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WCH Bulletin March 2014

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WCH Bulletin March 2014

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Page 1: WCH Bulletin March 2014
Page 2: WCH Bulletin March 2014

INSIDE THIS ISSUE:3-15

WCH Buzz

17-18

Credentialing News

33-38

News by Specialty

39-41

Q&A

19-32

Healthcare News

Get your CEU credits TODAYFor more information please contact Ilana Kozak

at 718-934-6714 ext 1214or by e-mail to: [email protected]

Follow Us:

Your Feedback is Important to Us, WCH itLet us know what topics you would like to see inthe upcoming issues. We are always looking forward to your feedback about our performance.

We ask for feedback and greatly appreciate the time our clients take to provide us with their opinions and suggestions regarding our work! Our New Jersey clients have asked us to include more New Jersey News in our bulletin, We Heard You! New Jersey providers please see New Jersey state related news and updates in our Healthcare section.

CHECK OUT PAGE 10Secure E-doc is a non-profit company that is affiliated with Cerebral Palsy Association of NYS, an organization that is committed to empower-ing people with disabilities. Make a diffrence in people’s lives Use Secure E-doc for your document Scanning, Filling and Shredding.

March 27th National Medical Biller Day!

2 www.wchsb.com WCH Bulletin March 2014

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WCH Buzz

WE DID IT!iSmart EHR - a Complete Ambulatory EHR

WCH is proud to announce that iSmart EHR Version 1.1 has successfully com-pleted the certification as a 2014 Meaningful Use Complete EHR. Date Certified: March 20, 2014.This has been a long and difficult journey to get to this point of the certification and we are extremely excited because we are now able to provide our clients with all services and products to comfortably and proficiently run their practice operations. Furthermore, WCH Management is proud of the incredible team that has helped to create and complete this cumbersome five year project. Once again we want to thank all of our workers, clients, and part-ners for your help, patience and belief in WCH.Now our team is starting to work on cli-ent’s requests for customized templates, reporting features, and further enhancing some of the EHR functionalities. We in-tend to finish all requests in the shortest time possible and of course we welcome

all suggestions and comments from ev-eryone. Stay tuned for more information on all EHR features that will be available on our website at www.wchsb.com in April.WCH has developed a strong relationship with Bank of America Practice Solutions, which is available to assist with the pur-chasing or leasing of WCH iSmart EHR Product. For more information about this please contact WCH directly.Thank you once again for your trust and support in our company.

Sincerely,Olga Khabinskay, COO

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WCH Buzz

Use Complete iSmart EHR to Improve Quality of Your Practice Using Complete Electronic Health Records (EHR) instead of paper charts has its benefits. WCH iSmart EHR is a Complete certified EHR where all aspect of clinical care are recorded in one system. This allows medical providers and their staff to manage all areas of a medical practice’s daily operations. From sched-uling appointments, to assessing a patient’s chief compliant to developing a treatment plan the Complete iSmart EHR with all its modules has useful information for the entire practice staff.

Check out these great Benefits of using Complete EHR:

Complete EHR iSmart EHR will help your practice:• Improve patient care• Become more efficient• Receive government incentive payments• Improve communication

EHR Facts:

of office based doctors began the use EHRs

of office based physi-cians reported that they intended to par-ticipate in meaningful use incentives

of providers re-ported that their EHR allows them to deliver better care

of providers reported that their EHR produce clinical benefits for the practice

Source: http://www.cdc.gov/nchs/data/databriefs/db143.htm

iSmart EHR is has completed ALL certification stages!The remaining modules have been successfully tested, iSmart is now A COMPLETE EHR

WCH it! get a full list of WCH iSmart EHR features visit http://wchsb.com/EHR/indexFor more information about WCH iSmart EHR, contact Olga Khabinskay

at 718-934-6714 X 1201

WCH Buzz

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WCH Buzz

FREE EHR IS NOT ALWAYS FREE??? The biggest drawback to free EMR systems seem to be data and security concerns. Kareo for its part has said on its website that they won’t sell the data to third par-ties, however, the company doesn’t list a fully privacy policy on its website. And both Practice Fusion and Hello Health make no such claims regarding data selling. This has many users and practices asking who owns the patient data in a free EMR, and what is being done with it?With iSmart EHR you will never have any Data and Security concerns.

Read more: http://www.kevinmd.com/blog/2013/09/hidden-cost-free-emr-systems.html

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Closer Look at inside WCH Chart Review Service

Who We Are:

• Elizaveta Bannova, CPMA, CPC, • Oksana Pokoyeva, CPMA, CPC• Veronika Mukhamedieva, CFPC

WCH Chart Review Service has been designed to improve the quality of our client’s medical records for smooth practice operations. WCH highly trained professionals will help ensure accuracy and completion of medical records. WCH invests heavily in training our professionals to increase their level of expertise to provide highest quality of service. WCH Professionals have several industry certifications including CPC, CFPC, CMRS, and CPCA to name a few with Proficiency across a wide range of services, includ-ing evaluation and management, anesthesia, surgical services, radiology, pathology and more.

What We Do:WCH certified professionals review complete records, chart notes and documentation associ-ated with each patient visit. Documents such as: face sheets, administration records, consent forms, admission notes, pre-operative notes, operative notes, postoperative notes, procedure notes and test results (EKG, X-rays, etc.) will be required to complete a chart review. At the completion of the review, a detailed report is generated outlining the findings from the review with suggested improvements and extensive feedback.

Key benefits of WCH Chart Review Service: • Identify accurate medical coding for diagnoses, procedures and services to be

reported to payers to ensure compliance.• Discover appropriate medical terminology for reporting Codes, diagnosis and

services.• Protect your practice against issues such as medical necessity, denied claims,

bundling issues and charge captures • Integrate medical coding and reimbursement rule changes into a practice’s reim-

bursement process.

• Zukhra Kasimova,CPC, CPB • Vyacheslav Kurdov, CPC• Olga Mirolyubova, CPC

Medical Chart Review services is solution to better clinical documentation. Protect your practice from surprising documentation requests! BE READY.

WCH Buzz

Every issue will bring you details of the work performed in each department, because we want you to know how we work and what we do for you.

For more details visit: www.wchsb.com/Medical-Chart-Auditing or Contact Elizaveta Bannova at 718-934-6714 x 1103 [email protected]

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WCH Buzz

Excellent Medical Chart Increase quality of Patient Care Better clinical documentation helps ensure the best outcomes of your patients’ treatment.Complete, legible documentation is the basis of every patient’s health record. Proper documentation and coding effects patient care, coordination, compliance, coding, billing and reimbursement. Accurate coding translates clinical documentation into a resource that can help providers improve the care of their patients and improve office operations and efficiency.Accurate coding is the secret to full and timely reimbursements from your medical claims. The most frequent errors in claim processing can be attributed to improper coding and/or a lack of necessary documentation.

WCH it to improve your office’s clinical documentation contact our coding professionals.

Our CPCs and CPMAs will improve your clinical documentation! Better clinical documentation:

• Adds to the quality of care your patients receives• Provides clear communication about patients for providers and administrative

staff• Providers support that the CPTs that were billed were actually rendered to the

patient

Questions about your coding and documentation? Contact Elizaveta Bannova Billing Department Vice Manager CMRS, CFPC at 718-934-6714 x 1103 or [email protected]

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WCH Buzz

Olga Khabinskay has been invited to speak by New York Hospitals to June graduates on the topic Credentialing for the new graduates. With over 12 years of experience in

credentialing, billing and office start up, Olga provides insight into business side of medicine. Most recently she spoke at Sunny Downstate and Beth Israel Hospital to last year residents of several departments.

In upcoming months, WCH is planning to extend the invitation for seminars to doctors in our office. Stay tunned for upcoming dates! Feel free to contact WCH with any credentialing questions. We are here to help you always!

WCH Educates Graduating Residents

If you feel that a seminar will be beneficial for the hospital where you work or any group or practice that might need consultations, please contact Olga Khabinskay at 718-934-67-14 ext 1201 or via email: [email protected] to schedule and arrange an educational seminar.

WCH it!

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Do it Right! WCH it!• Medical Billing - WCH it

• Credentialing - WCH it

• EHR - WCH it

• Healthcare Updates - WCH it

• Chart Reviews - WCH it

WCH Buzz

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Secure E-doc is a non-profit company that is affiliated with Cerebral Palsy Associa-tion of NYS, an organization that is com-mitted to empowering people with disabili-ties. Make a diffrence in people’s lives Use Secure E-doc for your document Scanning, Filling and Shredding.

Cerebral Palsy NY

11www.wchsb.com WCH Bulletin March 2014

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WCH Buzz

ICD-10 Testing Week

ICD-10 transition is fast approaching, It is true WCH Service Bureau is Ready!

For dates of service of October 1, 2014 (and after) providers are required to submit ICD-10 codes on their claims. CMS con-ducted a national testing week for current direct submitters to provide the opportunity to submit EDI test claims on March 3rd-7th in efforts to be fully prepared for the ICD-10 transition in October.

WCH IT department is pleased to announce that WCH have successfully completed the testing of ICD-10 claims. Claims with ICD-10 information were submitted to Medicare Contrac-tors, as a result test claims received the 277CA acknowledge-ment which confirmed that the claim were appropriately ac-cepted in to the Medicare system.

WCH AAPC certified professionals are now preparing for the AAPC ICD 10 certification. The ICD-10 certification is issued upon a completion of 16 hours of comprehensive ICD-10-CM training. The training includes evaluation exercises and case studies to assess your proficiency with the new code set. Suc-cessful completion of this course will satisfy AAPC’s certification maintenance requirements for ICD-10-CM.

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RELIEF TO ALL – CMS Announces RAC Audit Suspension The Centers for Medicare & Medicaid Services are suspending the ability of Recovery Auditor Contractors (RAC) to re-quest documents associated with claims reviews.Active recovery auditing includes sending additional documentation requests/semi-automated notification letters and initi-ating automated reviews which are now suspended!.Providers should note the important dates below:

• February 21, 2014 is the last day a Recovery Auditor may send a post-payment Additional Documentation Request (ADR)

• February 28, 2014 is the last day a MAC may send prepayment ADRs for the Recovery Auditor Prepay-ment Review Demonstration

• June 1, 2014 is the last day a Re-covery Auditor may send improper payment files to the MACs for ad-justment

The suspension of additional documenta-tion requests (ADRs) allows CMS transi-tion down the current contracts so that the Recovery Auditors can complete all outstanding claim reviews and other

processes by the end date of the current contracts. Now that the dates for sending Addition Documentation Request (ADR) letters have passed, CMS would like to remind providers that the Recovery Auditors can continue to conduct automated reviews (reviews that do not require soliciting medical record documentation from pro-viders) through June 1, 2014. Recovery Auditors will also continue to complete the reviews for the ADRs they’ve already sent as of 2/28/2014. Providers have 45 days to respond to an ADR and Recovery Auditors have up to 60 days to make a determination on the claim. In general, CMS will not conduct post-payment patient status reviews for claims with dates of admission October 1, 2013 through October 1, 2014.CMS will continue to update this Website with more information on the procure-ment and awards as information is avail-able.

Source: http://www.cms.gov/

WCH Buzz

ICD-10 SAMPLERW59.21XDBitten by turtle

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WCH Service Bureau Congratulates Everyone on Medical Billers Day, March 27 2014March 27th 2014 marks the recognition of Medical Billers throughout the state of NY and Nationwide. Medical Billing Profes-sionals contribute greatly to the system of medical care in assisting physicians and other healthcare professionals ensuring appropriate payment is received for ser-vices rendered. National Medical Billers Day was initiated by the AMBA (American

Medical Biller’s Association) beginning in 2008 in of the importance and involve-ment of medical billers in the health care industry.

WCH Medical Billing professionals are experts in a field that requires at-tention to detail, understanding and proficiency in the laws and regula-tions related to the insurance industry and healthcare industry. The work of WCH medical billers helps healthcare facilities maintain optimum level of efficiency, productive and compliance with rules and regulations on a daily basis.

HAPPY MEDICAL BILLERS DAY!Congratulate AMBA for recognizing and establishing this holiday.

WCH Buzz

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WCH Buzz

Chag Sameach Everyone! WCH staff is wishing you Happiness, Peace, Prosperity and all the Joys of Passover!Please be advised, in observance of Passover, WCH office will be operating at a special holiday schedule. • Tuesday, April 15, 2014 and Wednesday, April 16, 2014, WCH Office will be closed• Monday, April 21, 2014 and Tuesday, April 22, 2014, WCH Office will be closed

To find out more about WCH special holiday schedule please contact your account repre-sentative at WCH.

Happy Passover to you and your families!

Happy Passover!

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Credentialing NewsFee-For-Service Provider Enrollment Reporting Responsibilities for Individ-ual Physicians Enrolled in the Medicare ProgramReportable Physician Changes After enrolling in the Medicare Program, all physicians are responsible for main-taining and reporting changes in their Medicare enrollment information to their designated Medicare contractor. By reporting changes as soon as pos-sible, physicians will help to ensure that their claims are processed correctly. The reportable events listed below may affect claims processing, a payment amount, or a physician’s eligibility to participate in the Medicare Program. • Change in Practice Location occurs

when a physician establishes a new practice location, moves an existing practice location, closes an existing practice location, or changes any por-tion of an existing practice location address where Medicare information is sent.

• Change in Final Adverse Action occurs when a physician is debarred or ex-cluded by any Federal or State health care program, has his or her medical license suspended or revoked by a State licensing authority, was con-victed of a felony within the last 10 years, has his or her Medicare billing privileges revoked by a Medicare con-tractor.

• Change of Business Structure occurs when a physician changes his or her business structure (e.g., sole propri-etorship to sole incorporated owner or vice versa).

• Change in Organization Legal Busi-ness Name/Tax Identification Number occurs when a business owner chang-es the organization’s legal business name and/or Taxpayer Identification Number with the Internal Revenue Service.

• Change in Practice Status occurs when a physician decides to retire or voluntarily withdraw from the Medi-care Program. This type of change is referred to as a voluntary withdrawal.

Other Reportable Changes Include• Change in Reassignment of Benefits

occurs when a physician adds or voluntarily withdraws his or her reas-signment of Medicare benefits. Physi-cians must report this type of change on the CMS-855R.

• Change in Banking Arrangements or any Payment Information occurs when a physician changes his or her bank or bank account or makes other payment information changes. A phy-sician can update his or her electronic funds transfer information by sub-mitting the Electronic Funds Transfer Authorization Agreement (CMS-588) to his or her Medicare contractor.

Source: http://www.cms.gov/

To Report any changes to Medicare,please contact WCH Credentialing Department at 718-934-6714 ext 1214

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Credentialing News

All providers and suppliers who enrolled in the Medicare Program prior to March 25, 2011, are required to submit their en-rollment information so they can be revali-dated.If you received Provider Enrolment Re-validation letter in the mail, it is impor-tant that you respond within 60 days to avoid termination of the PTAN.

WCH it to successfully process revalidation enrollment applications for ONLY $360.00.If you receive a revalidation Letter CONTACT US RIGHT AWAY!For More information contact WCH Cre-dentialing Department Specialist Dora Mirkhasilova at 718-934-6714 ext 1310 or by email at [email protected]

DON’T IGNOR RE-VALIDATION REQUESTS – DON’T LOSE BILLING PRIVILEGES

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Healthcare News2014 PQRS Program OverviewDespite strong opposition from the physi-cian community, CMS finalized Calendar Year 2014 as the performance period for the 2016 PQRS penalties. Therefore, if CMS determines that an eligible profes-sional or group practice has not satisfac-torily reported through one of the final-ized 2014 reporting options for avoiding a payment adjustment or qualifying for a payment incentive for the January 1, 2014 through December 31, 2014 reporting pe-riod, the fee schedule amount for services furnished by the participating profession-al or group practice during 2016 would be 98.0 percent of the fee schedule amount that would otherwise apply to such ser-vices.CMS has established different reporting requirements for individual physician and non-physician providers, as well as group practices for participating in the 2014 PQRS program. Participation require-ments to qualify for a payment incentive differ from requirements for avoiding a payment penalty. However, qualifying for an incentive allows the individual or group practice to avoid the payment ad-justment.CMS has eliminated the Administrative Claims or the option of reporting one measure or measures group for avoiding the 2016 PQRS penalty. In addition, PQRS measures groups in 2014 will only be reportable through a registry and elimi-nated the six-month reporting option.

Summary of Changes:• 2014 PQRS measures group reporting

can only be done with a registry.• It will be easier for a provider to re-

port 2014 PQRS with a registry instead of using claims because a provider only needs to report 20 patients with a measures group and most measure groups have less than 9 measures.

• 2014 PQRS bonus is 0.5% of the total estimated Medicare Part B allowed charges.

• The penalty for not reporting 2014 PQRS is 2%.

• 2014 individual PQRS measures re-porting: report at least 9 measures, OR, if less than 9 measures apply to the eligible professional, report 1—8 measures, AND report each measure for at least 50 percent of the eligible professional’s Medicare Part B FFS patients seen during the reporting period to which the measure applies. Measures with a 0 percent perfor-mance rate would not be counted. The 9 measures need to cover at least 3 NQF domains: Patient Safety; Person and Caregiver-Centered Experience and Outcomes; Communication and Care Coordination; Effective Clinical Care; Community/Population Health; Efficiency and Cost Reduction

Source: http://www.ama-assn.org

ICD-10 SAMPLERY93.D1Injured while knitting

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Attention NY Medicaid Providers Medicaid Required by Federal Law to Change Electronic Remit-tance Delivery DateEffective April 7, 2014 (Cycle 1911) eMed-NY will no longer be permitted to make the X12 835 and the X12 820 electronic remittances available two weeks prior to release of payment. Electronic remit-tances will be available two days prior to the release of funds. The change is neces-sitated by requirements of Section 1104 of the Affordable Care Act (ACA) and the CAQH Committee on Operating Rules for Information Exchange (CORE), the author-ing entity for operating rules for Elec-tronic Fund Transfer (EFT) and Electronic Remittance Advice (ERA) transactions. CORE Rule 370 requires that transmission of the 835 cannot occur more than three days prior to the availability of the EFT. All providers receiving the 835/820 electronic remittance are affected and it is impor-tant that they assess what impact, if any, the change in the 835/820 delivery date may have on their business. The change will be implemented on April 7, 2014.

Therefore, electronic remittances for cycle 1911 that would have been avail-

able on 04/07/14 will not be delivered to eXchange or FTP accounts until 04/21/14, 2 days before the Check/EFT release date. No electronic remittances will be deliv-ered on 04/07/14 and 04/14/2014. For these two cycles electronic remittances will be released as follows:

The current payment schedule will not be impacted by this change. Payments will continue to be lagged for two weeks and two days from the issue date.

Information on the CORE Operating Rules can be found at: http://www.caqh.org/ORMandate_index.php Questions? Contact the eMedNY Call Cen-ter at 800-343-9000 or email [email protected]

Source: http://www.emedny.org

Healthcare News

Cycle19111912

Payment Issue Date4/7/144/14/14

Electronic Remittance Issue Date4/21/144/28/14

Payment Release Date4/23/144/30/14

WCH invoice will be effected by this change. Medicaid checks will be invoiced as checks are issued by Medicaid.

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Missing or Illegible SignaturesCMS issued revised CR6698 to clarify how Medicare contractors review Medicare claims and medical documentation sub-mitted by physicians and/or providers. Medicare requires that services provided/ordered be authenticated by the author. The method used for authenticating shall be a handwritten or electronic signature. Stamped signatures are not acceptable. National Government Services encour-ages physicians and providers to verify that a legible signature is present on all medical records during their quality check before the document is filed in the pa-tient’s permanent record. Acceptable Electronic Signatures• Chart “Accepted by” with provider’s

name• “Electronically signed by” with provid-

er’s name• “Verified by” with provider’s name• “Reviewed by” with provider’s name• “Released by” with provider’s name• “Signed before import by” with pro-

vider’s name• Digitalized signature: Handwritten and

scanned into the computer • “This is an electronically verified report

by John Doe, MD” • “Authenticated by John Doe, MD” • “Authorized by John Doe, MD” • “Digital Signature: John Doe, MD” • “Confirmed by” with provider’s name• “Closed by” with provider’s name• “Finalized by” with provider’s name• “Electronically approved by” with

provider’s name

Examples of medical records that re-quire a legible signature: • Dictated reports (provider should • proofread the dictation)• Outpatient visits• Laboratory or diagnostic orders/requi-

sitions (if you are unable to obtain a • copy of the physician’s progress notes

requesting the test to be performed)• Certificates of Medical Necessity • (CMNs)• Treatment plans/plan of care• Treatment log notes• Initial evaluations or current • reevaluations• Inpatient visits (if necessary obtain the

signed copy from the hospital)• Office visits (even if there is only one • provider at the practice location)

Note: If you notice the signature is il-legible when asked to supply medical records, please include a signature key, signature page, or a document from the provider/physician or compliance officer that affirms the signature is indeed the providers/physicians. This signature docu-ment can be submitted routinely for all requests for medical records.

Source: http://www.ngsmedicare.com

Healthcare News

ICD-10 SAMPLERW89.9xxAExposure to unspecified man-made visible and ultraviolet light, initial en-counter

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Healthcare News

CPT Code Use for Duration of Prolonged Services

The use of the time-based add-on codes requires that the primary E&M service have a typical or specified time published in the CPT Code Book.The following examples illustrate the correct reporting of prolonged physician or other qualified health care professional service with direct patient contact in the office setting:

Note: Prolonged service of less than 30 minutes total duration on a given date is not separately reported because the work involved is included in the total work of the E&M codes.

Source: http://www.ngsmedicare.com

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Healthcare News

Medicaid Beneficiaries Cannot Be BilledBy enrolling in the Medicaid program, a provider agrees to accept payment under the Medicaid program as payment in full for services rendered. A provider may not make a private pay agreement with a beneficiary to accept a Medicaid fee for a particular covered service and then pro-vide a different upgraded service (usually a service that is beyond the scope of the Medicaid program) and agree to charge the beneficiary only the difference in fee between two services, in addition to bill-ing Medicaid for the covered service. ACCEPTANCE AND AGREEMENT • When a provider accepts a Medicaid

beneficiary as a patient, the provider agrees to bill Medicaid for services provided or, in the case of a Medicaid managed care or Family Health Plus (FHPlus) enrollee, the beneficiary’s managed care plan for services cov-ered by the contract.

• The provider is prohibited from re-questing any monetary compensation from the beneficiary, or their respon-sible relative, except for any applicable Medicaid co-payments.

• The provider is prohibited from re-questing any monetary compensation from pregnant women or children who have been found to be presumptively eligible for Medicaid or beneficiaries found presumptively eligible for FPBP.

• A provider may charge a Medicaid beneficiary, including a Medicaid or FHPlus beneficiary enrolled in a man-aged care plan, only when both parties have agreed prior to the rendering of the service that the beneficiary is being seen as a private pay patient.

• This agreement must be mutual and voluntary. It is suggested that provid-ers keep the beneficiary’s signed con-sent to be seen as a private pay patient on file.

• If, for example, a provider sees a ben-eficiary, and advises them that their Medicaid card or health plan card is valid, eligibility exists for the date of service and treats the individual, the provider may not change their mind and bill the beneficiary for that service or any part of that service.

A provider who participates in Medicaid fee-for-service may not bill Medicaid fee-for-service for any services included in a beneficiary’s managed care plan, with the exception of family planning services, when a provider doesn’t provide such ser-vices under a contract with the recipient’s health plan. A provider who does not participate in Medicaid fee-for-service, but who has a contract with one or more managed care plans to serve Medicaid managed care or FHPlus members, may not bill Medicaid fee-for-service for any services. Nor may any provider bill a ben-eficiary for services that are covered by the beneficiary’s Medicaid managed care or FHPlus contract, unless there is prior agreement with the beneficiary that they are being seen as a private pay patient as described previously. The provider must inform the beneficiary that the services may be obtained at no cost from a pro-vider that participates in the beneficiary’s managed care plan.

Note: Due to the requirement that PRIOR agreement be made for reimbursement, Medicaid beneficiaries may never be charged for services rendered in an Emer-gency Room (except applicable Medicaid co-payments).

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CLAIM SUBMISSION Providers are strongly encouraged to con-firm eligibility and the appropriate payor every time a patient is seen and before rendering services. Providers of long term services and supports are encouraged to confirm eligibility on the 1st and 15th of each month, and, as applicable, promptly contact a recipient’s new managed care plan to ensure continued service authori-zation. The prohibition on charging a Medicaid or FHPlus recipient applies: • When a participating Medicaid pro-

vider or a Medicaid managed care or FHPlus participating provider fails to submit a claim to Computer Sciences Corporation (CSC) or the recipient’s managed care plan within the required timeframe; or

• When a participating Medicaid pro-vider or a Medicaid managed care or FHPlus participating provider submits a claim to CSC or the recipient’s man-aged care plan, and the claim is denied for reasons other than that the patient was not eligible for Medicaid or FHPlus on the date of service.

COLLECTIONS A Medicaid beneficiary, including a Medicaid managed care or FHPlus enrollee, must not be referred to a collection agency for collection of unpaid medical bills or otherwise billed, except for applicable Medicaid co-payments, when the provider has accepted the en-rollee as a Medicaid or FHPlus patient.

EMERGENCY MEDICAL CARE A hospital that accepts a Medicaid beneficiary as a patient, including a Medicaid or FHP-lus recipient enrolled in a managed care plan, accepts the responsibility for mak-ing sure that the patient receives all medi-

cally necessary care and services. Other than for legally established co-payments, a Medicaid or FHPlus recipient should never be required to bear any out-of-pocket expenses for: • Medically necessary inpatient services;

or, • Medically necessary services provided

in a hospital-based emergency room (ER).

This policy applies regardless of whether the individual practitioner treating the beneficiary in the facility is enrolled in the Medicaid program. When reimburs-ing for ER services provided to Medicaid managed care or FHPlus enrollees, health plans must apply the: • Applicable federal and state law and

regulation; • Provisions of the Medicaid Managed

Care/FHPlus Model Contract; and • Department Directives.

To avoid payment delays, hospitals are encouraged to query MEVS for a patient’s current eligibility status and appropriate payor, before preparing an emergency Medicaid application.

CLAIMING PROBLEMS If providers find a problem with a claim submission, they must first contact the CSC Call Center at (800) 343-9000. If the claim is for a service included in the

Source: http://www.health.ny.gov

Healthcare News

Continued! Medicaid Beneficiaries can not be billed

ICD-10 SAMPLERY93.J4Activity, winds and brass instrument playing

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Healthcare News

Beginning April 1, 2014, ValueOptions will No Longer Mail Paper Provider Authori-zation Letters for New York City Clients Beginning April 1, 2014, ValueOptions will no longer mail paper provider authoriza-tion letters for GHI, Emblem, VNS Choice Medicare and VNSNY Choice SelectHealth. Notices of new authorizations, and the letters themselves, are available on the ValueOptions online provider portal, Pro-viderConnect, secure and HIPAA-compli-ant platform for claim, authorization and credentialing transactions.Electronic authorization letters pro-vide several advantages over paper letters:

• Natural resources are conserved.• Providers will be able to access autho-

rization letters anytime with a secure internet browser.

• Providers may access authorizations within 24-48 hours of a decision in-stead of waiting days for the mail.

• Electronic authorization letters are not lost in the mail or a busy office.

• Providers may download an electronic image of the letter instead of printing.

The E-commerce initiative, which requires all network providers to electronically perform all routine transactions, includ-ing verification of eligibility inquiries, submission of authorization requests and submission of claims and recredentialing applications, begins January 2015.

Source: http://www.valueoptions.com

EmblemHealth EFT/ERA Enhancements Coming in 2014 EmblemHealth is pleased to be imple-menting PNC Remittance Advantage* in 2014. Remittance Advantage is an elec-tronic payment tool including electronic funds transfer of claims compensation and electronic remittance advice (EFT/ERA). This program deposits payments from EmblemHealth directly into your bank account and informs you of these payments. This program enhances our existing electronic funds transfer system.PNC Remittance Advantage will help you manage your practice accounts receiv-ables more efficiently via direct deposit, remittance advice and payment details

you can access online. The program is available to physicians, providers, facili-ties, hospitals and billing companies free of charge. All you need is a computer and an Internet connection.With PNC Remittance Advantage you will be able to:• Improve your cash flow• Reduce administrative expenses• Match payments to remittances quick-

ly and easily• Manage the destination of your claim

payments• Manage user access

Later, we will provide you with informa-tion about how to register to take advan-tage of PNC Remittance Advantage

Source: http://www.emblemhealth.com

26 www.wchsb.com WCH Bulletin March 2014

Page 27: WCH Bulletin March 2014

E/M Codes and Psychotherapy Documen ng Your Work

ONE EXAMPLE - New Pa ent OF AN E/M PLUS PSYCHOTHERAPY PROGRESS NOTE

Pa ent Iden er

Date

Diagnosis

E/M:

History

[Include required number of elements based on E/M level billed]

Examina on

[Include required number of bullets based on E/M level billed]

Medical Decision Making

[Include required documenta on based on E/M level billed]

Psychotherapy:

Time spent on psychotherapy services only________

[Include descrip on of type and content of psychotherapy provided]

List addi onal a endees, if any:

Legible Signature of Prac oner, Degree , Licensure

Documenta on of Psychotherapy Services

Documenta on for psychotherapy should be separate and iden able in the progress note. Your documenta on must support the add-on psychotherapy service as an addi on to the elements of the E/M service. Further, the approximate me spent providing face-to-face psychotherapy should be documented within the note and, as stated, should be separate from the me spent rendering the E/M service.

A separate diagnosis is not required for the repor ng of the E/M and psychotherapy service on the same date.

American Psychiatric Associa on: h p://www.psychiatry.org/home (Path: Prac ce > Managing a Prac ce > CPT Changes 2013) American Medical Associa on: h p://www.ama-assn.org/resources/doc/cpt/15-

psychotherapy-puente-musher.pdf Centers for Medicare & Medicaid h p://www.cms.gov/ (Path: Outreach & Educa on > MLN Educa onal Web

Guides)

Overview

Pa ents with psychiatric diagnoses may receive a medical evalua on and management (E/M) service on the same day as a psychotherapy service by the same physician (or other qualied health care professional). To report both E/M and psychotherapy, the two services must be signicant and separately iden able (within the same progress note is acceptable). Time parameters should be documented to denote the approximate me devoted to the psychotherapy service. These services are reported by using both the appropriate E/M code and add-on codes specic for psychotherapy when performed with evalua on and management services (90833, 90836, and 90838). When psychotherapy is provided in conjunc on with an E/M service, the standalone psycho-therapy codes (90832, 90834, and 90837) should not be used. See the CPT Code book for descrip ons and addi onal informa on.

The medical and psychotherapeu c components of the service should be separately iden ed within the progress note and should include the following informa on.

Documenta on Related to the E/M Service

The type and level of E/M service is selected based upon the level of interven on and is determined by key components of history, examina on, and medical decision-making. For new pa ents. 3 out of 3 of these components (history, examina on, and medical decision-making) are required; for established pa ents, 2 of the 3 components are required. (Time spent providing counseling and coordina on of care may not be used to determine the level of E/M service when E/M is performed in addi on to psychotherapy.) Documenta on reects the work performed:

History: Problem Focused, Expanded Problem Focused, Detailed, or Comprehensive

Examina on: Problem Focused, Expanded Problem Focused, Detailed, or Comprehensive

Medical Decision-Making: Straigh orward, Low, Moderate, or High The me associated with ac vi es used to meet criteria for the E/M service is not included in the me used for repor ng the psychotherapy service (i.e., me spent on history, examina on, and medical decision-making for the E/M service is not part of the psychotherapy me). The appropriate psychotherapy add-on code is selected based on the me of the psychotherapeu c interven on only, it does not include any of the me devoted to the E/M service. The approximate face-to-face me spent in the psychotherapy por on of the visit should be documented.

United Behavioral Health operating under the brand Optum

Resources:

This provider alert is not meant to replace the 1995 or 1997 CMS guidelines for documenta on. See resources above for addi onal informa on.

Healthcare News

27www.wchsb.com WCH Bulletin March 2014

Page 28: WCH Bulletin March 2014

Healthcare News

Nonphysician Practitioners Billing for Surgical ProceduresRecently, several providers have asked about the Medicare guidance for non-physician practitioners (NPPs) billing for surgical procedures. NPPs include nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs).State law or regulation governs PAs, NPs and a CNS’s scope of practice in the state in which the services are performed. The procedures for which NPPs can bill Medi-care must also meet the requirements defined in the Centers for Medicare & Medicaid Services (CMS) sections listed below:1. Section 190, “Physician Assistant (PA)

Services” 2. Section 200, “Nurse Practitioner (NP)

Services”3. Section 210, “Clinical Nurse Specialist

(CNS) Services”

Minor Surgical Procedures vs. Major Surgical Procedures When Billed by an NPPMinor surgical procedures (10-day global period) are generally covered when billed by an NPP if determined: • to be within the usual training of a PA/

NP/CNS; • that the risk of performing the proce-

dure would be acceptable when pro-vided by a nonphysician practitioner; and

• that the usual training includes exper-tise required to make the decision to perform the procedures

Major surgical procedures (90-day global period) are generally not a covered ser-vice when billed by a NPP.Refer to the CMS Physician Fee Schedule Look Up to search for specific code re-lated global periods.

Source: http://www.ngsmedicare.com

28 www.wchsb.com WCH Bulletin March 2014

Page 29: WCH Bulletin March 2014

Healthcare News

Beginning May 1, 2014 over 3,000,000 members of health benefits plans with in-surance or administered by Horizon Blue Cross Blue shield of New Jersey will begin accessing the Multiplan Network in the state of New Jersey. Horizon BCBSNJ, New Jersey’s Oldest and largest health insurance company has contracted with Multiplan to access the Multiplan Network for its members who seek care from a provider who does not participate in Horizon BCBSNJ’s network and is contracted with Multiplan. Reim-bursement for covered services rendered to horizon BCBSNJ members will be paid by Horizon BCBSNJ in accordance with the provider Multiplan Agreement typically at the Horizon BCBSNJ member’s out of network benefit level, unless specific cir-cumstances require that the claim be paid as an in network claim. This also means that Horizon BCBSNJ will be paying pro-

viders directly even if provider is a non-participant in Horizon BCBSNJ’ provider network.

PLEASE NOTE: For providers that partici-pate with one of Horizon BCBSNJ’s net-work, the agreement with Horizon BCBSNJ supersedes the Multiplan agreement, and provider will continue to be reimbursed under the terms of the Horizon BCBSNJ participation provider agreement. For claims that Multiplan agreement rates have been applied, the following message will be displayed: “This service is paid in accordance with the Multiplan discount rate agreements. Member liability is limited to applicable copays, coinsurance and deductibles.”For more information regarding this change, contact your WCH account rep-resentative today!

Attention New Jersey Providers!!!

29www.wchsb.com WCH Bulletin March 2014

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Horizon BCBS NJ New Health Care Reform Plans

PFAF AP

H orizon Blue Cross Blue Shield of New Jersey offers two new health plans as a result of the Affordable Care Act (ACA). Horizon Advance EPO and Horizon Advantage EPO combine the standard essential health benefits, preventive services and all ACA requirements with the features of a Horizon EPO plan

Ac

ce

ss

to

eff

ec

tiv

e a

nd

sa

fe c

are

Horizon Advance EPO

Our Horizon Advance EPO plans provide access to a subset of doctors and specialists in the Horizon Managed Care Network. These plans provide integrated medical and pharmacy benefits, including wellness and emergency care. Members must select a Primary Care Physician (PCP) to coordinate care and provide referrals to specialists who participate with the Horizon Advance EPO product. Horizon Advance EPO members can choose to maximize their benefits by using hospitals with the Preferred Tier 1 designation. Members can access other hospitals in the Horizon Hospital Network for an additional out-of-pocket cost.

J DOE

JGX3HZN00000000

PREVENTIVE CARE 100%

FAMILY DEDUCTIBLE $3000.00

FAMILY DEDUCTIBLE TIER 2: $5000.00OFFICE VISIT: $30.00

SPECIALIST: 30%

EMERGENCY ROOM: $100.00INN COINSURANCE: 70%/30%INN COINSURANCE TIER 2: 50%/50%

G9999

Horizon Advantage EPO

With our Horizon Advantage EPO plans, members have access to all doctors, specialists and hospitals that participate in the Horizon Managed Care Network. These plans provide integrated medical and pharmacy benefits, including wellness and emergency care. Although members are not required to select a PCP, there are lower out-of-pocket costs when certain care is coordinated through a selected PCP.

J DOE

JGZ3HZN00000000

PREVENTIVE CARE 100%

SINGLE DEDUCTIBLE $2000.00

OFFICE VISIT: $25.00

SPECIALIST: $50.00

EMERGENCY ROOM: $100.00

INN COINSURANCE: 60%/40%

G9999

Horizon Advantage EPO Essentials

Our Horizon Advantage EPO Essentials plan is available to individuals ages 30 years and younger or individuals who meet certain financial hardship conditions as certified by the Health Insurance Marketplace. This high-deductible plan provides integrated medical and pharmacy benefits, including wellness and emergency care, and financial security in the event of costly hospitalizations.

J DOE

JGZ3HZN00000000

PREVENTIVE CARE 100%

SINGLE DEDUCTIBLE $6350.00

EMERGENCY ROOM: $100.00

G9999

If you have questions about these plans, please call Physician Services at 1-800-624-1110 or our Institutional Services teams at 1-888-666-2535.

Page 31: WCH Bulletin March 2014

Healthcare News

Notification by a Business AssociateIf a breach of unsecured protected health information occurs at or by a business associate, the business associate must notify the covered entity following the discovery of the breach. A business asso-ciate must provide notice to the covered entity without unreasonable delay and no later than 60 days from the discovery of the breach. To the extent possible, the business associate should provide the covered entity with the identification of each individual affected by the breach as well as any other available information required to be provided by the covered entity in its notification to affected indi-viduals. The breach notification requirements only apply to breaches of “unsecured” PHI. Covered entities will need to negotiate with their business associates regarding the time frame and manner in which a business associate will notify the covered entity of the breach, and incorporate such information into their business associate agreements.

Breach ExceptionsThe HITECH Act includes three excep-tions to the definition of “breach”, which include situations where a violation of the Privacy Rule has occurred, but the viola-tion is not to be considered a breach. These exceptions include:

I. An unintentional acquisition, access or use of PHI by a workforce member or individual acting under the authority of a covered entity or business associate,

provided the PHI is not further used or disclosed in a manner that violates the Privacy Rule. Such individual must have acted in good faith and within the course and scope of his or her employ-ment or other professional relation-ship. HHS gives an example of a nurse mistakenly sending an e-mail with PHI to a hospital’s billing employee. After opening the e-mail, the billing em-ployee notifies the nurse and deletes the e-mail. No reportable breach has occurred in this situation.

II. An inadvertent disclosure of PHI from one covered entity or business asso-ciate employee to another similarly situated covered entity or business associate employee, provided the PHI is not further used or disclosed in any manner that violates the Privacy Rule. For example, a doctor and billing em-ployee may be similarly situated in that they are both authorized to view PHI, but a doctor and a receptionist may not be.

III. Unauthorized disclosures where the covered entity or business asso-ciate has a good faith belief that the unauthorized person to whom PHI is disclosed would not reasonably have been able to retain the information. HHS gives an example where a covered entity sends out explanations of ben-efits (“EOBs”) to the wrong individual. If the EOBs are returned by the post office, unopened, as undeliverable, the covered entity can conclude that the recipient did not retain the informa-tion (for EOBs that are not returned, HHS says this should be treated as a potential breach.

Source: www.hhs.gov

31www.wchsb.com WCH Bulletin March 2014

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Healthcare News

New York AG Looking Into Insurer’s Purge Of 2,000 Physicians The New York Post (12/31, Earle, Campa-nile) reports that New York Attorney Gen-eral Eric Schneiderman “is probing insur-ance giant UnitedHealth for booting 2,000 New York doctors from its Medicare Ad-vantage health plan.” The action “comes just days after The Post reported that the Medical Society of the State of New York is suing the company in Brooklyn federal court, charging the purge violates contracts with” physicians. In a letter to UnitedHealth, Schneiderman “request-ed information on the breakdown and number of physicians getting bumped,

as well as the number of patients who would lose their physician. The Capital New York (12/31, Nahmias, Goldberg) reports that Schneiderman’s office wrote in a letter that it was “concerned that seniors will have had insufficient time to make an informed choice” about new medical providers in the small amount of time between the announcement and the narrower network going into effect. The Medical Society of the State of New York last week filed a complaint arguing “that the proposed doctor terminations constitute a breach of contract that could jeopardize the health of as many as 8,000 New York Medicare patients under those doctors’ care.”

Source: Medical society of Brooklyn bulletin

32 www.wchsb.com WCH Bulletin March 2014

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News by Specialty

Sleep Study

Questionable Billing for Polysomnography Services by OIGWHY OIG DID THIS STUDY Increased Medicare spending on poly-somnography (a type of sleep study), along with growing concerns about fraud and abuse, prompted the Office of the Inspector General (OIG) to conduct this study. From 2005 to 2011, Medicare spending for polysomnography services rose from $407 million to $565 million, an increase of 39 percent. In addition, fraud investigators and sleep medicine profes-sionals have identified specific vulnerabil-ities regarding polysomnography services. In January 2013, a provider agreed to pay $15.3 million to settle allegations of false polysomnography claims billed to Medi-care and other Federal payers.

HOW OIG DID THIS STUDY OIG analyzed Medicare payments for polysomnography claims for 2011. The claims were from hospital outpatient

departments and nonhospital providers, such as physician-owned sleep laborato-ries and independent diagnostic testing facilities. They identified polysomnogra-phy claims that did not meet one or more of three Medicare requirements. OIG also identified providers with patterns of questionable billing using 11 measures of questionable billing, which included the 3 Medicare requirements and 8 additional measures developed in consultation with fraud investigators and sleep medicine professionals within and outside of OIG.

WHAT OIG FOUND Medicare paid nearly $17 million for polysomnography services that did not meet one or more of three Medicare requirements. Payments for services with inappropriate diagnosis codes composed a majority of these payments. Eighty-five percent of claims with inappropri-ate diagnosis codes came from hospital outpatient departments. Inappropriate payments might have been averted with effective electronic edits that automati-cally deny claims or suspend them for manual review. Further, 180 providers exhibited patterns of questionable billing for polysomnography services. Most of these providers submitted an unusually high percentage of claims for beneficia-ries with another polysomnography claim on the same day, which is questionable because beneficiaries can undergo only one polysomnography service in a day, as the process requires an overnight stay.

Source: http://oig.hhs.gov

33www.wchsb.com WCH Bulletin March 2014

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News by Specialty

1. HealthFirst – requires authoriza-tion for oral appliances:

Authorization should be requested by provider PRIOR to supplying the device, by any of 2 methods indicated below:

a. Over the phone, by calling HF authorization department directly at 8883944327, and faxing clinical documen-tation (if necessary) to fax#6463134603

b. By filling in prior authorization re-quest form located athttp://www.healthfirstny.org/sites/de-fault/files/files/pdfs/204.%20Requests-for-Outpatient-Authorization.pdf

Tips on how to fill in the form:- Type of service should be DME- POS (Place of Service) should be Home, POS 12, rationale: since this supply will be used by patient in home settings, POS 12 should be indicated on authoriza-tion request form and on claim form- Start of Care/End of Care: should be 3 month period (as normally 3 month is a period for which authorization is granted)

*If any additional documentation re-quested, you will be contacted at the

phone number you indicate in ‘Contact name and Phone’ Field** Normally, it takes from 3 to 7 days to process the request, so all services should be requested prior. In case authorization approved, approval date will always be the date you put as “Start of Care’ date on the authorization form

2. FidelisCare – oral appliances are NOT covered codes based on summary plan description for any of FidelisCare plans

Source: http://www.healthfirstny.org/

E0485

Oral device/appliance used to reduce upper airway collaps-ibility, adjustable or nonadjust-able, prefabricated, includes fitting and adjustment

E0486

Oral device/appliance used to reduce upper airway collapsibil-ity, adjustable or nonadjustable, custom fabricated, includes fitting and adjustment

A

B

E0485

Oral device/appliance used to reduce upper airway collaps-ibility, adjustable or nonadjust-able, prefabricated, includes fitting and adjustment

E0486

Oral device/appliance used to reduce upper airway collapsibil-ity, adjustable or nonadjustable, custom fabricated, includes fitting and adjustment

34 www.wchsb.com WCH Bulletin March 2014

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News by Specialty

Mental Health

Beacon Health Strategies will require primary source verifica-tion when a member receives treatment in an outpatient set-ting following discharge from a mental health hospitalization.

SUMMARY: Beacon Health Strategies, LLC (Beacon), has been contracted to manage the be-havioral health and substance abuse services for BMCHP. Beacon has been required by National Committee for Qual-ity Assurance (NCQA) to provide proof of service for supplemental data in order for it to be considered valid for Healthcare Ef-fectiveness Data and Information Set (HE-DIS) Mental Health Follow-up measures. Primary source verification is required only for supplemental data.

HEDIS MENTAL HEALTH FOLLOW-UP MEASURE (FUH): This measure reports the percentage of all members, six (6) years of age and older, discharged from an inpatient hos-pitalization for treatment of select men-tal health disorders that participated in appropriate outpatient therapy and/or program within seven (7) and thirty (30) days post discharge.

SUPPLEMENTAL DATA: HEDIS methodology allows organizations to use sources other than claims for cal-culating HEDIS measures. For the HEDIS FUH measure, supplemental data used to capture missing service data not received

through claims must be substantiated by documentation from the member’s health record. Subsequently, in order to meet this HEDIS requirement, if Beacon does not have a claim for an outpatient appointment, Beacon is requiring provid-ers submit an “encounter form” with the member’s outpatient appointment infor-mation.

Source: http://www.beaconhealthstrategies.com

ICD-10 SAMPLERR26.81Unsteadiness on feet

35www.wchsb.com WCH Bulletin March 2014

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Physical Therapy and Rehabilitation

Documenting Therapy and Rehabilitation Services The leading cause of payment errors for therapy services is “insufficient” docu-mentation in the medical records. Docu-mentation is often missing the required elements as outlined in the Centers for Medicare & Medicaid Services (CMS).For example, a provider indicates in the medical record: “Plan of Care: We would like to see the patient three times per week to initiate exercises and modali-ties to decrease pain and increase range of motion, stretching, strengthening and function.” This plan is missing key ele-ments to support the medical necessity of the service, such as measurable long-term goals, the patient’s diagnosis, the proposed type, duration and frequency of services required to achieve each goal, or anticipated plan of discharge.Additional widespread issues that result in “insufficient” documentation errors include: • Missing or illegible signature on the

plan of care; • Missing or illegible signature for physi-

cian’s certification; and • Missing legible signature and required

treatment minutes in narrative or on flow sheet.

• The CERT A/B MAC Outreach & Educa-tion Task Force recommends providers carefully review the following docu-mentation requirements and tips for ensuring complete and accurate medi-cal records.

Contents of Plan of CareThe plan of care shall contain, at mini-mum, the following information as re-quired by regulation.• Diagnoses. • Long term treatment goals -- Should

be developed for the entire episode of care and not only for the services provided under a plan for one interval of care.

• Type -- May be physical therapy, occu-pational therapy, or speech language pathology, or when appropriate, the type may be a description of a specific treatment of intervention.

• Amount -- Refers to the number of times in a day the type of treatment will be provided.

• Duration -- Number of weeks or the number of treatment sessions for the plan of care.

The plan of care shall be consistent with the related evaluation. The plan should strive to provide treatment in the most efficient and effective manner, balancing the best achievable outcome with the appropriate resources.

Signature and Certification of the Plan of CareThe legible signature and professional identity (e.g., MD, OTR/L) of the indi-vidual that established the plan, as well as the date it was established, must be recorded with the plan. A physician or NPP must certify (and date) the plan of care (*note: for CORF services, NPPs may not order or certify therapy servic-es). Certification may be established in the patient’s medical record through: • Physician’s or NPP’s progress note • Physician or NPP’s order* • Plan of care that is signed and dated

by a physician/NPP*

News by Specialty

36 www.wchsb.com WCH Bulletin March 2014

Page 37: WCH Bulletin March 2014

• Documentation must indicate that the physician/NPP* is aware that the therapy service is or was in progress; and

• Agrees with the plan, when there is evidence the plan was sent to the physician/NPP, or is available in the patient’s medical record for the physi-cian/NPP to review.

Treatment NoteThe purpose of treatment notes is to cre-ate a record of all treatments and skilled interventions that are provided and to record the time of the services to justify the use of billing codes and units on the claim. Documentation is required for every treatment day and every therapy service. Documentation of each treatment note must include the following required ele-ments: • Date of treatment. • Identification of each specific inter-

vention/modality provided and billed (both timed and untimed codes).

• Total timed code treatment minutes and total treatment time in minutes.

• Signature and professional identifica-tion of the qualified professional who furnished the services; or, for incident to services, supervised the services, including a list of each person who contributed to the treatment.

Avoid CERT Errors: Tips to Improve Therapy Documentation• Ensure the medical records submitted

provide proof the service(s) was certi-fied and rendered.

• Ensure the medical records provide justification supporting medical ne-cessity and that skilled services were needed.

• Create a complete plan of care, mak-ing certain to include your legible signature, professional identification (e.g., PT, OTR/L) and date the plan was established.

• Document when the plan of care is modified, including how it has been modified and why the previous goals were not met or could not be met.

• Confirm the plan of care is certified (recertified when appropriate) with physician/NPP legible signature and date.

• Clearly document, in minutes, the total time spent on timed-code treatment only and the total treatment time (in-cluding timed and untimed codes) in the patient’s record.

Source: https://www.qio.afmc.org/

News by Specialty

37www.wchsb.com WCH Bulletin March 2014

Page 38: WCH Bulletin March 2014

Nerve Conduction Studies and Electromy-ography Clarification Recent claim data analysis show that some providers are billing nerve conduc-tion studies (NCSs) and electromyography (EMG) on different days. Claim histories reveal that an NCS is performed and billed on one date of service followed by an EMG on a subsequent date of service. In most instances, both NCSs and EMGs are usually required for a clinical diagno-sis of peripheral nervous system disor-ders. Performance of one type of testing does not eliminate the need for the other. The intensity and extent of testing with NCS and EMG are matters of clinical judg-ment developed after the initial pre-test evaluation, and later modified during the testing procedure. If an NCS and an EMG are required, these services should be performed on the same day and billed appropriately. Providers are to use CPT codes 95885, 95886, and 95887 for EMG services when a NCS (95907-95913) is performed in conjunction with an EMG on the same day.

NCSs performed independent of needle EMG may only provide a portion of the information needed to diagnose muscle, nerve root, and most nerve disorders. When the NCS is used on its own without integrating needle EMG findings, or when a provider relies solely on a review of NCS data, the results can be misleading, and important diagnoses may be missed.

While a provider may choose to only perform an NCS, when performed alone

it is usually considered to be a screening exam. The only exception to this is a situ-ation when a provider may consider it ap-propriate to perform a NCS without doing an EMG for the diagnosis of carpal tunnel syndrome with a high pre-test probability.

Effective January 1, 2013, current pro-cedural terminology (CPT) codes 95907-95913 represent the number of nerve conduction studies performed (sensory or motor or H-reflex). CPT codes 95907-95913 can be reimbursed only once per nerve or named branch of a nerve, re-gardless of the number of sites tested or number of methods used on that nerve.

Source: https://www.ngsmedicare.com

News by Specialty

ICD-10 SAMPLERJ45.991Cough variant asthma

38 www.wchsb.com WCH Bulletin March 2014

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Questions and AnswersQuestion:Do IDTFs need to inform Medicare about every single service location?

Answer:One Enrollment per Practice Location.The IDTFs must separately enroll each of their practice locations (with the ex-ception of locations that are used solely as warehouses or repair facilities). This means that each enrolling IDTF can only have one practice location on its CMS-855B enrollment application; thus, if an IDTF is adding a practice location to its existing enrollment, it must submit a new, complete CMS-855B application for that location and have that location undergo a separate site visit. Also, each of the IDTF’s mobile units must enroll separately. Con-sequently, if a fixed IDTF site also con-tains a mobile unit, the mobile unit must enroll separately from the fixed location.For those IDTFs with multiple practice locations that were enrolled prior to the implementation date of this instruction, each practice location of the IDTF must meet all of applicable IDTF requirements, including those listed in this manual.

Failure to comply with any of these re-quirements at any practice location rep-resent the supplier’s noncompliance with 42 CFR § 410.33 as a whole, and will result in the revocation of its Medicare billing privileges.

Source: http://www.cms.gov

Question:I’m interested in billing patients for visits over Skype. Can I do this?

Answer:Yes, but be careful. Medicare Learning Network has a CMS policy directly on point stating rural providers may bill for certain telehealth services. Practitioners working in non-rural areas are not autho-rized to provide telehealth services for reimbursement from the Federal health program. Similarly, a practitioner is not authorized to bill federally funded plan beneficiaries out of pocket for covered services. So while the option remains to provide services to patients that are not covered and charge out of pocket expens-es, for Medicare beneficiaries you are not authorized to maintain telehealth visits, charge out of pocket, when the same visit would be covered by Medicare if the pa-tient were seen in your office.

Also, be careful how you store and main-tain any data from such visits, as same is protected health information and must be treated by adherence to your security policy, with required administrative, tech-nical and physical safeguards.Click here to see if your location quali-fies - http://datawarehouse.hrsa.gov/tele-healthAdvisor/telehealthEligibility.aspx

Answered by Jennifer Kirschenbaum, Esq

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Question:Medicare asked for records for a doc-tor who left the practice last year and took his files. What do we do now?

Answer:Yikes! Before I get to the “what do we do now” part of our answer, I’ll provide some basic information on custodianship of records. At all times a medical record is “owned” by the patient it is generated about and for. The practice the patient is visiting and who is treating is the custodi-an; notice the last sentence says practice and not doctor. Practice is identified as by tax ID number, Medicare billing number, contract with payor, employer of provid-ers, etc. There are many singular identify-ing characteristics of a “practice”, none of which are defined (except for maybe reputation) by a single provider. A “prac-tice” in Medicare’s eyes is the tax ID and identification number associated with the entire practice, not just one provider.

Here, we have a practice being audited by Medicare and a departed physician took records which the practice had an obliga-tion to maintain custodianship of. At all times the records belong to the patients; patients who were at the time patients of the practice. Should the physician had departed and patients followed, the pa-tients would then be a patient of the new practice the physician landed at. Most contracts have (or should have) provi-sions addressing access to records after the physician departs the practice; reason being for scenarios just like this - where a physician may need access to produce or defend.

Now to address what to do now - you can try to recover the records from the departed physician, explain to Medicare the situation and attempt to redirect their attention to the departed physician, or at-tempt to reason with Medicare and come to a resolution. I do not recommend trying any of the above without the assis-tance of your healthcare attorney.

Answered by Jennifer Kirschenbaum, Esq

Question:What is “8-minute rule” and how it affect physical/occupational therapy billing?

Answer:Physical Therapy billing codes are either timed or untimed codes for billing pur-poses. Untimed codes are reported as one unit per day. Timed codes are re-ported using the 8 Minute Rule.For billing, this rule means that any therapy timed procedure cannot be billed if that was performed for the less than 8 min. The following codes are timed codes:97032 – Electrical Stimulation (Manual), 97033 – Iontophoresis, 97035 – Ultrasound, 97039 – Unlisted, 97110 – Therapeutic Exercise, 97112 – Neuromuscular Reeducation, 97116 – Gait Training, 97124 – Massage, 97139 – Unlisted, 97140- Manual Therapy and 97530 – Therapeutic Activity.

Answered by Vyacheslav Kurdov, CPCBilling Department Supervisor of WCH Service Bureau, Inc.

Q&A

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Page 41: WCH Bulletin March 2014

Question:Is accreditation required for GHI cardi-ology diagnostic services.

Answer:Accreditation is not required to perform GHI cardiology diagnostic services, for more information Please contact the phy-sician and contracting hotline to verify the accreditation needed and if needed. 866-447-9717 option 4

Question:If the doctor is on vacation and there is another covering physician in place, who would bill for these services the covering or the absent provider? What is the legal process of billing in this scenario?

Answer:It depends on the time of absence. According to Medicare rule, a provider should bill regular physician with modifier showing that covering physician provided the service. Patient has to be established and schedule app with his regular physi-cian. For new patients it does not apply. Vacation cannot be more than 60 consec-utive days.

Answered by Olga Khabinskay, COO of WCH Service Bureau, Inc.

Q&A

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