Welcome To The Digital Learning Center · 6 © Economedix, LLC 2000 - Present - All Rights Reserved The –AI Modifier Medicare has a –AI modifier to distinguish between the use

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© Economedix, LLC 2000 - Present - All Rights Reserved

Welcome To The Digital Learning Center

Presented by …

Your Partner In Building High Performance Practices


Today’s Presentation

Medicare Update 2011

Medicare Changes for 2011

Effecting Billing, Coding,

Documentation and Reimbursement


Course Faculty

R. Thomas (Tom) Loughrey, MBA, CCS-P

• Chairman, CEO & Co-Founder of Economedix

• Certified Coding Specialist

• BS Degree from Pennsylvania State University

• Earned an MBA in Health & Hospital Administration

from the University of Florida

• Former Hospital Administrator

• Former Owner of a Medical Billing Company

• Consultant to Physician Practices & Medical Societies

• Member of Various Professional Organizations

Dealing with Medical Practice Management

• Developed and Presented Thousands of Seminars

& Workshops Dealing with Practice Management

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ACCME Disclosure

R. Thomas (Tom) Loughrey, MBA, CCS-P

In accordance with the policies on disclosure of the

Accreditation Council for Continuing Medical

Education, presenters for this program, except for any

noted below, have identified no personal relationships

with a health care product company which, in the

context of their topics, could be perceived as a real or

apparent conflict of interest.

No conflicts were disclosed


Today’s Course

o ICD-9 Update Overview

o ICD-10 Update

o CPT Update

o Consults

o Telehealth Changes

o New Payment Rates &

Policies

o Medicare Physician

Fee Schedule

o MAC Update

o E- Prescribing

o Welcome to Medicare

Physical

o PQRI

o PECOS

o ASC Update

o OIG Work Plan

o Beneficiary Updates

o Medicare as the

Secondary Payer


ICD-9 Update

The 2011 ICD-9 Update applies to claims

with a date of service after October 1, 2010

ICD-9 codes must be compliant as of the

date of service

New, revised and discontinued codes can

be found at:http://www.cms.gov/ICD9ProviderDiagnosticCodes/

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ICD-10 Update

Medicare has issued a Final Rule establishing the changeover from ICD-9 to ICD-10 as of October 1, 2013

https://www.cms.gov/ICD10/

Example: Diabetes with retinopathy and macular edema – E11.311

None of the changes will take effect until that time.

Minimal updates to ICD-9 in October 2011 and no updates in October 2012


ICD-10 Update - Example


ICD-9 / ICD-10 diagnosis comparison: Finger Laceration

ICD-9 ICD-10

Documentation Requirements

Is it simple or complicated?

Is there tendon involvement?

Documentation Requirements:

Is it the right hand or the left?

Which finger is it?

What segment of the finger is lacerated?

Is it the initial encounter or a subsequent

encounter or sequela?

Is the nail damaged

Are there fractures?

Is there a foreign body involved?

Are any tendons injured?

Sample result: Simple finger

laceration, 883.0

Sample result: laceration w/o FB, right

index finger w/o damage to nail, initial

encounter, S61.210a

ICD-9 and ICD-10 Comparison –

Finger Laceration

In this example, ―S61‖ refers to an open wound of the wrist, hand and fingers;

―.21‖ refers to fingers without damage to the nail and without a foreign body;

the sixth digit ―0‖ refers to the right index finger and the seventh digit ―a‖ refers

to the initial encounter for the injury.

https://www.cms.gov/ICD10/

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CPT Update

The 2011 CPT codes from the American

Medical Association go into effect on

January 1, 2011

Claims submitted with a DOS prior to

1/1/11 must use the 2010 codes

New, revised and discontinued codes can

be found in the current CPT books http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-

your-practice/coding-billing-insurance/cpt.shtml


Consultations

Medicare No Longer Pays for Consults

99241- 99255 (effective in 2010)

• Must bill for a visit – out-patient or in-

patient

• Must now pay attention to new patient vs.

established patient

• Some private payers are transitioning to

this particularly for their Medicare

Advantage products


The Impact

99204 New Patient Office Visit $158.39

99214 Est. Patient Office Visit $104.31

99244 Out-patient Consult $205.64

Difference of $101.33 for an established

patient visit and a difference of $47.25 for

a new patient visit.

Just one of each per week is an annual

income difference of $7,726.16Fees based on 2009 Medicare allowable for Southern California.

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So What To Do Now?

Medicare’s instruction for 2010 is to bill for

an appropriate initial hospital visit (99221 –

99223) in place of the Inpatient

Consultation (99251 – 99255)

For Outpatient consults (99241 – 99245)

bill the appropriate outpatient visit code

(99201 – 99215). These codes are divided

between new and established patients


Key Component Requirements

O/P Visits

O/P

Consult History Examination

Decision

Making

99201/99212 99241 PF PF SF

99202/99213 99242 EPF EPF SF

99203/99214 99243 Det Det Low

99204/99215 99244 Comp Comp Mod

99205/99215 99245 Comp Comp High

PF- Problem Focused

EPF – Expanded Problem Focused

Det – Detailed

Comp – Comprehensive

SF – Straightforward

Low

Mod – Moderate

High


Key Component Requirements

Initial

Hospital

Care I/P Consult History Examination

Decision

Making

N/A 99251 PF PF SF

N/A 99252 EPF EPF SF

99221/99304 99253 Det Det Low

99222/99305 99254 Comp Comp Mod

99223/99306 99255 Comp Comp High

PF- Problem Focused

EPF – Expanded Problem Focused

Det – Detailed

Comp – Comprehensive

SF – Straightforward

Low

Mod – Moderate

High

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The –AI Modifier

Medicare has a –AI modifier to distinguish

between the use of 99221-99223 (Initial

Inpatient care codes) and 99304-99306

(Initial Nursing Facility Care) for admits

and consults

The Physician of Record (admitting

physician) is to use the –AI modifier to

indicate his/her unique status.


2011 Telehealth Changes

G0406 – Follow-up I/P Consult, 15 minutes by

Telehealth


Telehealth


Telehealth

These are now the only consults Medicare will reimburse


New Payment Rates & Policies

Establishment of an Effective Billing Date for

Physicians and Non-Physician Practitioners: For

services furnished up to 30 days prior to

the effective date of enrollment

• For services furnished up to 90 days prior to

the effective date if the President has declared

an emergency

• Timely filing period is now one year from the

date of service

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Submitting Claims after a Final Adverse Action or CMS Revocation: The final rule provides that a physician or non-physician practitioner is not allowed to bill for services furnished after certain reportable events, including:

A Federal exclusion or debarment, or felony conviction;

A State license suspension or revocation; or

A practice location is determined to be not operational by CMS or its contractor.

For all other revocation actions, individual practitioners will be required to submit all outstanding claims within 60 days of the effective date of revocation.



Revised Reporting Responsibilities for Physicians and Non-Physician Practitioners:

The rule requires physicians to notify their Medicare contractor of a change of ownership, final adverse action, or change of location within 30 days of the reportable event.

Failure to notify the designated contractor of a change related to a final adverse action or a change of location may result in an overpayment from the date of the reportable event.

Overpayments not refunded may result in False Claims Act violation


Medicare Physician Fee Schedule

Conversion factor

In 2010, the conversion factor goes from

$36.0846 to $33.9764 (total fee schedule

is budget neutral compared to 2010)

Medicare Physician Fee Schedule is

available from your Medicare Carrier or

MAC

RBRVS is at:http://www.cms.hhs.gov/PhysicianFeeSched/PFSRVF/list.asp#TopOfPage

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2011 Non-Facility Pricing Amount =

[(Work RVU * Work GPCI) +

(Transitioned Non-Facility PE RVU * PE GPCI) +

(MP RVU * MP GPCI)] * Conversion Factor (CF)

2011 Facility Pricing Amount =

[(Work RVU * Work GPCI) +

(Transitioned Facility PE RVU * PE GPCI) +

(MP RVU * MP GPCI)] * CF

The conversion factor for CY 2011 is $33.9764.




MAC Update

All areas of the country are now covered by A/B MACS (Medicare Administrative Contractors

A/B MACs will administer both Part A & B

15 Designated jurisdictions – 7 started in 2008 and five more in 2009 and ther remainder in 2011

http://www.cms.hhs.gov/MedicareContractingReform/

Plan is to reduce MACs to 10 in next few years

http://www.cms.hhs.gov/MedicareContractingReform/

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A/B MAC Jurisdictions


Future A/B MAC Jurisdictions


Welcome to Medicare Physical

Payment for Initial Preventive Physical

Examination (IPPE)

CMS will increase the work RVUs for the IPPE.

The IPPE is reported with code G0402 and is

valued at 1.34 work RVUs in 2009. For 2010 CMS

will increase the work RVUs for this service to

2.30 work RVUs.

This value was crosswalked from code 99204,

Evaluation and management new patient, office

or other outpatient visit.

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Ultrasounds for AAA

Coverage provided for the following:

Must receive a referral as a result of an IPPE

Must be provided by an authorized supplier

Patients must have one of the following:

Family Hx of AAA

Male >65 but < 75 who has smoked at least 100

cigarettes in lifetime

Pt who manifests other risk factors associated

with increased risk for AAA


Ultrasounds for AAA

The following codes and modifiers should

be used:

G0389 U/S, B-scan and or real time with

image documentation

Modifiers TC and 26

The annual Part B deductible is waived

for this service


Part B Updates

Part B deductible is raised from $155.00 to

$162.00.

This amount is payable by the patient and

may not be waived by the provider.

This is in addition to the 20% co-payment that

applies to most allowed services.

Many patients have Medicare supplemental

insurance that will cover the cost of the

deductible and co-payments.

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Primary Care Bonus

Primary care physicians who derive at least

60% of their Medicare charges from new

and established patient visits (99201-

99215) will receive a ten percent incentive

bonus

Paid quarterly.

Check for more details. http://www.acponline.org/running_practice/practice_management

/payment_coding/bonus.htm


Annual Wellness Visit

Medicare will now cover an Annual Wellness Visit (AWV) under Part B.

CMS established a billing code that physicians must use to bill for a first AWV service, G0438, and a subsequent AWV service, G0439.

The 2011 Medicare payment—not adjusted for geography—is approximately $172 for G0438 and $111 for G0439

Medicare will pay the full amount, meaning that the beneficiary does not have to pay the typical 20 percent copayment nor pay any deductible.

Patients must have been Medicare beneficiaries for at least 12 months in order to qualify for this benefit.


Other Preventive Services Covered

Medicare will now also cover other preventive

care services that have been ranked as either

―A‖ or ―B‖ by the US Preventive Services Task

Force.

The list of these services can be seen at

http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.

Medicare provides first dollar coverage with no

deductible and no co-payment requirement.

http://www.acponline.org/running_practice/practice_management/payment_coding/bonus.htm

http://www.acponline.org/running_practice/practice_management/payment_coding/bonus.htm

http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs

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E- Prescribing Bonus for 2011

The Medicare 2011 e-prescribing incentive

program is in many ways similar to the structure of

the 2010 program.

Important changes, however, are that the bonus

payment for successful 2011 participation has

decreased to 1% and,

you must participate in 2011 to avoid a payment

penalty in 2012.

Details http://www.acponline.org/running_practice/technology/eprescribing/medic

are_program_overview.pdf.


Home Health Certification

A New Requirement for Face-to-Face Encounter as Part of the Process for Certifying Beneficiary Home Health Care.

The Patient Protection and Affordable Care Act of 2010 mandates that a physician conduct in a face-to-face encounter to certify a beneficiary need for home health care services.

The CMS rules to implement this provision require that the face-to-face encounter must occur within the 90 days prior to the start of home health care, or

within the 30 days after the start of care.

Check for more details

http://www.cms.gov/MLNMattersArticles/downloads/SE1038.pdf.


Physician Quality Reporting

Physician Quality Reporting Initiative (PQRI) now called Physician Quality Reporting System or just “PQR”

To participate in the 2011 Physician Quality Reporting, individual eligible professionals may choose to report information on individual Physician Quality Reporting quality measures or measures groups:

(1) to CMS on their Medicare Part B claims,

(2) to a qualified Physician Quality Reporting registry, or

(3) to CMS via a qualified electronic health record (EHR) product.

May earn up to 1.0% of total allowed charges for the year

http://www.acponline.org/running_practice/technology/eprescribing/medicare_program_overview.pdf

http://www.acponline.org/running_practice/technology/eprescribing/medicare_program_overview.pdf

http://www.cms.gov/MLNMattersArticles/downloads/SE1038.pdf

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Physician Quality Reporting

Maintenance of Certification Program Incentive

Beginning in 2011, physicians will have the opportunity to earn an additional incentive of 0.5% by working with a Maintenance of Certification entity and by completing the following:

Satisfactorily submitting data on quality measures under PQR, for a 12-month reporting period either as an individual physician or as a member of a selected group practice.

AND

More frequently than is required to qualify for or maintain board certification:

• Participate in a Maintenance of Certification Program, and

• Successfully complete a qualified Maintenance of Certification Program practice assessment.

More information at: http://www.cms.gov/PQRI/


PECOS

In the new ruling, CMS requires providers to use its new system for provider enrollment. This system, already being used by Medicare MACs, is an Internet-based national enrollment repository known as the Provider Enrollment, Chain and Ownership System (PECOS).

With PECOS, CMS states that "Medicare contractors will fully process most complete Internet-based PECOS enrollment applications within 30 to 45 calendar days," compared to 60 to 90 calendar days in the current paper-based enrollment process.

All Providers must be registered with PECOS by 1/1/2011 in order to continue to be paid (currently deferred)


PECOS

Check your enrollment at: https://www.cms.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS

.asp

There is a short article detailing information on ordering referring status.

At the bottom of this article there are several files that can be downloaded.

The first two are files of all physicians enrolled in PECOS.

The first is a PDF file and the second is an Excel file.

They are massive. The PDF file is over 15,000 pages long. The Excel file is over 840,000 lines. Most users will not be able to open that complete file.

The PDF file is viewable and is listed alphabetically with the physician’s NPI number

http://www.cms.gov/PQRI/

https://www.cms.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS.asp

https://www.cms.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS.asp

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2011 New Audit Targets - OIG

Excessive Payments for Diagnostic Tests: The OIG will review payments for certain high-cost diagnostic tests to determine whether they were medically necessary.

Place of Service Errors: The OIG will look at whether physicians properly code the place of service on claims for services provided in hospital outpatient settings.

Part B Imaging Services: Medicare pays physicians for interpretations based on the Medicare physician fee schedule, which includes practice expenses. The OIG will review this component of imaging services to determine whether payments reflect actual expenses.


2011 New Audit Targets - OIG

Payments for End Stage Renal Disease Beneficiaries Entitled to Medicare Under Special Provisions: The OIG will review claims for ESRD beneficiaries entitled to Medicare coverage only because of special circumstances.

Frequency of Replacement of Supplies for Durable Medical Equipment: The OIG will review DME suppliers’ compliance with Medicare requirements for frequently replaced supplies.


Beneficiary Related Update

MyMedicare.gov

http://mymedicare.gov/

View claim status

Order duplicate MSN (Medicare Summary

Notice) or replacement Medicare card

View eligibility

View enrollment

View or modify drug list and pharmacy

information

http://mymedicare.gov/

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Beneficiary Related Update

Medicare Premiums and Deductibles

Monthly Premium $115.40. Persons with

incomes over $85,000 (single) or $170,000

(married) will pay higher premiums

Some exceptions for lower income persons

previously enrolled in Medicare. Rate

remains at $96.40

Part A Deductible $1,132

Part B Deductible $162


Income Adjusted Premiums for Part B

Beneficiaries who file an

individual tax return with

income:

Beneficiaries who file a joint

tax return with income:

Income-related

Monthly

Adjustment

amount

Total

Monthly

Premium

amount

Less than or equal to $85,000 Less than or equal to $170,000 $115.40 $115.40

Greater than $85,000 and less

than or equal to $107,000


than or equal to $214,000 $46.10 $161.50




than or equal to $320,000 $115.30 $230.70




than or equal to $428,000 $184.50 $299.90

Greater than $214,000 Greater than $428,000 $253.70 $369.10


Medicare as Secondary Payer

Medicare has revised the

questionnaire to be used with new

patients to determine if Medicare

should be the primary payer or the

secondary payer

http://www.cms.gov/transmittals/downloads/R53MSP.pdf

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Summary

Download and use the information found in the RBRVS tables for how Medicare will handle individual codes

Update your charge tickets and provide in-service training

Make a calculation on how much the e-prescribing and PQRI could bring your practice

Be very careful and accurate in the 855 applications. These are notoriously delayed for the slightest problem.

Watch your timely filing dates


Thank you for participating in this seminar presentation from

Economedix!

Please direct questions to …

[email protected]

To earn CME credits for this course please complete the Evaluation / CME Form and

FAX it back to Economedix within 7 days of the teleconference.

Please direct questions to …

[email protected]

To earn CME credits for this course please complete the Evaluation / CME Form and

FAX it back to Economedix within 7 days of the teleconference.

Documents

Welcome To The Digital Learning Center · 6 © Economedix, LLC 2000 - Present - All Rights Reserved The –AI Modifier Medicare has a –AI modifier to distinguish between the use