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WCH Newsletter Fall 2012
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WCH TIMES
WCH Service Bureau is a proud member of the following professional organizations:
ISSUE 20Fall 2012
A BIG THANKS TO OUR READERS. WE REACHED 1500 !
ICD 10 DEADLINE-October 1, 2014
Welcome to our Fall Edition!
ICD 10 DEADLINE-October 1, 2014
Credentialing Live WebinarJoin Us forCredentialing Live WebinarJoin Us for
page 11
CHANGES IN MENTAL HEALTH FOR 2013CHANGES IN MENTAL HEALTH FOR 2013page 8
WCH Service Bureau is a proud member of the following professional organizations:
CPT CODING UPDATES FOR 2013CPT CODING UPDATES FOR 2013page 12
Welcome to our Fall Edition!
INSIDE THIS ISSUE:
4 WCH TIMELINE21
6
7 22
7 22
8
CREDENTIALING NEWS10
11
HEALTHCARE UPDATES12
14
15
15
16
17
18 27 NEWS BY SPECIALTY28 STATES UPDATES
19 29 QUESTIONS AND ANSWERS30 FEEDBACK
20
WCH Referral Program for our clients
WCH New virtual website Assistant!
Help for Hurricane Sandy disaster
Primary Care Payment and vaccine administration charge increase
Enhanced autism mandate effective November 2012
Avoid claim denials: bill with codes listed on your fee schedule
AMA set to Urge Medicaid Eligibility expansion
CMS details Medicaid primary-care Changes in Mental Health For 2013 - payments boost
prepared per request of our clients
Independent Diagnostic Testing Facility ("IDTF") enrollment Health Care Law delivers higher payments
to primary care physiciansCredentialing Live Webinar
CPT Coding Updates for 2013Obama Administration moves forward to
OIG'S 2013 work plan what should you Implement Health Care Lawexpect next year
Emblem Health updateReminder for Behavioral Health providers
United Health Care (UHC) DME Modifier Changes in Sleep Management Requirement in 2013
Precertification HIP Service area expansion affects GHI
Higher use of Advanced Imaging Services HMO providersby providers who self-refer costing Medicare millions Neighborhood Health Plan Updates
Stark Law (physician self-referral) Behavioral Health Screening
Advanced Beneficiary Notice
How might Medicare penalties affect you?
Geographic payment adjustments, Medicare's disputed borders
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WCH CORNER
WCH Times | 4
WCH TIMELINE
Clients will find Registration form on WCH WCH PUBLICATION RECEIVED website to receive CEU credit. CEU CREDITS
WCH Bulletin and WCH Times have been each approved for 1 CEU credit by AMBA - American Medical Billing Association.
WCH is proud to offer numerous opportunities for professional growth and certification/licence maintenance.We offer a fast and convenient way to earn CEU credit. Each publication gives you 1 CEU credit.
From January 1, 2013 all WCH publications will be under package subscription.
On your online profile you can review your CEU credits and maintaing full credit list.
CHANGES IN THE BILLING DEPARTMENT WCH is continuing to grow and expand our departments! The billing department has reached over fifty employees. Our department updated staff is below.
Oksana Pokoyeva, CPC, CPMA, Billing Department Manager
Elizaveta Bannova, CMRS, CFPC, CPC, Vice Manager
Zukhra Kasimova,CPC, [email protected]
Victoria Uzakova,[email protected]
WCH Times | 5
SOCIAL MEDIA DEPARTMENT
Social Media Department promotes WCH services through different channels of marketing:
We Invite You To Join Us! Please Visit .
Department pushes the WCH into new social media spaces, drives innovation and online communication programming in this arena, provides platform for real-time conversation, collaboration and idea sharing. Plus we can do it all for you! If you want to promote your services, please contact us:
wchsb.com
WCH PANTHERS-RACE FOR CURE 2012On September 9, 2012, WCH has taken part in 2012 Komen New York City Race for the Cure in Central Park.We were honored and privileged to take part of such an extraordinary event that not only benefited the foundation by helping them reach the goal of $6 million, but also to promote awareness of local breast cancer screening, education and outreach programs.
Valeriya Designer M
Aksyonova, Olesya Petrenko, arketing Manager
REMINDER, WCH IS A DIRECT SUBMITTER WITH NEW JERSEY MEDICAID! WCH is 5010 compliant with NJ Medicaid Program and we are approved as direct vendor to submit claims. We can assure you that YOUR CLAIMS ARE IN GOOD HANDS.
Refer WCH Billing Service to Your Colleagues and Friends!
Reward Program.WCH will provide you with , the
deal is worth
Only happy clients refer others, and we want to make sure we exceed the expectations of every client who passes through our doors.
WCH understands that we can only grow if we provide quality service and achieve maximum reimbursement for our clients.
For any questions please contact Olga Khabinskay
We are grateful for referrals that come our way and pleased to offer a Referral
2 complimentary insurances for credentialing$800, for every client that will sign with us.
If you know anyone experiencing difficulty with their current billing service, or a new friend that
needs to start the billing process , WCH is here to help!
WCH Referral Program for our clients
General Manager888-924-3973 (x 1201), 718-934-6714
skype: [email protected]
WCH Times | 6
The Internal Revenue Service (IRS) announces excluded from those individuals' taxable qualified disaster treatment of payments to income.victims of Hurricane Sandy Qualified disaster relief payments include
amounts to cover necessary personal, family, living or funeral expenses that were not covered by insurance. They also include
expenses to repair or rehabilitate personal residences or repair or replace the contents to
The Internal Revenue Service alerted the extent that they were not covered by employers and other taxpayers that because insurance. Again, these payments would not Hurricane Sandy is designated as a qualified be included in the individual recipient's gross disaster for federal tax purposes, qualified income.disaster relief payments made to individuals
Source: by their employer or any person can be
We thought you could find this useful. If you know anybody who could also benefit from this tax break - forward it to them.
www.irs.gov/uac/Hurricane-Sandy-Qualified-Treatment-of-Payments
WCH Times | 7
WCH new virtual website assistant! As you are remember few months ago we announced winnerof the WCH Contest. The winner is Ilya Mirolyubov and hisvirtual website assistant octopus.In the nearest future our clients and visitors will see on WCHwebsite the new virtual website assistant. Virtual assistantwho is main functional will have quicker and easy contact withtechnical support, general manager, account representativesas many others planed functions.
HELP FOR HURRICANE SANDY DISASTER
Need help? Click on me for any questions
CHANGES IN MENTAL HEALTH FOR 2013 - PREPARED PER REQUEST OF OUR CLIENTS
Psychiatry: Significant changes to codes and guidelinesNew codes:џ Interactive complexityџ Psychiatric diagnostic evaluationџ Psychotherapyџ Psychotherapy for crisisџ Pharmacologic management
Interactive Complexity- Add-on code (90785) used to report communication factors that complicate psychiatric services- Typical factorsџ Third parties involved with care (guardians, caregivers)џ Require others to be involved with the care (interpreters)џ Require third parties (welfare agencies, schools)
Interactive Complexity cont...- Can be used with the following codes:џ Diagnostic psychiatric evaluation (90791,90792)џ Psychotherapy (90832,90834,90837)џ Psychotherapy with E/M (90833,90836,90838,99201 -99255, 99304-
99337,99341 -99350)џ Group psychotherapy (90853)
Interactive Complexity, cont...- Do not report with:џ Psychotherapy for crisis (90839,90840)џ E/M performed without psychotherapy
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Should you have any questions about the changes, please do not hesitate to contact your account representative in the billing department. WCH will be working to update superbills for our clients and is in process of education our staff about the changes in the billing and collection process.
CALL WCH 888-WCHEXPERTS
Source: American Psychiatry Association
џ Psychiatric Diagnostic Evaluation (90791, 90792)џ 90801,90802 deletedџ Biophysical assessment including history, mental status and recommendationsџ Do not report on the same date as E/Mџ - If medical service is performed on same DOS as psychiatric diagnostic
evaluation, report 90792џ For interactive complexity, report 90785 with 90791 or 90792џ Do not report 90791 and 90792 on the same DOS
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CREDENTIALING NEWS
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We have been researching this topic for many months and finally received an official answer from New York State Department of Health concerning proper arrangement between supervising physician and IDTF.
HEALTHCARE UPDATESCPT CODING UPDATES FOR 2013
џ 186 new codes џ 119 deleted codesџ 263 revised codesџ 18 revised CPT® modifiersџ Guideline changes
Pediatric Critical Care Transportџ New codes report services provided by the
control physician during an interfacility transport- 99485 and 99486
Complex Chronic Care Coordination Servicesџ For clinical staff time directed by a physician or other qualified health care providerџ Reported for coordination of services (medical and psychosocial)џ Time basedџ - Reported per calendar monthBased on whether patient has face-to-face encounter during the month
Clinical indications that qualify:- One or more chronic illnesses expected to last at least 12 months- Acute exacerbation or decompensation- Functional decline- Medical Decision Making must be moderate or high
Psychotherapy (90832-90838)џ 90804-90809, 90810-90815, 90816-90822 and 90823-90829 deletedџ New codes are based on timeџ Add-on codes used when psychotherapy is performed on the same DOS as
E/Mџ Do not include time performing the E/M service as psychotherapy timeџ For interactive psychotherapy, report 90785 with the psychotherapy code
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Time(min)
Psychotherapy Psych andE/M
Psych andInteractive Psych
Psych, InteractivePsych and E/M
16-37 90832 E/M,90833 90832,90785 E/M,90833,90785
38-52 90834 E/M,90836 90834,90785 E/M,90836,90785
53> 90837 E/M, 90838 90837.90785 E/M,90838,90785
џ Psychotherapy in Crisis (90839, 90840)џ Urgent assessment of a patient with a life threatening or complex conditionџ Reported based on timeџ - If performed 30 minutes or less, report with 90832 or 90833џ Do not report with psychiatric diagnostic evaluation (90791, 90792), psychotherapy
codes (90832-90838) or other psychiatric services (90785-90899)
Pharmacologic management (90863)џ 90862 was deletedџ New code is an add-on code that can only be reported with psychotherapy codesџ Do not use time spent performing pharmacologic management to determine
psychotherapy codesџ If the provider is permitted to bill with E/M codes (eg, psychiatrist), report the
service as an E/Mџ Do not report 90863 with an E/M code
Documentation must include:- Condition of the patient- Total time spent performing coordination services for complex chronic care- Based on clinical staff timeџ If physician performs coordination services, the time is added to the clinical
staff time to support the code
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Complex Chronic Care Coordination Services99488 (first hour)99489 (each additional 30 minutes)99487 (first hour)
MDM Face-to-face visit within 7 days
Face-to-face visit within in 8 to 14 days
Moderate 99495 99495
Hight 99496 99495
(SNFs) OIG'S 2013 WORK PLAN WHAT џ Home Health Agencies (HHAs) SHOULD YOU EXPECT NEXT YEARџ Hospice (Medicare & Medicaid)
2013 Work Plan by the Numbers:џ Medical Equipment and Supplies џ Home and Community-Based Services
OIG's Results: Reporting on 2011 data, OIG (HCBS)
projected recoveries of $5.2 billion ($4.6 џ Physicians
billion in investigative work and $627.8 million in audit work). Source: OIG
џ Identified $19.8 billion in possible savings based on OIG's recommendations for legislative, regulatory, or administrative changes.
џ Excluded 2,662 individuals and entities; participated in 723 criminal actions and 382 civil actions.
Providers Under Review:
џ Hospitals џ Nursing Homes & Skilled Nursing Facilities
Source: American Psychiatry Association
WCH Times | 14
eligibility and/or obtain treatment authorization for Universal Health Care Medicare members by calling 1-800-327-7959.
Claims ProcessingEffective , claims for authorized covered services rendered to Universal Health
REMINDER FOR BEHAVIORAL HEALTH PROVIDERS Care Medicare members must be submitted to
the following address: Magellan Behavioral Health (Magellan) Magellan Behavioral Health PO Box 1928announced that Universal Health Care has Maryland Heights, MO 63043selected Magellan as their behavioral health
care vendor. As a provider for Magellan, you If you have any questions regarding this may have members in treatment whose care is information, please contact 1-800-788-4005managed by Universal Health Care.
Source: Magellan Behavioral Health and Universal Authorization and Eligibility VerificationHealth Care Medicare
Effective November 1,2012, verify benefit
November 1, 2012
and oral devices, appliances and related supplies)
Effective November 1, 2012, the prior CHANGES IN SLEEP MANAGEMENT authorization requirement applies to Anthem
PRECERTIFICATION Blue Cross members who participate in As we previously communicated, effective Anthem Blue Cross Local and individual health
, Anthem Blue Cross will plans, including HMO members who are not require precertification for the following enrolled with a PMG/IPA as well as HMO elective sleep diagnostic and treatment members enrolled in the following PMG/IPAs: services: Scripps Clinic/Scripps Coastal Medical Center, џ Home sleep test (HST) Scripps Foundation and The Industry Health џ In-lab sleep study (PSG) Network. Effective January 1, 2013, it also will џ Titration study apply to members covered by Medicare џ Initial treatment order (APAP, CPAP, BPAP Advantage.
and oral devices, appliances and related The requirement does not apply to the supplies) following members:
џ Ongoing treatment order (APAP, CPAP, BPAP
November 1, 2012
WCH Times | 15
џ Those in the Federal Employee Program sleep testing and therapy services, including (FEP) the need for use of a facility vs. doing the test
џ Those for whom Anthem Blue Cross is in the home. For therapy services, members secondary coverage, including those whose must meet usage criteria for the continued primary insurance carrier is Medicare rental of equipment and replacement of
џ HMO members, with the exception of those supplies noted above.
For Sleep testing and therapy service only, Precertification requests for sleep testing and both ordering physicians (those referring the therapy services will be handled by AIM member for sleep testing) and servicing Specialty HealthSM (AIM), an affiliate of providers (free-standing or hospital labs that Anthem Blue Cross. Requests will be reviewed perform sleep testing) may submit requests to against AIM Obstructive Sleep Apnea AIM. Diagnostic & Treatment Clinical Guidelines.
Source: Anthem Blue CrossAIM will consider the medical necessity of
contrast, the average number of HIGHER USE OF referrals made by providers who ADVANCED IMAGING remained self-referrers or non-
SERVICES BY PROVIDERS self-referrers declined during this period. This comparison WHO SELF-REFER suggests that the increase in the COSTING MEDICARE average number of referrals for
MILLIONS switchers was not due to a GAO's analysis showed that general increase in the use of providers' referrals of MRI and imaging services among all CT services substantially providers. GAO's examination of increased the year after they all providers that referred an began to self-refer--that is, they MRI or CT service in 2010 purchased or leased imaging showed that self-referring equipment, or joined a group providers referred about two practice that already self- times as many of these services referred. Providers that began as providers who did not self-self-referring in 2009--referred refer. Differences persisted after to as switchers--increased MRI and CT referrals accounting for practice size, specialty, on average by about 67 percent in 2010 geography, or patient characteristics. compared to 2008. In the case of MRIs, the These two analyses suggest that financial average number of referrals switchers made incentives for self-referring providers were increased from 25.1 in 2008 to 42.0 in 2010. In WCH Times | 16
likely a major factor driving the increase in Human Services, which oversees CMS, stated referrals. it would consider one recommendation, but
did not concur with the others. GAO maintains What GAO Recommends CMS should monitor these self-referred GAO recommends that CMS improve its ability services and ensure they are appropriate.to identify self-referral of advanced imaging
Source: gao.govservices and address increases in these services. The Department of Health and
Penalties: Penalties for violating the Stark Law STARK LAW (PHYSICIAN SELF-include denial of payment, refund of payment, REFERRAL)imposition of a $15,000 per service civil
Stark Law “prohibits physicians from making monetary penalty, and imposition of a
referrals for designated health services (DHS) $100,000 civil monetary penalty for each
payable by Medicare to an entity with which arrangement considered to be a circumvention
he or she (or an immediate family member) scheme.
has a financial relationship (ownership, investment, or compensation), unless an
Be Compliant: To help you stay in compliance exception applies,” according to the Centers
with the Stark Law:for Medicare & Medicaid Services (CMS).
1. Offer all patients a written list of choices for Specifically, covered DHS include:
obtaining the care your physicians are џ Clinical laboratory services
recommending.џ Physical therapy services
2. Disclose any financial relationship with any џ Occupational therapy services
entity that is on the list offered to patients.џ Outpatient speech-language pathology
services Source: news.aapc.comџ Radiology and certain other imaging
servicesџ Radiation therapy services and suppliesџ Durable medical equipment (DME) and
suppliesџ Parenteral and enteral nutrients,
equipment, and suppliesџ Prosthetics, orthotics, and prosthetic
devices and suppliesџ Home health servicesџ Outpatient prescription drugsџ Inpatient and outpatient hospital services
WCH Times | 17
liability to the beneficiary when Medicare ADVANCED BENEFICIARY NOTICEpayment for a particular procedure or service The Centers for Medicare & Medicaid is bundled into payment for other covered Services (CMS) recently released a new procedures or services. An ABN should never Advanced Beneficiary Notice of Noncoverage be applied as a Band-Aid cure to gain (ABN), making it a perfect time to refresh your payments in spite of sloppy coding, or as a way understanding of this form and make sure you to “game” Medicare beneficiaries.are using it appropriately.
ABNs Are NOT Required in an EmergencyABN BasicsABNs are never required in emergency or The ABN is a standard form that a medical urgent care situations. CMS policy prohibits practice can use to inform a patient that giving an ABN to a patient who is “under Medicare may deny coverage for a duress,” including patients who need recommended or desired item or service. It emergency department services before explains why Medicare may deny the item or stabilization.service, and provides a cost estimate for it. An
ABN also notifies the patient of his Source: news.aapc.comresponsibility to pay for the noncovered item
or service, if he chooses to receive it. In many cases, a provider cannot seek payment from the patient for unpaid Medicare services if an ABN was not properly issued.CMS periodically revises the ABN. The most recent version, Form CMS-R-131 (release date March 2011), is mandatory as of Jan. 1, 2012. Previous versions of the ABN (release date March 2008) are no longer being accepted. The “Revised ABN CMS-R-131 Form and Instructions” may be downloaded from the CMS website.ABNs must be reproduced on a single page (either letter or legal size). To be safe, reproduce the ABN “as is” from the CMS website; except where specifically allowed by the form instructions, “to integrate the ABN into other automated business processes,” you may not customize the ABN.
How NOT to Use an ABNDo not use an ABN to bill a patient for additional fees beyond what Medicare reimburses for a given procedure or service. The ABN does not allow the provider to shift
WCH Times | 18
HOW MIGHT MEDICARE PENALTIES AFFECT YOU?2013 will be a crucial year for physicians to avoid possible pay reductions under quality reporting and health information technology programs.
Successfully reporting quality measures and achieving meaningful use of an EHR in 2013 will prevent a doctor's Medicare rates from being reduced by 3.5% in 2015 for noncompliance.
For some physicians, preventing the electronic rates would not be decreased.prescribing noncompliance penalty will mean
Physicians who first reported achieving using claims to report that they utilized the
meaningful use in 2011 won't need to move technology during at least 10 patient
onto the next stage until 2014.encounters between , and
The 2014 calendar year also marks the last . Others who earned e-opportunity for eligible physicians and other prescribing bonuses in 2012 will be exempt health professionals to stop a 2015 Medicare from the 2% penalty in 2014.EHR noncompliance penalty of 1% in 2015. An
CMS requires doctors who e-prescribe for eligible professional must adopt and
patients to attach the code G8553 to the demonstrate meaningful use of an EHR system
applicable claims for their Medicare services. by . The penalty is set to grow
The code signals that the physician used a to 3% by 2017 for physicians who continue not
health information technology system to send to participate.
an electronic order for medication to a Eligible professionals who do not successfully pharmacy.participate in the physician quality reporting
Members of a physician group practice can system in 2013 will see their Medicare pay
work together to nullify the penalty, according reduced by 1.5% in 2015.
to newer options added by CMS. For instance, Physicians have a couple of options to report groups of two to 24 eligible professionals can to the Medicare agency from among the 200 report the e-prescribing measure at least 75 PQRS measures. Reporting measures group(s) times over the six-month 2013 reporting through the registry option is presented as the period to stop the penalty.easiest method for a physician to prevent a
CMS will pay an estimated $27 billion in EHR penalty and earn a bonus. CMS will provide a
incentive payments through 2016, and each list of active registries in early 2013 — most of
physician can earn up to $44,000 from which will have been part of the program in
Medicare or $63,750 from Medicaid by 2012.
adopting and using the technology. Others Reporting individual measures or measures who do not participate will see their Medicare groups using Medicare claims or an EHR also pay reduced over the years, but Medicaid
January 1, 2013June 30, 2013
October 1, 2014
WCH Times | 19
are options for physician practices. Physicians quality and lower cost than other large-group will receive a bonus equal to 0.5% of their physicians who are subject to the modifier 2013 Medicare pay if they participate in PQRS. adjustment. Like the 2015 PQRS penalty, the The incentive will rise an additional 0.5% for 1% reduction will be based on 2013 PQRS physicians participating in a maintenance-of- data.certification program.
CMS is limiting the modifier's scope to Failure to report PQRS measures successfully physicians practicing in groups of 100 or more in 2013 will lead to a Medicare penalty of 1.5% eligible professionals, but agency officials have on 2015 rates. The reduction will be 2% in warned that this is only temporary. The 2016 and each subsequent year. For now, CMS modifier adjustment eventually will affect all is planning to use a PQRS reporting period well physicians, CMS said in its 2013 Medicare final before the authorized penalty year to physician fee schedule.determine who will see their Medicare pay
reduced.Tool that can give you an idea of whether you can expect payment bonuses or penalties in For larger practices, failing to report PQRS future years measures also will lead to a 1% penalty in
2015 under Medicare's value-based payment modifier program, which is designed to pay more to practices that provide care at a higher
Source: ama-assn.org/amednews
http://www.ama-assn.org/amednews/site/media/medicarebonus.htm
doctors' rates also are GEOGRAPHIC PAYMENT inaccurate when compared with ADJUSTMENTS: one another.
MEDICARE'S DISPUTED Medicare uses geographic BORDERSadjustments to pay more in The map Medicare uses to set areas deemed to have higher physician pay rates based on costs of providing care to location could become more seniors. The Centers for nuanced if Congress adopts Medicare & Medicaid Services recommendations for revised
employs a patchwork of 89 pay locales to set localized payments.rates in a budget-neutral environment. As a result, a doctor treating a Medicare patient in Physicians practicing in all parts of the country midtown Manhattan receives more than a long have agreed that Medicare payments doctor providing the same service in rural have been too low for too long, but a growing West Virginia.chorus of health policy officials say these
WCH Times | 20
Medicare uses a complex system when adjusting payments to reflect the costs of How Medicare GPCIs affect physician paypracticing medicine across the country. Such Medicare geographic practice cost indexes are expenses as rent, staff salaries and the cost of among several factors affecting the final fee living in an area are designed to be reflected in that a doctor in a particular area receives for a pay rates. service. Each locality has GPCIs that are CMS is required to account for such price applied to the relative value units (RVU) for a differences using indexes that adjust the given service based on physician work portions of doctors' fees attributed to practice requirements (Work), practice expenses (PE) expenses, medical liability costs and the and professional liability insurance costs (MP). amount of physician work required to provide The resulting figure is multiplied by a care. Each locale has geographic practice cost conversion factor (CF) to determine the dollar indexes, or GPCIs, that are multiplied by the amount for a service.relative values corresponding to each of these
Source: Physician fee schedule search, Centers for factors, which then impacts the final amount Medicare & Medicaid Servicesthat Medicare pays a doctor for a given service
in a particular area.
AVOID CLAIM DENIALS: What is the impact of this change?BILL WITH CODES To ensure accurate processing of
LISTED ON YOUR FEE claims going forward, claims billed with procedure codes not listed on SCHEDULEthe applicable fee schedule(s) will Summary of change: be denied or pended for further Effective , information. If your contract uses a Medicaid Managed Care (MMC) and Child
CMS-based fee schedule, please be aware Health Plus (CHP) claims received by some codes listed on CMS are not payable HealthPlus, an Amerigroup Company, under New York Medicaid. If the code is not containing procedure codes not priced by the recognized or payable under New York fee schedule or not a payable code under New Medicaid, the code will not be reimbursed. York Medicaid as listed in your provider Your claim might be denied if you don't bill agreement, may be denied or pended for with the most current, applicable procedure further review.code to reflect the service(s) rendered, per your contract and fee schedules. Claims billed What this means to you: To get paid timely in line with the fee schedule will be processed and accurately, please be sure to bill with the accordingly.most current, applicable procedure codes
listed on your fee schedule and ensure the Source: Magellan Behavioral Health and Universal code is payable under New York Medicaid.Health Care Medicare
January 1, 2013
WCH Times | 21
The current federal poverty level for a family AMA SET TO URGE MEDICAID of four is an income of $23,018; the AMA will ELIGIBILITY EXPANSIONurge the expansion of Medicaid eligibility to
The American Medical Association will those whose income is up to 133% of the
advocate for increasing Medicaid payments for federal poverty level.
physicians and—in states where it is invited by the state's medical societies to do so—for
The resolution also noted that caring for the expanding Medicaid eligibility under the terms
uninsured produces "huge financial burdens" of a new policy approved by the AMA House
on doctors' offices and hospitals.of Delegates.
Source: Moderhealth The resolution calling for the policy noted that, according to the U.S. Supreme Court's ruling on the Patient Protection and Affordable Care Act, the Medicaid expansion called for by the law is optional and that an estimated 15.1 million additional people could become eligible if the option is exercised nationwide.
The rule specifies that federal funding will be CMS DETAILS MEDICAID PRIMARY-provided to states to increase payments for CARE PAYMENTS BOOSTphysicians practicing in family medicine,
The CMS issued a final rule temporarily general internal medicine, pediatric medicine
increasing primary-care physician payments and related subspecialties. It also clarifies, that
from Medicaid.primary-care services provided by practitioners working under the personal
The rule, which implements a provision of the supervision of any qualifying physician can
Patient Protection and Affordable Care Act, qualify for the higher payment rate.
details the extent and target of the increase, which takes effect in January and lasts through
The CMS, in the rule, gives states several 2014.
options for implementing the rate increase in fee-for-service and managed-care settings. For
The provision is designed to match Medicare example, states either can pay in accordance
rates, but the rule specifically covers only the with all Medicare locality adjustments within
difference between the Medicare rate and the state or develop a rate for each code
states' Medicaid rates as of . The based on the mean Medicare rate for all
additional federal funding may not be enough counties in the state.
to increase the rate to Medicare levels because some states have enacted Medicare Source: CMS.org provider rate cuts since middle -2009.
July 1, 2009
WCH Times | 22
primary care services reimbursed fee for PRIMARY CARE PAYMENT AND service and through managed care. It provides VACCINE ADMINISTRATION CHARGE 100 percent federal matching funds for the
INCREASE difference in payment between the applicable CMS put on display in the Federal Register Medicare payment in those years and the the final rule implementing Payments for Medicaid rate in effect as of July 1, 2009. Services Furnished by Certain Primary Care This final rule also updates the interim Physicians and Charges for Vaccine regional maximum fees that providers may Administration under the Vaccines for Children charge for the administration of pediatric Program as authorized by sections vaccines to federally vaccine-eligible children 1902(a)(13), 1902(jj), 1905(dd) and 1932(f) of under the Vaccines for Children (VFC) the Social Security Act. The rule provides that program. states reimburse certain primary care physicians in calendar years (CYs) 2013 and Source: CMS.org
2014 at rates not less than the Medicare rates in effect in those calendar years. This minimum payment level applies to specific
In addition to payment improvements, the HEALTH CARE LAW DELIVERS health care law includes numerous initiatives HIGHER PAYMENTS TO PRIMARY designed to bolster primary care and
CARE PHYSICIANS strengthen the primary care workforce, including an expansion of medical residency Health and Human Services (HHS) positions for primary care physicians, new announced the final rule implementing the investments in physician assistant and nurse part of the health care law that delivers higher practitioner training, and an unprecedented payments to primary care physicians serving expansion of the National Health Service Medicaid beneficiaries. The new rule raises Corps, which provides scholarships and loan rates to ensure doctors are paid the same for repayments to primary care providers who treating Medicare and Medicaid patients and practice in underserved areas.does not raise costs for states.
The final rule implements the Affordable Care Source: hhs.govAct's requirement that Medicaid pay physicians practicing in family medicine, general internal medicine, pediatric medicine, and related subspecialists at Medicare levels in Calendar Years 2013 and 2014.
This payment increase goes into effect in January of 2013.
WCH Times | 23
Diagnosis is defined as assessments, ENHANCED AUTISM MANDATE evaluations, or tests to diagnose whether a EFFECTIVE NOVEMBER 2012person has ASD.
New York State has enacted a mandated The new law supplements the existing NYS
benefit for screening, diagnosis and treatment mandate relating to autism, which prohibits
of autism spectrum disorder (ASD). ASD refers plans from excluding benefits for otherwise
to any pervasive developmental disorder as covered services because they are provided to
defined in the most recent edition of the DSM, diagnose or treat autism. The new law is
including: intended to provide parity for people with
џ Asperger's syndrome autism by requiring equitable coverage of the
џ Autistic disorder disorder by insurance companies.
џ Childhood disintegrative disorder џ Pervasive developmental disorder (not Source: emblemhealth.com
otherwise specified) (PDD-NOS) џ Rett's disorder
discriminating against individuals because of a OBAMA ADMINISTRATION MOVES pre-existing or chronic condition. Under the FORWARD TO IMPLEMENT
rule, insurance companies would be HEALTH CARE LAW, ban allowed to vary premiums within limits,
only based on age, tobacco use, family discrimination against size, and geography. people with pre-existing
conditions A proposed rule outlining policies and The Obama administration standards for coverage of essential moved forward to implement health benefits, while giving states more provisions in the health care law flexibility to implement the Affordable that would make it illegal for insurance Care Act. companies to discriminate against people with pre-existing conditions. The provisions of the A proposed rule implementing and expanding Affordable Care Act also would make it easier employment-based wellness programs to for consumers to compare health plans and promote health and help control health care employers to promote and encourage spending, while ensuring that individuals are employee wellness. protected from unfair underwriting practices
that could otherwise reduce benefits based on The Obama administration issued: health status. A proposed rule that, beginning in 2014, prohibits health insurance companies from Source: CMS.gov
WCH Times | 24
and electronic claim submissions which took EMBLEM HEALTH UPDATEplace both before and after the storm and are EmblemHealth has relaxed all of its prior processing accordingly.authorization requirements for covered
services. All such services performed by Please note: EmblemHealth's employee voice participating providers may be performed mail system is not functional at this time. If without prior authorization. EmblemHealth you experience issues with their phone lines, requests that participating providers submit please log into emblemhealth.com and notification of procedures, admissions and proceed directly to the Message Center and provision of Home Care, DME, and other send the inquiry instantly via the general services. The relaxation of prior authorization information dropdown to communicate with rules also applies to all services managed by them. their delegated entities on behalf of
EmblemHealth (GHI and HIP). Source: EmblemHealth To verify benefits and eligibility, please
continue to access their secure provider portal.
Claims OperationsEmblemHealth claims processing is operational. They have received both paper
* RR - RentalUNITED HEALTH CARE (UHC) DME * KH - Initial claim, purchase or first month MODIFIER REQUIREMENT IN 2013rental Effective , UHC will require
that items eligible for purchase or rental be * KI - Second or third monthly rentalsubmitted with the appropriate modifier(s)
* KJ - Capped rental months four to fourteendesignating which is being billed. The policy
* KR - Partial monthnow states that if a modifier is not applied, the charge will be considered a "purchase." IF an * NU - New Equipmentitem is eligible for either rental or purchase, * UE - Used Equipmentand you do not submit it with the required modifier, the claim will be denied and Source: UHC updatesreturned.
For those codes on UHC fee schedule that allow both rental and purchase, one of the following modifiers must be reported:
January 1, 2013
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HIP SERVICE AREA EXPANSION AFFECTS GHI HMO PROVIDERS
HMO network who are not already in the HIP network will be invited to participate in certain HIP commercial HMO benefit plans: HIPaccess
Pending approval from the NYS Departments I, HIP Prime HMO, HIP POS, Direct Pay HMO,
of Health and Financial Services (DOH and Direct Pay POS and Healthy NY.
DOFS, respectively), EmblemHealth anticipates Source: nhp.orgmerging its company GHI HMO Select, Inc.
(GHI HMO) into HIP Health Plan of New York (HIP) on or around November 1, 2012. In accordance with DOH requirements, notices have been sent to GHI HMO contracted providers in July and again in August, 30 days apart. A final notice will be sent once the merger is approved. Most providers in the GHI
Outpatient and home Physical Therapy (PT)NEIGHBORHOOD HEALTH PLAN Outpatient and home Speech Therapy (ST)UPDATESMost Surgical Day Care (SDC)
Effective December 1, 2012, the following Please Note: HVMA members seeking services will no longer require prior PT/OT/ST services will continue to require authorization:authorization.Outpatient and home Occupational Therapy
(OT) Source: unitedhealthcare.com
BEHAVIORAL HEALTH SCREENINGSTo be eligible for reimbursement, Primary Care
Neighborhood Health Plan (NHP) requires that Providers (MDs and NPs) must use specific, Primary Care Providers (PCPs) offer periodic clinically appropriate behavioral health and medically necessary inter-periodic screens screening tools accommodating different age to members under the age of 21 in accordance ranges while allowing some flexibility for with the Early and Periodic Screening, provider preference and clinical judgment. Diagnosis and Treatment (EPSDT) and Additionally, procedure code 96110 must be Preventive Pediatric Healthcare Screening and billed with the appropriate U modifiers (U1 - Diagnosis (PPHSD) Periodicity Schedules. This U8) indicating the type of provider who requirement applies to MassHealth members conducted the screening and whether a only. behavioral health need was identified. NHP reimburses one (1) screening per member per day, regardless of the number of Claims submitted without the corresponding U screening tools administered for a member on modifier are subject to deny.a single day. Source: unitedhealthcareonline.com
WCH Times | 26
RadiologyCardiology All CTA exams, including 71275, 1)TEE studies are billed with CPT require 3D post-processing. Coronal codes 93312 through 93318. The and sagittal reconstructions, even if most common codes billed by a
sent with the axial images, do not constitute 3D.hospital department are codes 93312 and 93318. Medicare has also issued two HCPCS As noted in the fall 2008 issue of Clinical codes that would be reported if the TEE is Examples in Radiology, CTA is a distinct type of performed with contrast for Medicare patients: service that includes post-processing for C8926 and C8927. angiographic reconstructions. In order to report
these, the physician needs to use different 2) The most common way that facilities charge techniques that can all broadly be classified as out for cardiac catheterization procedures is by 3D techniques. These include maximum procedure. In general, surgery departments bill intensity pixel (MIP) reconstruction, volume-by time-based because the surgical procedure rendered images, or other 3D techniques.usually only requires one CPT code and one revenue code (RC) to bill. Even if more than one surgical code is required, they almost always The Centers for Medicare & Medicaid end up with RC 360. For example: A Services finalized the policy to apply laproscopically performed appendectomy the MPPR to the PC and TC of the requires CPT code 44970 and RC 360. second and subsequent advanced
imaging procedures furnished to the same In a cardiac cath, several CPT codes may be beneficiary in the same session by a single required along with different revenue codes. physician or by multiple physicians in the same For example: If ultrasound guidance is used to group practice. However, due to operational gain access into the body, CPT code 76937 (RC limitations, it did not actually apply the MPPR 402) is assigned, and the cardiac cath (LHC) to services performed by multiple physicians in would be CPT code 93458 (RC 480). If a the same group practice (same national radiology procedure is performed in addition to provider identifier [NPI]). However, this will the cardiac cath, different CPT and revenue change on and after January 1, 2013, and the codes are assigned. For example: Lower MPPR will apply to multiple physicians in same extremity angiography would be CPT code group practice.75716 (RC 320). Based on the aforementioned, Source of information: it is understandable why surgery departments
bill time-based where one element of time (two hours) is attached to RC 360 and assigned a CPT code by the health information management (HIM) department. However, when there is the possibility of numerous CPT and revenue codes, most departments bill by individual procedure.
panaceahealthsolutions
NEWS BY SPECIALTY
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PROVIDERS PUSH BACK ON MEDICAID INQUIRIES
June 1, 2012November 1, 2012
Source: Modernhealth news
with lawmakers. Lawyers pay an annualized fee of $342 to renew a license in Illinois. Acupuncturists pay $250. Optometrists pay The Texas Health and Human $200.Services Commission's Office of
Inspector General is trying to reclaim hundreds of millions in misspent Medicaid money. But
CHANGES TO NEW YORK after months of investigations, more medical providers are saying publicly that they have MEDICAID BENEFITSbeen wrongly targeted. They say a controversial Summary of change: The state of federal rule that allows the inspector general to New York has made changes to the stanch the flow of Medicaid payments as it Medicaid contract affecting coverage of certain pursues fraud investigations is crippling procedures. These changes are applicable to all businesses, denying providers due process and Medicaid Managed Care and Family Health Plus harming patients by jeopardizing the state's (FHP) enrollees. The effective dates for these limited network of Medicaid providers. changes occur between , and
.
Back Pain Treatment Effective June 1, 2012.HEALTH FIRST TO ACQUIRE What's changing? Coverage is eliminated for the FLORIDA DOCTORS PRACTICEfollowing treatments:
Health First, an integrated Rockledge, џ Prolotherapy
Florida health system, plans to џ Systemic corticosteroids
acquire Melbourne Internal Medicine џ Therapeutic facet joint steroid injections in
Associates, a multispecialty physician practice.the lumbar and sacral regions with or without
Financial terms of the deal were not disclosed. CT or fluoroscopic image guidance
Health First said that it plans to combine the џ Injections of steroids into intervertebral discs
new practice with its existing physician group џ Continuous or intermittent traction
and rename the entity Health First Medical Group. It will have a total of 250 physicians who
Why the change? The above treatments are will work in a number of locations.
considered ineffective or experimental and investigational. Pharmaceuticals (prescription and nonprescription) to reduce pain and
ILLINOIS DOCTORS PAY LESS TO practitioner-ordered physical therapy for
RENEW THEIR LICENSES treatment of back pain are still covered.Illinois doctors pay less to renew their licenses than many other professions,
according to a department presentation shared
STATES UPDATES
WCH Times | 28
QUESTIONS AND ANSWERS
WCH Times | 29
Question:t
Question:t
What type of documentation does Medicare require for recording the annual wellness visit (AWV)?
You'll want to document the AWV the same way you document all other services that your practice performs — thoroughly and carefully. According to a directive on the Web site of Trailblazer Health Enterprises, “Physicians, qualified non-physician practitioners, and medical professionals are required to use the 1995 or 1997 E/M documentation guidelines to document the medical records with the appropriate clinical information. All referrals and a written medical plan must be included in the documentation.”
Source:acponline.org
How does WCH assure the security and availability of the software and the practice's data?
Security is an important factor to us; your practice's information will always be backed up and assured security. During the course of every day, including weekends and holidays, the computer sever automatically generates the back-up file every four (4) hours. At the end of each day, the last back up file is automatically written to a data CD. In addition there to, at the end of each week, the last back-up file is automatically written to a CD. Therefore, there are a total of eight (8) CDs at the end of each week that is stored on external drive safely, in a fire-proof facility. WCH provides technical support Sunday-Friday through phone, e-mail, or in person. Your data and access is reliable at any time. Data in our PMBOS program is confidently stored and is only given access to parties which are authorized by the client and WCH Service Bureau. All information and paperwork you provide to our company will only be used for work purposes only. We will not share your information with outside parties. Our staff signs a confidentially agreement to assure that your information will not be accessed outside of WCH Service Bureau.
Answer:t
Answer:t
F.A.Q
Olga Khabinskay,General Manager
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