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ICD-10 UPDATE on page 6
ICD-10 UPDATE on page 6
Breast CancerAwarenesson page 3
Breast CancerAwarenesson page 3
EMR Registered for
Certificationon page 7
EMR Registered for
Certificationon page 7
Credentialing TIPSon page 11
Credentialing TIPSon page 11
4
WCH invites you for an educational conference
How to Overcome the OccurringHealthcare Industry Challenges
WhenthOctober 29 , 2013
at 6:30-9:30PM
WhereBank of America Tower 1 Bryant Park (W 43st),
New York, NY
Direction:
42 St - Bryant Pk
(B, D, F, M) 5 Av (7, 7X)Times Sq - 42 St (S)
Click here to register TODAY!Register on our website www.wchsb.com
For information call us at718-934-6714 Ex. 1202 or 1214
Or e-mail [email protected]
Light dinner will be served.There is no cost to attend this event.
You may bring guests with you!
Featured Speakers:
Olga Khabinskay,COO, WCH Service Bureau Inc.Solving todays challenges between doctors and insurances.
Kenneth Music,Vice President, Bank of AmericaPractice SolutionsMedical Practice financing solutions.
Mathew J. Levy,Principal/Partner, Kern Augustine Conroy & Schoppmann, P.C.A legal view on physician practice audits from insurancecompanies.
John V. Pellitteri ,CPA, Grassi & Co.Merger Mania- is it the right option for your practice?
Peter Bechtel,President of Well Track OneMedicare annual visit programcompliance and patients health improvement.
42 St - Bryant Pk
IN THIS ISSUE
21
News by
State
22-23
Questions &
Answers
Follow Us:
Get your CEU credits TODAYFor more information please contact Marianna Shapiro at 718-934-6714 ex. 1202
or by e-mail to: [email protected]
3
WCH Corner
Breast Cancer
Awareness
Month
4
Education
Conference
5
WCH Event
in the News!
6
ICD-10
Update
7
WCH iSmart
EMR
8-9
WCH ICode
11-12
Tips for
Successful,
Timely Provider
Credentialing
13-18
Healthcare
News
19-20
News by
Specialty
Organizational charities around the globe are coming together this month to increase
awareness of the disease and raise funds for research, prevention diagnosis, treatment and
cure of breast cancer.
Since 2009, WCH team has been an active contributor to the Susan G. Komen foundation for
a cause we believe is extraordinary. It is important to us at WCH to help increase awareness of
breast cancer screenings and promote education and outreach programs in the fight again
breast cancer.
Our goal is to make a difference by spreading the word about mammograms and encourage
our healthcare community, our clients, staff and partners to get involved.
The race is over, but it is not too late to donate to support the NYC race for the Cure on
Behalf of WCH panthers. If you wish to support our team, please kindly make your contribution
by following this link: www.secure2.convio.net
WCH Corner
3WCH Newsletter Fall 2013 www.wchsb.com
WCH and Bank of America are Joining Forces to Educate the Healthcare Community this Fall.
WCH and Bank of America are joining forces solutions and service such as starting up
to educate the healthcare community this fall. new practices, selling and purchasing
We are organizing a free educational and medica l pract ices , bus iness debt
networking event on October 29th, 2013 at 6:30 c o n s o l i d a t i o n , o f f i c e e x p a n s i o n ,
PM in NYC. Join us to get resources and tools commercial real sate, equipment financing
which will help overcome the healthcare and additional financing options available
industry challenges. for healthcare providers.
The topic of the conference is "How to џ Matthew Levy is a nationally recognized Overcome the Occurring Healthcare Industry healthcare attorney from Kern Augustine Challenges". The healthcare industry is Conroy & Schoppmann PC, a full service changing and there are many challenges and healthcare law firm. Matthew Levy will issues that arise. Your participation would add present on the topic of audits from value to your practice and will help you to plan a insurance companies and how to effectively good strategy to withstand and overcome all handle them.changes currently happening in Healthcare џ John Pellitteri is a healthcare management industry. We took a careful and thoughtful consulting leader and the accounting approach, inviting speakers that we feel would service practice leader and partner at Grassi enlighten you on the most vulnerable aspects & Co who will talk about practice and be able to provide most extensive and consolidation, mergers and effective comprehensive answers to most of your healthcare accounting practices.questions from all aspect of private practice. џ Peter Bechtel is the president and founder of We are covering a wide range of issues and Well Track one, a Medicare annual visit providing solutions. program specialist who will be presenting
ways effectively conduct annual wellness
visits while increasing revenue and џ WCH will present the solutions to solving the improving patient's health.
complex challenges that occur in today's
ever-changing healthcare industry. WCH There is no registration fee, the event is COO, Olga Khabinskay with 11 years of completely free, you can bring guests and we experience will talk about the controversial are providing food and beverages.topics of medicine and present to you To register please go to solutions that will help you overcome the For more information or questions occurring challenges. please contact:
џ Ken Music, Regional manager for Bank of Ilana Kozak, General Manager,America Practice solutions will discuss loan WCH Service Bureau,options available to providers when it E-mail: comes time to turn dreams into reality. Bank phone: (718) 934-6714 ext. 1214of America will present the many different
ABOUT TOPICS AND SPEAKERS
www.wchsb.com
WCH Event in the News!
For the first time ever, WCH Service Bureau's Chief Operation Officer, Olga Khabinskay,
made a TV appearance!
On Monday October 7th Olga appeared on a TV talk show, OPEN, promoting the upcoming
WCH conference in October.
Olga was invited as a guest speaker to the BronxNet studio to elaborate about the WCH
and Bank of America sponsored event on October 29th, 2013.
Dr. Bob Lee, the host on the show OPEN, interview Olga regarding the importance and
impact of the conference “How to overcoming the current healthcare industry challenges”.
See more on: www.bronxnet.org
5WCH Newsletter Fall 2013 www.wchsb.com
Quick Update on ICD-10 Implementation Plan
We are currently in process of the implementation of ICD 10 education for our clients.
All WCH billing clients receive updates and materials available through CMS and other sources. We
will distribute upcoming webinars, educational conferences and materials to our clients. We promote
awareness and share our resources for ICD-10 training with our clients so that everyone has the
opportunity to evaluate the different options and measures that need to be taken in order to be ready for
the ICD 10.
WCH continues to encourage and strongly recommend that our clients begin using our E-superbill
feature. Utilizing our free E-supber will allow our client to be ready to begin the testing period and thus be
trained and comfortable during and after the transition period.
All WCH billing department staff went through training for ICD-10 CM anatomy and physiology
terminology. We have completed our internal education about the systems and coding diagnosis. Our
AAPC certified professionals will now be preparing for the ICD-10 CM proficiency assessment exam
administered by AAPC. The exam will measure the understanding of ICD 10 format and structure,
groupings and categories of codes, the ICD-10 official guidelines and coding concepts.
6 WCH Newsletter Fall 2013 www.wchsb.com
The WCH IT team continues to work as much as 15 hours a day to complete our Electronic
Medical Records System, which will be integrated with our billing system in near future.
We bring to you our most recent WCH update.
Since our September publication, we have made significant progress. We are proud to present to
you the details:
џ
џ Certification with Dr.First (e-Prescribing Vendor) is in progress.
Initial submission was made to Dr.First and feedback was
received. The second submission is now under review by Dr.First.
џ ONC requires 24 MU Modules for certification to be Certified EHR Technology (CEHRT). We have
partially completed 75% and are still working on
the remaining modules.
The road to certification is lengthy and difficult,
however we will get there to provide top quality
product to our customers. WCH , is
currently being reviewed to ensure that the necessary
technological capability, functionality and security
standards are met. WCH standards are
met is scheduled to be completely certified by the end
of the season.
To inquire about WCH ,
please contact
Ilya Mirolyubov
E-mail:
Skype: wchsb.ilyam
phone: (718) 934-6714 ext. 1111
iSmart EMR
iSmart EMR
iSmart EMR
iSmart EMR
WCH has registered for Certification with Drummond Group, ONC
Certification Body, contracts for MU certification is signed
WCH ismart
EMR registered
for certificationAn update about WCH EMR
7WCH Newsletter Fall 2013 www.wchsb.com
Call Kenneth Music at 1.855.318.4146, or e-mail
[email protected] can also visit us online at
www.bankofamerica.com/practicesolutions
A completed CAQH profile puts practitioners a step
ahead in the process, particularly in getting on
Medicaid insurance panels.
Choose Your Location
Panels are open or closed to practitioners,
depending on where they will practice. When a
doctor decides to join a practice, he knows which
insurances the practice takes already, but that
doesn’t mean the insurers will accept additional
practitioners. At the start, this can be an important
element in deciding which panels to join.
If the office can’t help, a reputable credentialing
company can tell you with a phone call whether
panels are closed to a specialty. That saves time in
applying, only to be rejected weeks or months later.
Open Closed Doors
Too often, panels are closed, especially in cities
where numerous doctors of the same specialty
practicing within blocks of one another may request
credentialing. But there are ways around these
rejections.
When doctors close an office or retire, they
often forget to inform insurers of their inactive
status, which prevents another doctor from taking
over that spot in the network. The insurance
company isn’t likely to know, and isn’t likely to tell
you. This can only be challenged by a phone call to
the practice or a site visit to see if it is still in
business.
Differentiating your practice is key. Describing
detailed specifics, such as all certifications,
specialized equipment being used in the practice,
specific experience, and even awards could set the
doctor apart and open up a panel spot.
How Many Is Too Many?
Can a practice thrive taking on Medicare,
Medicaid, and five other insurances? Do they need
more?
The answer is, “It depends.” It’s incredibly time
consuming for someone in an office to submit
applications for more than a dozen insurances.
Tips for Successful, Timely
Provider Credentialing
Lessen frustration during the
insurance credentialing process.
By Olga Khabinskay
Payer networks, healthcare
organizations, and hospitals require
credentialing to accept a provider in
a network or to treat patients at a hospital or
medical facility. The seemingly straightforward
credentialing process is fraught with complications
that can frustrate even the most patient
practitioner. The good news is there are ways to
save time, aggravation, and rejection during the
process. But first, it’s important to know the purpose
of credentialing.
Why Get Credentialed?
Credentialing involves obtaining and evaluating
documentation regarding a medical provider’s
education, training, work history, license, regulatory
compliance record, and malpractice history. If a
doctor is not “credentialed” by the insurance
company, Medicare, or Medicaid plan, he or she can
still submit claims, but the doctor may not be paid
unless the patient has out-of-network benefits.
Begin the Paperwork
The process starts with the credentialing
form—some 20-40 pages, on average. Most
insurers require a license, hospital affiliation, and
malpractice insurance. They also may use much of
the information that can be compiled in the Council
for Affordable Quality Healthcare (CAQH) profile,
which is a database on every practitioner. CAQH is a
non-profit alliance of health plans and trade
associations working to simplify healthcare
administration through industry collaboration on
public-private initiatives.
11WCH Newsletter Fall 2013 www.wchsb.com
At the start, due to costs, it’s practical to be on five
to 10 insurance panels, although there are as many
as 60 insurance plans. You may wish to apply to
several additional panels, in case the doctor is not
immediately accepted to the most-favored plans.
Be (or Hire) an Advocate for Your Approval
It would be great if sending in the form, waiting
a few weeks, and being approved were the reality.
The reality is that the credentialing process requires
you to shepherd your paperwork through, answer
questions and provide additional information, and
ensure everything is correct and has been received.
Otherwise, you’re likely to be rejected.
Here are a few tips on how to prevent this from
happening:
Communication is key! Establish a friendly
rapport with the provider relationship representative
at the insurance company who is handling your
case. Find out all of his or her contact information at
the outset, and communicate in a clear and
effective way (as often as once a day) to answer
related questions and follow up on processing
applications.
Ensure accurate information. Remember the
three C’s: Correct, Complete, and Concise. All three
will result in a smoother processing of your
application. Make sure all information is submitted
at the same time according to a checklist (which is
usually provided with the application). Ensure the
documentation is mailed with a tracking number.
Verify the information was received.
Manage the process. Keep dates on your
calendar for tracking and follow up. This will lead to
faster processing. Set reminders for yourself to call
and verify the status of your application on a regular
basis by phone and email.
If this all sounds like a lot to manage (and
dealing with five to 10 insurance panels can, in itself,
become a full time job), that’s why there are services
that can help.
Consider a Service to Lessen Aggravation
A reputable credentialing service—which often
also offers medical billing and insurance auditing
services, etc.—can shave weeks off an approval by
making sure the form is filled out correctly the first
time, keeping it on track, and providing requested
information. A credentialing service’s established
insurance company contacts, and their ability to
determine the appropriate insurances ahead of
time, will save a lot of aggravation and rejection.
Most credentialing companies will charge
approximately $400-$600 per insurance application.
That may sound like a lot, but it’s a wise investment
that enables practitioners to start billing and making
money sooner. With earlier acceptance to an
insurance panel, the reimbursement from only three
patients will cover the cost. Balance the cost of
weeks of approval delays verses how many patients
can be seen and billed and that amount suddenly
seems negligible.
Olga Khabinskay is chief operating officer of
WCH Service Bureau ( ), a global
provider of healthcare practice services offering an
array of billing and healthcare management
services for large and small medical groups and
practitioners. WCH provides medical billing,
credentialing, coding, chart auditing, and
customized medical software solutions, as well as
receptionist services and Continuing Education Unit
(CEU) credits. She is a member of the Jamaica, N.Y.,
local chapter.
www.wchsb.com
Source: www.news.aapc.com
12 WCH Newsletter Fall 2013 www.wchsb.com
Healthcare NewsDual Eligibles Program Launched:
On August 26, 2013, the CMS announced
that the State of New York will partner with CMS
to test a new model for providing Medicare-
Medicaid enrollees with the stated intent of
providing a more coordinated, person-centered
care experience. Under the demonstration,
known as “Fully Integrated Duals Advantage”
(FIDA), New York and CMS will contract with
Medicare-Medicaid Plans to coordinate the
delivery of covered Medicare and Medicaid
services for participating Medicare-Medicaid
enrollees. New York and CMS will contract with
health plans known as “FIDA Plans” that will
oversee the delivery of covered Medicare and
Medicaid services for Medicare-Medicaid
enrollees in New York City, Long Island, and
Westchester County. New York is the seventh
state to establish a Memorandum of
Understanding with CMS to participate in the
Initiative.
Additional information on the ongoing
development and implementation of the New
Y o r k d e m o n s t r a t i o n i s a v a i l a b l e a t :
. P h y s i c i a n s
considering participation in a FIDA Plan should
contact KACS for assistance.
If you have any questions, please contact
Mathew Levy, Esq., at 516 -294-5432.
Mathew J. Levy
Partner
Kern Augustine Conroy &
Schoppmann, P.C.
http://www.health.ny.gov/health_care/medicai
d / r e d e s i g n / m r t _ 1 0 1 . h t m
State LawLate breaking news on medical-legal
developments affecting physicians and health care
providers.
September 23rd Marks Start of New HIPAA:
As noted numerous times in prior Statlaws
and other KACS publications, September 23,
2013, marks the enforcement date for
HIPAA Privacy, Security and Data Breach
Notification regulations, as amended by the
HITECH Omnibus Rule. Among other things,
revised Notices of Privacy Practices must be
distributed as of that date, along with
implementation of new patient rights and new
covered entity obligations. More information
can be found at and at:
FDA Issues New Opioid Labeling Guidelines:
The Food and Drug Administration (FDA)
has approved new labeling guidelines for
extended-release and long-acting opioid pain
relievers, such as Oxycontin, in an attempt to
curb what it calls an epidemic of prescription
painkiller abuse in the country. The Centers for
Disease Control and Prevention notes that
nearly three out of four prescription drug
overdoses are caused by prescription
painkillers. According to the FDA, the new
labeling requirements and other actions are
intended to help prescribers and patients make
better decisions about who can benefit from the
use of these medications and to reduce
problems associated with their use. See the new
labeling guidelines and other safety measures at
www.drlaw.com
http://www.hhs.gov/ocr/privacy/hipaa/admini
strative/index.html.
http://www.fda.gov/Drugs/DrugSafety/Informa
tionbyDrugClass/ucm363722.htm.Source: www.drlaw.com
14 WCH Newsletter Fall 2013 www.wchsb.com
Occasionally, a physician may see a patient in the office and send that patient immediately to the
hospital for admission. In such a case, you may consider the history and physical (H&P) taken in the
office when determining the inpatient admission level (e.g., 99223 Initial hospital care, per day, for the
evaluation and management of a patient, which requires these 3 key components: A comprehensive
history; A comprehensive examination; and Medical decision making of high complexity.). Although
the H&P do not have to be dictated at the hospital, if any additional workup is performed at the hospital,
you may consider that work—in addition to the H&P performed in the office—when assigning a service
level.
What you should not do is report an office visit (e.g., 99215 Office or other outpatient visit for the
evaluation and management of an established patient, which requires at least 2 of these 3 key
components: A comprehensive history; A comprehensive examination; Medical decision making of
high complexity.) in addition to the inpatient admission. Instead, choose a single code (the admission)
that best describes all of the evaluation and management (E/M) work provided to the patient on that
day.
Office E/M + Inpatient Admission = One Code
Source: www.news.aapc.com
Effective Sept. 10, the Centers for Medicare & Medicaid Services (CMS) has revised its Evaluation
and Management (E/M) Documentation Guidelines (DG), to allow physicians to use the 1997 DG for an
extended history of present illness (HPI) with the other elements of the 1995 DG to document an E/M
service. As a result, “the status of three or more chronic conditions” qualifies as an Extended HPI for
either set of DGs.
The revised guideline is presented as a Question and Answer on the CMS website:
FAQ on 1995 & 1997 Documentation Guidelines for Evaluation & Management Services.
Can a provider use both the 1995 and 1997 Documentation Guidelines for Evaluation and
Management Services to document their choice of evaluation and management HCPCS code?
For billing Medicare, a provider may choose either version of the documentation
guidelines, not a combination of the two, to document a patient encounter. However, beginning for
services performed on or after September 10, 2013 physicians may use the 1997 documentation
guidelines for an extended history of present illness along with other elements from the 1995
guidelines to document an evaluation and management service
Question:
Answer:
CMS Allows '97 Extended HPI with '95 Guidelines
Source: www.news.aapc.com
EmblemHealth Coverage for Physician Assistant џPerformed under the general supervision of an Services MD/DO
The professional services of a physician џNot otherwise precluded from coverage assistant (PA) may be covered in network if he or because of one of the statutory exclusions. she is contracted, meets the qualifications listed Types of PA Services That May Be Coveredbelow and is legally authorized to provide services Pas may provide services billed under all levels of in the state where the services are performed. CPT evaluation and management codes, and Payments are allowed for assistant at surgery diagnostic tests, if furnished under the general services and services provided in all areas and supervision of a physician. Examples of services settings permitted under applicable state licensure that PAs may provide include services traditionally laws, but only if no facility or other provider is paid reserved to physicians, such as examinations with respect to the provision of such professional (including the initial preventive physical services. examination), minor surgery, setting casts for Qualifications for Pas simple fractures, interpreting X-rays, and other APA must meet the following qualifications: activities that involve an independent evaluation or џGraduated from a PA educational program treatment of the patient's condition.
accredited by the Accreditation Review Services Otherwise Excluded From Coverage Commission on Education for the Physician PA services may not be covered if they are Assistant (or its predecessor agencies, the otherwise excluded from coverage even though a Commission on Accreditation of Allied Health PA may be authorized by state law to perform Education Programs [CAAHEP] and the them.Committee on Allied Health Education and Physician Supervision Accreditation [CAHEA]) or The PA's physician supervisor (or a physician
џPassed the national certification examination designated by the supervising physician or
administered by the National Commission on employer as provided under state law or
Certification of Physician Assistants (NCCPA) regulations) is primarily responsible for the overall
and direction and management of the PA's
professional activities and for assuring that the џ Be licensed by the state to practice as a PA services provided are medically appropriate for the Covered Servicespatient. The physician supervisor (or physician Services are covered if they meet all four of the designee) need not be physically present with the following criteria:PA when a service is provided to a patient and may џConsidered physician's services if provided by a be contacted by telephone, if necessary, unless doctor of medicine or osteopathy (MD/DO) state law or regulations require otherwise.Performed by a person who meets all the PA
qualifications and is legally authorized to
perform the services in the state in which they
are performed
Coverage for Physician Assistant Services
Source: www.emblemhealth.com
15WCH Newsletter Fall 2013 www.wchsb.com
It is needed to be enforced that providers follow
these guidelines as it is mandatory by Medicare and
it will also be beneficial to their claims processing.
Audit Findings
џThe following results are based upon the
completion of the review for JK Part B.
џ In May 2013, there were 857 services billed with
850 (99.2%) cutback or denied
џ In June 2013, there were 794 services billed with
790 (99.5%) cutback or denied
џ In July 2013, there were 1,024 serviced billed
with 1,018 (99.4%) cutback or denied
REASONS:
џ Lacks referral for therapy
џ Lacks initial evaluation/plan of care
џ Initial evaluation did not meet documentation
requirements outlined in LCD
џ Lacks functional limitations and effects on
activities of daily living to establish baseline data
necessary for assessment of rehabilitation
potential
џBilled number of services were not supported
(i.e., the billed units exceed the allowable units
for the documented time)
џCodes and/or units billed did not match the
modalities or times documented
џUp-coding E-stim services and lacking
documentation of 1:1 per CPT requirement of
specific services
џ Lacking progress reports with CMS-required
elements
џNonresponse to development letters
џ Illegible documentation
џMissing or illegible provider signature
џ Incomplete or missing beneficiary information
A service-specific prepayment audit was
recently conducted by the National Government
Services Medical Review Department for
Jurisdiction K Part B claims in Connecticut and New
York. The audit focused on claims billed with
current procedural terminology (CPT) codes 97001-
97799 and G0283, with the exclusion of codes
97602, 97597, and 97598 for family practice
providers (08). This article includes the results of
that audit and recommendations to help providers
submit these types of claims correctly in the future.
Records are reviewed to determine if the billed
procedure code met all documentation
requirements as referenced in Local Coverage
Determination (LCD) for Outpatient Physical and
Occupational Therapy Services (L26884). To be
considered reasonable and necessary, the services
must meet these Medicare guidelines however, not
all providers follow the initial steps. The most
common errors stated are errors that can have been
avoided if providers pay closer attention in the steps
they are taking when creating a bill. Services for
CPT therapy codes were denied or reduced if
documentation did not support the service billed as
defined in LCD L26884 and the Centers for Medicare
& Medicaid Services (CMS) Internet-Only Manual
(IOM) Publication 100-02, Medicare Benefit Policy
Manual, Chapter 15, Section 220-230, “Covered
Medical and Other Health Services.”
Medicare follows basic straight forward
guidelines which are available to all providers. If
every provider follows Medicare guidelines, than
claims will be submitted correctly in the future, and
many denials will be avoided.
Source: ngsmedicare.com
Jurisdiction K Part B Prepayment Audit Results for CPT Code 97001-97799 and G0283
16 WCH Newsletter Fall 2013 www.wchsb.com
Effective on April 1, 2013 the following CPT procedure codes were added:
џ90791 - PSYCHIATRIC DIAGNOSTIC EVALUATION-Practitioner Non-Facility Fee is $93.26 and Facility Fee
is $59.78.
џ90846 - FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT)- Practitioner Non-Facility Fee is
$52.48 and Facility Fee $42.92.
New York State Medicaid Update
The Centers for Medicare & Medicaid Services (CMS) and the New York
State Department of Health (DOH) have established a federal-state partnership
to implement the Medicare-Medicaid Alignment Initiative (Demonstration) that
will better serve individuals eligible for both Medicare and Medicaid.
Under the partnership, DOH and CMS will contract with Fully Integrated Duals Advantage Plans in
providing integrated services that address individual's medical, behavioral, and social needs. The effective
date is expected to begin on July 1, 2014 and it will continue until December 31, 2017. The FIDA will provide
New York eligible individuals with seamless access to all physical health, behavioral health, and long-term
supports and services; a choice of plan and providers with choices being facilitated by an independent broker;
and care planning and coordination by patient- centered interdisciplinary teams. In addition, this
demonstration will allow FIDA plans to test alternative payment arrangements with their network provider.
New Codes for Clinical Psychologist
Source: www.health.ny.gov
Source: www.health.ny.gov
Influenza Vaccine Coverage Expanded
For dates of service on or after August 1, 2013, the following influenza vaccine
codes will be available for billing for certain age groups:
For influenza vaccine codes, the following would be available for billing for certain
age groups:
џ 90672 INFLUENZA VIRUS VACCINE, QUADRIVALENT, LIVE, FOR INTRANASAL
USE. For beneficiaries 2 years of age to 49 years of age:
џ 90685 INFLUENZA VIRUS VACCINE, QUADRIVALENT, SPLIT VIRUS, PRESERVATIVE FREE, WHEN
ADMINISTERED TO CHILDREN 6-35 MONTHS OF AGE, FOR INTRAMUSCULAR USE. For beneficiaries 6
months to 35 months only:
џ 90686 INFLUENZA VIRUS VACCINE, QUADRIVALENT, SPLIT VIRUS, PRESERVATIVE FREE, WHEN
ADMINISTERED TO INDIVIDUALS 3 YEARS OF AGE AND OLDER, FOR INTRAMUSCULAR USE.
Source: www.health.ny.gov
17WCH Newsletter Fall 2013 www.wchsb.com
Low Back Pain Coverage Guidelines
The following mentioned are based on limitations because of not being medical necessity. Effective
November 1, 2013 the following procedures and subjected to limitation, as they are considered ineffective for
the treatment of chronic low back pain:
џ62290 Injection procedure for discography, each level; lumbar.
џ72295 Discography, lumbar, radiological supervision and interpretation.
The following conditions also are considered not to be medical necessity:
џLumbago, low back pain syndrome, lumbalgia, as represented by 2013 ICD-9 code 724.2.
џUnspecified backache, vertebrogenic syndrome not otherwise specified, as represented by 2013 ICD-9
code 724.5.
Limitation to Coverage for Functional Electrical Stimulation (FES)
Effective November 1, 2013 also for Medicaid fee-for-service beneficiaries, and for Medicaid Managed
Care and Family Health Plus (FHPlus) enrollees, services/procedures, Durable Medical Equipment, and
supplies to provide Functional Electrical Stimulation via transcutaneous, percutaneous, and implanted
devices, are subject to limitation. Medicaid will continue to cover Functional Electrical Stimulation for other
indications, if medically necessary. For those patients with electrodes and/or stimulators implanted prior to
October 1, 2013, Medicaid will continue to cover the devices and supplies, and provide reimbursement to
replace/revise/remove devices as medically necessary, regardless of patient diagnosis. In addition, there is no
change to the policy regarding, and no limitation to the use of:
џDiaphragmatic/phrenic pacing device and related services and supplies (implantation of this device can be
represented by CPT codes 64575, 64580, 64585, 64590, and 64595);
џVagus nerve stimulator device and related services and supplies (implantation of this device can be
represented by CPT codes 61885, 61886, 64553, 64568, 64569, 64570);
џSacral nerve stimulator device and related services and supplies (implantation of this device can be
represented by CPT codes 64561, 64581, 64590).
The following limitations consist of:
џSpinal cord injury, as represented by ICD-9-CM codes 952.xx, 907.0-907.2, 767.4, 806.x 806.xx.
џHead injury (850.11-850.12, 850.2-850.9, 851.xx, 852.xx, 853.xx, 854.xx).
џCerebral palsy (343.0-343.9). Upper motor neuron diseases (Parkinson's Disease, 332.0-332.1; Late effects
of Acute Poliomyelitis, 138; Anterior horn cell diseases, 335.0, 335.10-335.19, 335.20-335.29, 335.8-335.9;
Multiple Sclerosis, 340; Other demyelinating diseases, 341.0-341.1, 341.8-341.9, 341.20-341.22).
Source: www.health.ny.gov
Source: www.health.ny.gov
18 WCH Newsletter Fall 2013 www.wchsb.com
News by Specialty
Outpatient Cardiology Prior Authorization
Program for Unitedhealthcare community Plan
Beginning November 1, 2013 , UnitedHealcare
Community Plan's new Outpatient Cardiology Prior
Authorization program will take effect .Once a prior
authorization request for the planned service is
received, a clinical coverage review will be
conducted to determine whether the service is
medically necessary.
Cardiology Prior Authorization
The ordering provider must notify UHC prior to
scheduling any of the following cardiology services
for UnitedHealthcare Community Plan members
џDiagnostic cauterizations
џElectrophysiology implants
џEchocardiograms
џStress echocardiograms
Note: Ordering providers are not required to notify
UHC of cardiology services rendered in emergency
rooms, observation units, urgent care facilities, or
dur ing inpat ients stays except for
electrophysiology implants. Rendering providers
must notify us prior to providing electrophysiology
implant services in an inpatients setting.
Additional details about the Cardiology Prior
Authorization program, included answers to
Frequently Asked Questions, Quick Reference
Guides, the complete list of procedure codes
requiring prior authorization and evidence based
c l i n i c a l g u i d e l i n e s a r e a v a i l a b l e a t
UnitedHealthcareOnline.com . Clinical recourses.
For additional questions, contact your
UnitedHealthcare network Management
representative or call 888-362-3368
Cardiology
Source: www.unitedhealthcareonline.com
Radiology
Two New Approved Radiology Codes for
Urologists — Effective September 1, 2013
Effective immediately, the following two radiology
codes have been approved for urologists, as part of
the Self-Referral Payment Policy. These procedure
codes do not require additional accreditation.
џ CPT 74455 — Urethrocystography, voicing,
radiological supervision and interpretation
џ CPT 76775 — Ultrasound, retro peritoneal, real
time with image documentation; limited
Source: www.emblemhealth.com
19WCH Newsletter Fall 2013 www.wchsb.com
Behavioral Health
Fidelis Modification of Behavioral Health
authorization requirements
Fidelis Care is pleased to announce changes
in the authorization requirements for outpatient
behavioral health (BH) services that will
significantly simplify and streamline the process
for providers and members.
Effective for dates of service on or after
September 1, 2013, authorizations will no longer
be required for most outpatient behavioral
health (mental health and substance abuse)
services and behavioral health professional
home care visits provided by participating
providers.
All BH services provided by non-participating
providers will continue to require authorization.
These changes apply to all products offered
by Fidelis Care.
Source: www.fideliscare.org
20 WCH Newsletter Fall 2013 www.wchsb.com
News by State
Data analysis reveals a potential problem with requirements as found in the Centers for Medicare
the billing and utilization of chiropractic services in and Medicaid Services Internet-Only Manual 100-
all Jurisdiction 6 (J6) Part B states (Illinois, 02, Medicare Benefit Policy Manual, Chapter 15,
Minnesota, and Wisconsin). Recent BESS data Section 240 the Local Coverage Determination
showed utilization of 12.0% of the nation's (LCD) for Chiropractic Services (L27350), and the
Medicare services with J6 having 7.73% of the Supplemental Instructions Article for Chiropractic
Medicare population.The Contractor Error Rate Services (A47385).
Testing (CERT) contractor has found the highest Illinois, Minnesota, and Wisconsin providers
chiropractic manipulation error level for current will receive an Additional Development Request
procedural terminology (CPT) code 98942, (ADR letter) detailing the specific documentation
chiropractic manipulative treatment (CMT); spinal, being requested for the billed service. If you receive
five regions has shown a high error rate. an ADR letter for this service-specific review,
To better identify common billing errors, please submit the requested information within 30
develop educational efforts, and prevent improper days of receipt of the request. Failure to submit the
payment, National Government Services, Inc. requested documentation in a timely manner may
Medical Review will be implementing a widespread result in denial of the billed service.
service-specific prepayment review of CPT 98942.
Services billed for CPT 98942 must meet the
Medicare coverage and documentation
Announcing a Service-Specific Prepay Audit of
CPT CODE 98942 for Illinois, Minnesota and
Wisconsin
Source: www.cms.gov
21WCH Newsletter Fall 2013 www.wchsb.com
Questions & AnswersQuestion:
Answer:All financial records and supporting
documents are to be retained for 3 years by a
designated, responsible individual of the outgoing
contract or in accordance with Government
contract requirements. If any litigation claims or
audits are begun before the expiration of the 3-year
period, all records shall be retained until the
completion of the action or until the end of the
regular 3-year period, whichever comes last. The 3-
year period begins on the date the outgoing
contractor submits its final deliverables, as listed in
Section F of the QIO contract, to CMS.
The name, address, and telephone number of
the designated individual responsible for retaining
records should be given to the PO.
How long is a medical practice required to
keep their Explanation of Benefits Retention of
financial records?
Question:
Answer:There are a few answers to this question, and
not necessarily a correct answer in the bunch.
I cannot tell you who should automatically qualify
as the Privacy Officer, but answers include: (1) the
practice owner or a managing partner; (2) the
individual versed in the privacy laws and responsible
for staying up to date; or (3) the individual
responsible for resolving patient HIPAA issues. In
some practices the individual qualifying for each
point set forth above is the same person; for many
practices there is not one person meeting each of
the 3 requirements set forth above, and the decision
of who to anoint Privacy Officer is more difficult. If
the latter describes your practice arrangement, let
me take this opportunity to caution against forcing
this responsibility upon an unwilling employee, or an
individual who has not been with the practice for an
extended period of time with experience in
compliance. Another consideration when selecting
your privacy officer, remember - the practice owner
is the captain of the ship and will be held
responsible should the practice not remain in
compliance (and discovered), and therefore, may be
the best person to be named as the responsible
party.
Answered by:
How do I know who to choose in my practice
as the Privacy Officer?
Elizaveta Bannova
Billing Department Vice Manager,
CMRS, CFPC
Skype: wchsb.lizab
e-mail: [email protected]
Source: www.cms.gov
Jennifer Kirschenbaum, Esq.
Kirschenbaum & Kirschenbaum, P.C.
200 Garden City Plaza
Garden City, New York 11530
(516) 747-6700 (tel)
(516) 747-6781 (fax)
22 WCH Newsletter Fall 2013 www.wchsb.com
Question:
Answer:No, they are not on the list of providers due for
site visit. This list includes Ambulance Suppliers,
Independent Clinical Laboratory, IDTF, Physical
Therapists Enrolling as Individuals or Groups, and
Portable Xray Suppliers
Does Medicare conduct a site visit for
Intensive Cardiac Rehabilitation Suppliers
enrollment?
George Osipyants
Credentialing Specialist
e-mail: [email protected]
Question:
Answer:The only code exist is T1013 Sign language or
oral interpretive services, per 15 minutes which in
only covered by Medicaid. The health care
professional or facility responsible for the care must
pay for the cost of an interpreter. Health care
professionals or facilities cannot impose a
surcharge on an individual with a disability directly
or indirectly to offset the cost of the interpreter. The
cost of the interpreter should be treated as part of
overhead expenses for accounting and tax
purposes. Tax relief is available for expenditures
made toward interpreters. The Internal Revenue
Service may allow a credit of up to 50% of
cumulative eligible access expenditures made
within the taxable year that exceed $250 but do not
exceed $10,250. This tax credit may be applied to
reasonable and necessary business expenditures
made in compliance with ADA standards in order to
provide qualified interpreters or other accessible
tools for individuals with hearing impairments.”
Can I be reimbursed for the sign language
interpreter?
Source: www.drlaw.com23WCH Newsletter Fall 2013 www.wchsb.com
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