

The new data set has information for over 880,000 distinct health care providers who collectively received $77 billion in Medicare payments in 2012, under the Medicare Part B Fee-For-Service program. With this data, it will be possible to conduct a wide range of analyses that compare 6,000 different types of services and procedures provided, as well as payments received by individual health care providers.

The information also allows comparisons by physician, specialty, location, the types of medical service and procedures delivered, Medicare payment, and submitted charges. Physicians and other health care professionals determine what they will charge for services and procedures provided to patients and these “charges” are the amount the physician or health care professional generally bills for the service or procedure.

"Data transparency is a key aspect of transformation of the health care delivery system,” said CMS Administrator Marilyn Tavenner. “While there’s more work ahead, this data release will help beneficiaries and consumers better understand how care is delivered through the Medicare program.”

Last May, CMS released hospital charge data allowing consumers to compare what hospitals charge for common inpatient and outpatient services across the country.

To view the physician dataset, please visit: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier.html.

 

Below is an article published by CGS Medicare on 4-9-14 which is self-explanatory.

Debra Farley
Billing Director
BILLPro Management Systems
4-10-14


April 9, 2014

Mandatory Payment Adjustment Percentage of 2% Extended for Medicare Fee-for-Service (FFS) Claims (Sequestration)

The Q&As below were previously issued via Technical Direction Letter (TDL)-13276 dated March 25, 2013. Claim Adjustment Reason Code (CARC) 253 has since replaced the previous CARC 223:

Question: How is the 2% payment reduction under sequestration identified on the electronic remittance advice (ERA) and the standard paper remittance (SPR)?

Answer: Claim adjustment reason code (CARC) 253 is used to report the sequestration reduction on the ERA and SPR.

Question: What is the verbiage for CARC 253?

Answer: "Sequestration – reduction in federal payment."

The Q&A below was previously issued via TDL-13321 dated April 19, 2013. The below change is for the Sequestration through date only:

Question: How long is the 2% reduction to Medicare fee-for-service claim payments in effect?

Answer: The sequestration order covers all payments for services with dates of service or dates of discharge (or a start date for rental equipment or multi-day supplies) April 1, 2013 through March 31, 2015.

In the April 2014 issue of Anthem's publication "Network Update" an article appeared titled "Correct use of the GY Modifier."  It is attached to this post

Debra Farley
Billing Director
BILLPro Management Systems
4-54-14

Quoted below (in blue) is an article appearing in the Thursday, 4-3-14 issue of "CMS MLN CONNECTS Weekly Provider eNews":

Mandatory Payment Reduction of 2% Continues through March 31, 2015, for the Medicare FFS Program - "Sequestration"

    For the Medicare Fee-for-Service (FFS) program, claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will continue to incur a 2 percent reduction in Medicare payment through March 31, 2015.  Claims for durable medical equipment (DME), prosthetics, orthotics, and supplies, including claims under the DME Competitive Bidding Program, will continue to be reduced by 2 percent based upon whether the date-of-service, or the start date for rental equipment or multi-day supplies, is on or after April 1, 2013.  The claims payment adjustment will continue to be applied to all claims after determining coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments.  Though beneficiary payments for deductibles and coinsurance are not subject to the 2 percent payment reduction, Medicare's payment to beneficiaries for unassigned claims is subject to the 2 percent reduction.  CMS encourages Medicare physicians, practitioners, and suppliers who bill claims on an unassigned basis to continue discussions with beneficiaries the impact of sequestration on Medicare's reimbursement.  Questions about reimbursement should be directed to your Medicare Administrative Contractor.

Debra Farley
Billing Director
BILLPro Management Systems
4-5-14
   

Below is an e-mail from CMS announcing a new policy "SE1416 – Updating Beneficiary Information with the Benefits Coordination & Recovery Center (formerly known as the Coordination of Benefits Contractor)."  The full article is available by clicking on the link provided.

This information should be provided to your office staff.


Debra Farley
Billing Director
BILLPro Management Systems
4-5-14

    From: CMS MLNMatters-L [mailto:MedlearnMatters-L@CMS.HHS.GOV]
    To: MLNMATTERS-L@LIST.NIH.GOV
    Sent: Fri, 04 Apr 2014 10:44:38 -0500
    Subject: New/Revised Articles Posted to MLN Matters (1/1)
   
    New:

    SE1416 – Updating Beneficiary Information with the Benefits Coordination & Recovery Center (formerly known as the Coordination of Benefits Contractor)

    http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1416.pdf

     

Please see the CGS Medicare e-mail below received yesterday with the subject "President Obama Signs the Protecting Access to Medicare Act of 2014" and click on the link for the full article.

Please note that the article states "The new law extends several expiring provisions of law. We have included Medicare billing and claims processing information associated with the new legislation. Please note that these provisions do not reflect all of the Medicare provisions in the new law, and more information about other provisions will be forthcoming."  That is why there is nothing mentioned of the delay until 10-1-2015 for ICD-10 implementation -- more information will be coming.


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


        From: MedicareEmailList@cgsadmin.com
        To: debra@billpro.net
        Sent: Thu, 03 Apr 2014 16:52:18 -0500
        Subject: Ohio Part B News from CGS

        Ohio Part B News from CGS
        President Obama Signs the Protecting Access to Medicare Act of 2014 – On April 1, 2014, President Obama signed into law the Protecting Access to Medicare Act of 2014. This new law prevents a scheduled payment reduction for physicians and other practitioners who treat Medicare patients from taking effect on April 1, 2014. This new law maintains the 0.5 percent update for such services that applied from January 1, 2014 through March 31, 2014 for the period April 1, 2014 through December 31, 2014. It also provides a zero percent update to the 2015 Medicare Physician Fee Schedule (MPFS) through March 31, 2015. Read more...

        http://www.cgsmedicare.com/ohb/pubs/news/2014/0414/cope25254.html

Below is an article appearing in the publication, "Part B Insider (Multispecialty) Coding Alert, Volume 15, Number 12 that is of interest.  Please do share with any practice this is respective to.

Part B Insider (Multispecialty) Coding Alert
Part B Mythbuster: Make Your Global Period X-Ray Claims Picture Perfect- Published on Fri, Mar 28, 2014
Find out when to apply modifier 76.

Myth: X-rays that you shoot or interpret during the global period are not billable to Medicare because payers include these charges in the surgical package.

Reality: Practices that don’t bill their x-ray charges are throwing away thousands of dollars in rightful reimbursement.

Scenario: An established patient reports to your office with pain, swelling, and tenderness of the left wrist and forearm. The physician diagnoses the patient with a buckle fracture of the wrist, which he stabilizes with a splint before sending the patient home. The patient returns four weeks later and the physician takes two follow-up x-rays of the patient’s forearm.

Bill Those Follow-Up X-Rays

The challenge: You should report fracture care (25600, Closed treatment of distal radial fracture [e.g., Colles or Smith type] or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation) and any x-rays performed for the initial visit. But can you report the follow-up x-rays?

The solution: Go ahead and report those films. If your practice performed and interpreted the x-rays, report 73090 (Radiologic examination; forearm, two views).

X-rays determine the patient’s condition and the course of care, so they are not included in global packages. You can also report any follow-up x-rays separately. If you don’t separately report the x-rays, you risk losing significant reimbursement.

Because Medicare payers will reimburse about $28 each time you report 73090, failing to report the x-rays could be an expensive mistake over the course of a year.

When a fracture care code is selected, this only includes the initial casting and all follow-up visits within the 90 day global period. All x-rays, subsequent castings and supplies are not included in the fracture care code. These services and supplies are not considered as edits or mutually exclusive codes by the Correct Coding Initiative (CCI).

Billing x-rays outside of the global period doesn’t apply only to fracture care claims. In fact, diagnostic services are not considered part of the global package in general, and may be billed separately.

Per the American Academy of Orthopaedic Surgery’s Global service data guidelines and CCI, the only x-rays that are included in a procedure are those that are intra-operative, such as checking the placement if a manipulation was performed before the cast was placed. X-rays that are taken pre- and post-reduction , i.e. before manipulation and after manipulation and casting have taken place, are reported using the correct CPT® code from the radiology section and appending a modifier 76 (Repeat procedure or service by same physician or other qualified healthcare professional) to the post-reduction x-ray.


Debra Farley
Billing Director
BILLPro Management Systems
4-2-14

Your attention is directed to the Healthcare Billing and Management Association's e-mail (please scroll down) which I came into today.  It says it all.

Please click on the following link to view how the Senate voted and for more details to this issue.

     http://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=113&session=2&vote=00092&utm_source=APRIL+2014+Newsletter+03%2F31%2F2014+8pm&utm_campaign=&utm_medium=email

We have noted from our client community in the last couple of months, the nervousness that has prevailed when the implementation date for ICD-10 was 10-1-14.  Now that we will have a year's extension, after the President signs the bill, we all know how seriously preparation for ICD-10 is and that we must CONTINUE to prepare.  ICD-10 is not going to be delayed forever!

In the coming weeks, BILLPro will be providing its clients with their top 100 ICD-9 diagnoses codes billed since 1-1-2014.  We would ask that this be used as a tool so that your practice can begin to convert the ICD-9 codes to the proper ICD-10 codes.  As a reminder, very, very few ICD-9 codes can be crosswalked to only one ICD-10 code.  We  must also take into consideration that come 10-1-15 there will be a period of dual coding necessary as we are sure there will be some payers who will not be ready for ICD-10 and those payers that are not required to accept ICD-10.

STAY TUNED!

Debra Farley
Billing Director
BILLPro Management Systems
4-1-14

        From: HBMA [mailto:info@hbma.org]
        To: debra@billpro.net
        Sent: Mon, 31 Mar 2014 19:47:34 -0500
        Subject: Senate Passes SGR Patch/ICD-10 Delay

        [ ]

         
        March 31, 2014

        To:          HBMA Membership
        From:    GR Committee
        Re:         SGR Patch/ICD-10 Delay

        The United States Senate has joined the House of Representatives and passed legislation to prevent a 24% cut in physician fee schedule payments from occurring tomorrow (4/1) as previously scheduled.  Instead, Medicare physician fee schedule payments will continue to be paid as they have been for the past 3 months.   Although the legislation must be signed by the President in order to become effective, the President has indicated that he will sign this legislation once it reaches his desk.

        The so-called SGR Patch approved by Congress will be in effect for 12 months, expiring on March 31, 2015.  Between now and then, Congress will have to enact a permanent fix or enact another patch to prevent a huge drop in Medicare Physician payments next April 1.

        In addition to preventing the SGR related reduction, Congress approved language extending various other Medicare provisions slated to expire at Midnight tonight.  These include:

            Extends Medicare work Geographic Practice Cost Index (GPCI) floor for 1 year
            Extends Medicare therapy cap exception process for 1 year
            Extends Medicare ambulance add-on payments for 1 year
            Extends Medicare adjustment for Low-Volume hospitals for 1 year
            Extends Medicare-dependent Hospital (MDH) program for 1 year

        In addition to these “extenders” Congress also approved a one-year delay in the effective date of the ICD-10 transition.  As you know, ICD-10 has been scheduled to take effect on October 1, 2014.  Due to Congressional intervention, the new effective date will be October 1, 2015.

        A more detailed discussion of the short-term fixes and how Congress intends to pay for these fixes will be in the HBMA March Washington Report.

        The Healthcare Billing & Management Association (HBMA) is a member-led trade association committed to the education of medical billers and promotion of high ethical and professional standards within the industry. HBMA also advocates and educates legislative stakeholders and federal agencies to improve the business of medical billing and the practice of healthcare. HBMA members manage claims on behalf of hospital-based physicians, physician practices and other providers, and represent more than 30,000 individuals and over 600 companies. To learn more about HBMA, please visit www.hbma.org.
        Copyright 2014 HBMA. All Rights Reserved.

         

           

Your attention is directed to the Healthcare Billing and Management Association's e-mail (please scroll down) which I came into today.  It says it all.

Please click on the following link to view how the Senate voted and for more details to this issue.

     http://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=113&session=2&vote=00092&utm_source=APRIL+2014+Newsletter+03%2F31%2F2014+8pm&utm_campaign=&utm_medium=email

We have noted from our client community in the last couple of months, the nervousness that has prevailed when the implementation date for ICD-10 was 10-1-14.  Now that we will have a year's extension, after the President signs the bill, we all know how seriously preparation for ICD-10 is and that we must CONTINUE to prepare.  ICD-10 is not going to be delayed forever!

In the coming weeks, BILLPro will be providing its clients with their top 100 ICD-9 diagnoses codes billed since 1-1-2014.  We would ask that this be used as a tool so that your practice can begin to convert the ICD-9 codes to the proper ICD-10 codes.  As a reminder, very, very few ICD-9 codes can be crosswalked to only one ICD-10 code.  We  must also take into consideration that come 10-1-15 there will be a period of dual coding necessary as we are sure there will be some payers who will not be ready for ICD-10 and those payers that are not required to accept ICD-10.

STAY TUNED!

Debra Farley
Billing Director
BILLPro Management Systems
4-1-14


        From: HBMA [mailto:info@hbma.org]
        To: debra@billpro.net
        Sent: Mon, 31 Mar 2014 19:47:34 -0500
        Subject: Senate Passes SGR Patch/ICD-10 Delay


         
        March 31, 2014

        To:          HBMA Membership
        From:    GR Committee
        Re:         SGR Patch/ICD-10 Delay

        The United States Senate has joined the House of Representatives and passed legislation to prevent a 24% cut in physician fee schedule payments from occurring tomorrow (4/1) as previously scheduled.  Instead, Medicare physician fee schedule payments will continue to be paid as they have been for the past 3 months.   Although the legislation must be signed by the President in order to become effective, the President has indicated that he will sign this legislation once it reaches his desk.

        The so-called SGR Patch approved by Congress will be in effect for 12 months, expiring on March 31, 2015.  Between now and then, Congress will have to enact a permanent fix or enact another patch to prevent a huge drop in Medicare Physician payments next April 1.

        In addition to preventing the SGR related reduction, Congress approved language extending various other Medicare provisions slated to expire at Midnight tonight.  These include:

            Extends Medicare work Geographic Practice Cost Index (GPCI) floor for 1 year
            Extends Medicare therapy cap exception process for 1 year
            Extends Medicare ambulance add-on payments for 1 year
            Extends Medicare adjustment for Low-Volume hospitals for 1 year
            Extends Medicare-dependent Hospital (MDH) program for 1 year

        In addition to these “extenders” Congress also approved a one-year delay in the effective date of the ICD-10 transition.  As you know, ICD-10 has been scheduled to take effect on October 1, 2014.  Due to Congressional intervention, the new effective date will be October 1, 2015.

        A more detailed discussion of the short-term fixes and how Congress intends to pay for these fixes will be in the HBMA March Washington Report.

        The Healthcare Billing & Management Association (HBMA) is a member-led trade association committed to the education of medical billers and promotion of high ethical and professional standards within the industry. HBMA also advocates and educates legislative stakeholders and federal agencies to improve the business of medical billing and the practice of healthcare. HBMA members manage claims on behalf of hospital-based physicians, physician practices and other providers, and represent more than 30,000 individuals and over 600 companies. To learn more about HBMA, please visit www.hbma.org.
         

Medicare issued on 1-15-14 article MM8488, "Revised Beneficiary Liability and Messages Associated with Denials for Claims for Services Furnished to Incarcerated Beneficiaries."   Please click on the link below for the full article.s

    http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8488.pdf


Debra Farley
Billing Director
BILLPro Management Systems
3-31-14

Please see the Medicare DMEPOS e-mail below

Debra Farley
Billing Director
BILLPro Management Systems
3-29-2014

    From: Jurisdiction B DME MAC [mailto:dmemaclistserve@anthem.com]
    To: debra@billpro.net
    Sent: Fri, 28 Mar 2014 15:30:54 -0500
    Subject: Correct Coding – Definitions Used for Off-the-Shelf versus Custom Fitted Prefabricated Orthotics (Braces) - Revised


    As part of the 2014 HCPCS update codes were created describing certain off-the-shelf (OTS) orthotics.  Some of these codes parallel codes for custom fitted versions of the same items.

    When providing these items suppliers must:

        Provide the product that is specified by the ordering physician, i.e. (1) type of orthosis and (2) method of fitting (OTS or custom fitted)
        Be sure that the medical record justifies the need for the type of product and method of fitting
        Be sure only to use the code that accurately reflects both the type of orthosis and the appropriate level of fitting
        Have detailed documentation that justifies the code selected for custom fitted versus OTS codes)

    The following definitions will be used for correct coding of these items.

    Off-the-shelf (OTS) orthotics are:

        Items that are prefabricated

        They may or may not be supplied as a kit that requires some assembly. Assembly of the item and/or installation of add-on components and/or the use of some basic materials in preparation of the item does not change classification from OTS to custom fitted

        OTS items require minimal self-adjustment for fitting at the time of delivery for appropriate use and do not require expertise in trimming, bending, molding, assembling, or customizing to fit an individual
        This fitting does not require expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthoses to fit the item to the individual beneficiary

    The term "minimal self-adjustment" is defined at 42 CFR §414.402 as an adjustment the beneficiary, caretaker for the beneficiary, or supplier of the device can perform and that does not require the services of a certified orthotist (that is, an individual who is certified by the American Board for Certification in Orthotics and Prosthetics, Inc., or by the Board for Orthotist/Prosthetist Certification) or an individual who has specialized training.  For example, adjustment of straps and closures, bending or trimming for final fit or comfort (not all-inclusive) fall into this category.

    Fabrication of an orthosis using CAD/CAM or similar technology without the creation of a positive model with minimal self-adjustment at delivery is considered as OTS.

    Custom fitted orthotics are:

        Devices that are prefabricated

        They may or may not be supplied as a kit that requires some assembly.  Assembly of the item and/or installation of add-on components and/or the use of some basic materials in preparation of the item does not change classification from OTS to custom fitted

        Classification as custom fitted requires substantial modification for fitting at the time of delivery in order to provide an individualized fit, i.e., the item must be trimmed, bent, molded (with or without heat), or otherwise modified resulting in alterations beyond minimal self-adjustment
        This fitting at delivery does require expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthosis to fit the item to the individual beneficiary

    Substantial modification is defined as changes made to achieve an individualized fit of the item that requires the expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthotics such as a physician, treating practitioner, an occupational therapist, or physical therapist in compliance with all applicable Federal and State licensure and regulatory requirements. A certified orthotist is defined as an individual who is certified by the American Board for Certification in Orthotics and Prosthetics, Inc., or by the Board for Orthotist/Prosthetist Certification.

    Use of CAD/CAM or similar technology to create an orthosis without a positive model of the patient may be considered as custom fitted if the final fitting upon delivery to the patient requires substantial modification requiring expertise as described in this section.

    A certified orthotist is defined as an individual who is certified by the American Board for Certification in Orthotics and Prosthetics, Inc., or by the Board for Orthotist/Prosthetist Certification.

    Kits are:

        A collection of components, materials and parts that require further assembly before delivery of the final product
        The elements of a kit may be packaged and complete from a single source or may be an assemblage of separate components from multiple sources by the supplier

    A summary classification algorithm is included at the end of this document to assist is determinations about the type of product and correct code selection.

    Refer to the Contractor Supplier Manual, applicable Local Coverage Determination and related Policy Article for additional information about other coverage, coding and documentation requirements.

    For questions about correct coding, contact the PDAC Contact Center at (877) 735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or e-mail the PDAC by completing the DME PDAC Contact Form located on the PDAC Web site: https://www.dmepdac.com/

    Classification Algorithm - Overview of Criteria

    Determining Proper Coding of Prefabricated Orthotics

    The following question and answer relates to whether a prefabricated orthotic is properly billed using a code for a custom fitted orthotic versus one furnished off-the-shelf and does not address medical necessity for the item.  The descriptors for the HCPCS codes for custom fitted orthotics include the following nomenclature:

        Off-the-shelf (OTS) - Prefabricated item that requires minimal self-adjustment such as being trimmed, bent, molded, assembled, or otherwise adjusted to fit the beneficiary. Minimal self-adjustment does not require the expertise of a certified orthotist or an individual with equivalent expertise.
        Custom fitted - Prefabricated item that requires substantial modification e.g., has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by certified orthotist or an individual with equivalent expertise.

    Question: Is the prefabricated orthotic furnished with custom fitting that is and can only be provided by an individual with expertise or furnished off-the-shelf (OTS)?

    Answer: Classification depends on (1) what must be done at final fitting and (2) who must do it.  Expertise of a qualified practitioner and substantial modification at the time of delivery qualify the items for classification as custom fitted.  Fail either one of these criteria and the item is classified as off-the-shelf.

     
       

Please see the Medicare DME e-mail below announcing revisions to the AFO and pneumatic compression devices LCD

Debra Farley
Billing Director
BILLPro Management Systems
3-28-14


    From: Jurisdiction B DME MAC [mailto:dmemaclistserve@anthem.com]
    To: debra@billpro.net
    Sent: Thu, 27 Mar 2014 15:30:54 -0500
    Subject: LCD and Policy Article Revisions Summary for March 27, 2014

          

    LCD and Policy Article Revisions Summary for March 27, 2014

    Outlined below are the principal changes to DME MAC Local Coverage Determinations (LCDs) and a Policy Articles (PA) that have been revised and posted.  Please review the entire LCD and each related PA for complete information.

    Ankle-Foot/Knee-Ankle-Foot Orthosis
    LCD
    Revision Effective Date: 01/01/2014
    COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
    Added: References to off-the-shelf (OTS) and custom fitted
    Added: New and revised 2014 HCPCS codes to coverage statements
    Revised: Specific ICD-9 diagnosis codes contained in the narrative are replaced with a reference to the applicable diagnosis code tables
             
    HCPCS CODES AND MODIFIERS:
    Added: L4361, L4387, L4397
    For the following codes, the descriptor was changed: L1902, L1904, L1906, L1907, L4350, L4360, L4370, L4386, L4396, L4398

    DOCUMENTATION REQUIREMENTS:
    Added: Documentation requirement for custom fitted vs. OTS

    Policy Article:
    Revision Effective Date: 01/01/2014
    NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
    Added: Correct coding statement for prefabricated orthoses
    Added: Denial statement for incorrect coding

    CODING GUIDELINES:
    Added: Definitions of off-the-shelf and custom fitted
    Added: Respective off-the-shelf and custom fitted codes to coding statements
    Added: Definitions for minimal self-adjustment, substantial modification and kits



    Pneumatic Compression Devices
    LCD
    Revision Effective Date: 07/01/2013
    COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
    Added: Information that item(s) in policy are subject to ACA 6407 requirements

    POLICY SPECIFIC DOCUMENTATION
    REQUIREMENTS:
    Added: ACA 6407 information

    Policy Article
    Revision Effective Date: 07/01/2013
    NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
    Added: ACA 6407 information

Please see the Ohio BWC e-mail below which contains much important information.

Please pay particular attention to the ICD-9, ICD-10 information.  We have confirmed with our software developer that the billing system is already programmed and will accommodate submission of both ICD-9  and ICD-10 codes come 10-1-2014 (implementation date for ICD-10), depending upon a payer.  In all likelihood there will be other payers who will not be able to accept ICD-10 codes effective 10-1-2014 for one reason or the other.


Debra Farley
Billing Director
BILLPro Management Systems
10-21-14


    From: Ohio Bureau of Workers' Compensation [mailto:donotreply@bwc.state.oh.us]
    To: debra@billpro.net [mailto:debra@billpro.net]
    Sent: Mon, 17 Mar 2014 13:34:49 -0500
    Subject: Provider eNews - March 2014

    [BWC eNews Newsletter]
       

    March 17, 2014
       


BWC will be ICD-10 ready and will meet providers’ needs

    BWC projects are under way to ensure we are ready for the conversion from International Classification of Diseases (ICD) – 9 diagnosis codes to ICD-10 on Oct. 1, 2014. It is BWC’s priority to mitigate the impact this conversion could have on providers’ services and reimbursements.

ICD-9, ICD-10 codes

    As a part of this effort, we are reviewing claims allowances and bill-review processes so we can accommodate both ICD-9 and ICD-10 codes. BWC will, for a transitional period, continue to accept bills containing ICD-9 codes after Oct. 1, 2014.

    However, it's our intent to establish a date when the transition period will end. After that date, we will no longer accept ICD-9 codes. We will communicate that update on our website, www.bwc.ohio.gov, and in future Provider eNews issues.
       
       
       

As we all are aware, effective 1-1-2014 there was a huge change to CPT 69210 (cerumen removal).  The 2014 CPT description reads, "Removal impacted cerumen requiring instrumentation, unilateral."  Along with that there are parenthetical notes which state "(For bilateral procedure, report 69210 with modifier 50) (For cerumen removal that is not impacted or does not require instrumentation, eg, by irrigation only, see E/M service code, which may include new or established patient office or other outpatient services {99201-99215}, hospital observation services {99217-99220, 99224-99226}, hospital care {99221-99223, 99231-99233}, consultations {99241-99255), emergency department services {99281-99285}, nursing facility services {99304-99318}, domiciliary, rest home, or custodial care services {99324-99337}, home services {99341-99350})"

We have been investigating an issue with Medicare (to include Railroad Medicare and Medicare Advantage Plans) processing claims when 69210 is being billed bilaterally and the claim is correctly submitted with the -50 modifier.  The 69210 is being denied stating "the procedure code is inconsistent with the modifier used or a required modifier is missing." 

In speaking with Ken in customer service at CGS Medicare this morning, he confirmed the information we obtained through research on the internet (please seer two articles below).   Therefore, EFFECTIVE IMMEDIATELY, FOR MEDICARE (AGAIN TO INCLUDE RAILROAD MEDICARE AND THE MEDICARE ADVANTAGE PLANS), MODIFIER -50 IS NOT TO BE APPENDED TO 69210 WHEN PERFORMED BILATERALLY.   CODE 69210 IS TO BE BILLED AS ONE (1) UNIT NO MATTER IF PERFORMED UNILATERALLY OR BILATERALLY.  WE SHALL REVISIT THIS  ISSUE COME JANUARY 2015 -- HOPEFULLY CMS WILL RECONSIDER ITS STANCE AND COMMENCE FOLLOWING CPT GUIDELINES.

BILLPro shall commence correction of these claims.

                                                                 ARTICLES

Article posted on the American Academy of Family Physician's site dated Tuesday Feb 11, 2014
                  (http://blogs.aafp.org/fpm/gettingpaid/entry/medicare_turns_deaf_ear_to)

Medicare turns deaf ear to CPT changes on cerumen removal

Medicare payment policy doesn't always match the American Medical Association's Current Procedural Terminology (CPT).

The Centers for Medicare & Medicaid Services (CMS) provided another example of that recently in the final rule on the 2014 Medicare physician fee schedule.

For 2014, CPT revised its description of code 69210 to read, “Removal impacted cerumen requiring instrumentation, unilateral.” Previously, the code description read, “Removal impacted cerumen (separate procedure), 1 or both ears.” To account for situations in which the procedure is provided on both ears at the same encounter, CPT 2014 states, “For bilateral procedure, report 69210 with modifier 50.”

Unfortunately, CMS sees things differently. In the new 2014 fee schedule, CMS stated its opinion that the procedure will typically be done on both ears at the same encounter, because “the physiologic processes that create cerumen impaction likely would affect both ears.” CMS did not provide any evidence or citations to support this opinion.

CMS went on to say, “Given this, we will continue to allow only one unit of CPT 69210 to be billed when furnished bilaterally.” Consequently, CMS elected to maintain the 2013 work value of 0.61 for CPT code 69210 when the service is furnished.

The bottom line is that Medicare will pay you the same amount for 69210 whether you do one ear or two, even though the CPT descriptor now says it is for one ear only.

If only CMS could hear how ridiculous that sounds.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Article posted on the American Academy of Otolaryngology-Head and Neck Surgery's site dated 2-5-14
                          (http://www.entnet.org/Practice/CMS-News.cfm)
                   
Academy Works to Resolve Concerns Related to CMS 2014 Payment Policy for Removal of Cerumen (69210) (2/5/2014)

On February 3, the Academy held a conference call with CMS regarding its reimbursement policy for cerumen removal, CPT 69210, after hearing from Academy members who've experienced issues with billing 69210 using the -50 modifier.  Per CMS instruction on the call, this reimbursement policy will remain in place through CY 2014 as an interim value for the service which was finalized in the Final Medicare Physician Fee Schedule (MPFS) for 2014.  As a reminder, CMS implemented this payment policy based on their disagreement with the assumption by the RUC that this procedure will be furnished in both ears only 10 percent of the time, as they feel the physiologic processes that create cerumen impaction likely will affect both ears.  Based on CMS' guidance, the Academy recommends that members NOT report 69210 using modifier -50, as MACs are denying these claims entirely and not paying for even one unit reported.  This requires providers to reprocess the denied claim which takes additional time and administrative effort.  CMS has stated they will not issue a transmittal to providers at this time, and have asked the Academy to share this coding directive with members.  We are working with the Agency to provide them with concrete data related to the percentage of time 69210 is provided bilaterally, in hopes that this will allow them the necessary evidence to revisit this payment policy in CY 2015.  As the dialogue continues with CMS, we will keep members apprised of our progress on these advocacy efforts via the weekly e-news, monthly HP-Update, and printed Bulletin.  Please email us with any questions at:  healthpolicy@entnet.org.
 


Debra Farley
Billing Director
BILLPro Management Systems
3-21-14

Please click on http://www.roadto10.org/ to access the FREE CMS resource that provides information about ICD-10.  Please see the information below which was cut/pasted from the CMS website.


CMS has created “Road to 10� to help you jump start the transition to ICD-10.

Built with the help of small practice physicians, “Road to 10� is a no-cost tool that will help you:

    Get an overview of ICD-10 by accessing the links on the left
    Explore Specialty References by selecting a specialty below
    Click the BUILD YOUR ACTION PLAN box to create your personal action plan

To get started and learn more about ICD-10, navigate through the links on the left side of the page. If you’re ready to start building an action plan, select the BUILD YOUR ACTION PLAN box.

Select a profile below to explore the common codes, primers for clinical documentation, clinical scenarios, and additional resources associated with each specialty. You can also get started on your own plan now by choosing BUILD YOUR ACTION PLAN below.


Debra Farley
Billing Director
BILLPro Management Systems
3-14-14