Keeping Up to Date with KLA
CMS Issues Date of Death Occurrence Code
April 30th, 2012
Government benefits being paid to deceased beneficiaries is a growing problem in the U.S.
The National Uniform Billing Committee has created a new "occurrence" code to help capture deaths on the billing document.
Beginning October 1, 2012, occurrence code "55" must be included when patient discharge status code 20 (expired), 40 (expired at home), 41 (expired in a medical facility), or 42 (expired – place unknown) is present on the claim form. Failure to include the code will result in a rejection of the claim.
Don't "Slip and Fall" Off of Medicare Rolls
April 16th, 2012
With all the paper that flows through your office, it would be easy to overlook a letter from CMS asking you to revalidate your Medicare enrollment. Failure to do so could result in you falling off the program.
Remember how difficult it was to get enrolled the first time?
Just to be sure, you may wish to check the lists of providers sent notices to revalidate their Medicare enrollment by scrolling to the "Downloads" section at http://www.CMS.gov/MedicareProviderSupEnroll/11_Revalidations.asp on the Centers for Medicare & Medicaid Services (CMS) website.
That site currently contains links to lists of providers sent notices from September 2011, through January 2012. Information on revalidation letters sent in February will be posted in late March.
For ease of reference, the lists are in order by National Provider Identifier and the date the notice was sent.
Ah-Choo! Coding for Allergy Injections
March 21st, 2012
If a patient presents at your office for an allergy injection, don't forget to capture all billable charges.
Per CPT 2012, Allergy Immunotherapy Codes 95115 through 95117 "include the professional services necessary for allergen immunotherapy. Office visit codes may be used in addition to allergen immunotherapy if other identifiable services are provided at that time."
In addition to code 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) or 95117 (… two or more injections), remember to include the code for the vaccine if provided by you.
In appropriate cases, you may also bill for an office visit.
An example from Family Practice Coding Alert:
An FP sees a patient due to nasal congestion (478.19), and then the patient receives her scheduled bimonthly series of two allergy injections for allergic rhinitis due to pollen (477.0). The physician performs and documents a level-two E/M service. You may report 99212 and 95117, according to Medicare rules.
According to the Correct Coding Initiative, a modifier is not needed to code both codes.
In appropriate cases, you may even bill 99211, other staff services, with an allergy injection. Just be sure the reason for the evaluation and management services is well documented. Examples could include:
- The patient was running a fever; and the staff member queried about other symptoms.
- The patient complained about dermatitis or soreness after the least injection; and the staff member shared known reactions to the injection.
- The patient had not been following the set schedule for injetions; and the staff member investigated why.
Although modifiers have not been required according to CCI edits since 2008, some private insurance companies do not follow standard edits. In those cases you may need to append modifier 25 to the evaluation and management code.
In all cases, be sure to use accurate diagnosis linking.
You Say MSN, I Say EOMB
March 15th, 2012
Do you remember when an explanation of the benefits provided to a patient covered by Medicare was called an Explanation of Medicare Benefits (EOMB)?
I do. In fact, I completely missed the name change to Medicare Summary Notice (MSN).
Medicare announced today that it has again redesigned the statement sent to beneficiaries as part of a new initiative – “Your Medicare Information: Clearer, Simpler, At Your Fingertips”.
The new MSN will be available to beneficiaries this week at www.MyMedicare.gov, Medicare's secure website for beneficiaries. In 2013, the paper version of the form will be mailed to beneficiaries quarterly.
Per Medicare: "This MSN redesign reflects more than 18 months of research and feedback from beneficiaries to provide enhanced customer service and respond to suggestions and input."
You may see a side-by-side comparison of the former and redesigned MSNs at http://www.CMS.gov/apps/files/msn_changes.pdf.
So You Thought HIPAA Wasn't Such a Big Deal?!?
March 14th, 2012
Thanks to Attorney Erin Brisbay McMahon, a partner with the law firm of Wyatt, Tarrant & Combs with offices in Memphis, for sharing the information below:
Some of you may remember that several years ago, BCBS of Tennessee suffered a theft of hard drives with PHI on them from a mall in Tennessee. That was on a Friday night; an alarm went off at BCBS alerting that something was wrong at the mall but it was considered a low-risk alarm so no one checked on it until the Monday following. Despite BCBS notifying patients and providing credit monitoring and hiring Kroll Solutions to beef up security (which itself cost millions), it settled potential HIPAA violations with HHS for $1.5 million.
News Release
FOR IMMEDIATE RELEASE
March 13, 2012
Contact: HHS Press Office
(202) 690-6343
HHS settles HIPAA case with BCBST for $1.5 million
First enforcement action resulting from HITECH Breach Notification Rule
Blue Cross Blue Shield of Tennessee (BCBST) has agreed to pay the U.S. Department of Health and Human Services (HHS) $1,500,000 to settle potential violations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules, Leon Rodriguez, Director of the HHS Office for Civil Rights (OCR), announced today. BCBST has also agreed to a corrective action plan to address gaps in its HIPAA compliance program. The enforcement action is the first resulting from a breach report required by the Health Information Technology for Economic and Clinical Health (HITECH) Act Breach Notification Rule.
The investigation followed a notice submitted by BCBST to HHS reporting that 57 unencrypted computer hard drives were stolen from a leased facility in Tennessee. The drives contained the protected health information (PHI) of over 1 million individuals, including member names, social security numbers, diagnosis codes, dates of birth, and health plan identification numbers. OCR’s investigation indicated BCBST failed to implement appropriate administrative safeguards to adequately protect information remaining at the leased facility by not performing the required security evaluation in response to operational changes. In addition, the investigation showed a failure to implement appropriate physical safeguards by not having adequate facility access controls; both of these safeguards are required by the HIPAA Security Rule.
“This settlement sends an important message that OCR expects health plans and health care providers to have in place a carefully designed, delivered, and monitored HIPAA compliance program,” said OCR Director Leon Rodriguez. “The HITECH Breach Notification Rule is an important enforcement tool and OCR will continue to vigorously protect patients’ right to private and secure health information.”
In addition to the $1,500,000 settlement, the agreement requires BCBST to review, revise, and maintain its Privacy and Security policies and procedures, to conduct regular and robust trainings for all BCBST employees covering employee responsibilities under HIPAA, and to perform monitor reviews to ensure BCBST compliance with the corrective action plan.
HHS Office for Civil Rights enforces the HIPAA Privacy and Security Rules. The HIPAA Privacy Rule gives individuals rights over their protected health information and sets rules and limits on who can look at and receive that health information. The HIPAA Security Rule protects health information in electronic form by requiring entities covered by HIPAA to use physical, technical, and administrative safeguards to ensure that electronic protected health information remains private and secure.
The HITECH Breach Notification Rule requires covered entities to report an impermissible use or disclosure of protected health information, or a “breach,” of 500 individuals or more to HHS and the media. Smaller breaches affecting less than 500 individuals must be reported to the secretary on an annual basis.
Individuals who believe that a covered entity has violated their (or someone else’s) health information privacy rights or committed another violation of the HIPAA Privacy or Security Rule may file a complaint with OCR at: http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html.
The HHS Resolution Agreement can be found at http://www.hhs.gov/ocr/civilrights/activities/agreements/index.html
Additional information about OCR’s enforcement activities can be found at http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/index.html.
Erin Brisbay McMahon Wyatt, Tarrant & Combs, LLP 250 West Main Street, Suite 1600 Lexington, KY 40507-1746 859.288.7452 (direct dial) 859.259.0649 (fax) emcmahon [at] wyattfirm [dot] com CIRCULAR 230 DISCLAIMER: THE FOREGOING CORRESPONDENCE WAS NOT WRITTEN OR INTENDED TO BE RELIED UPON, NOR CAN IT BE USED BY, ANY TAXPAYER FOR THE PURPOSE OF AVOIDING FEDERAL TAX PENALTIES. THIS DISCLAIMER IS MADE TO COMPLY WITH THE REQUIREMENTS OF CIRCULAR 230 WHICH GOVERNS PRACTICE BEFORE THE INTERNAL REVENUE SERVICE.
Have You Visited the AMA Website Recently?
March 12th, 2012
The AMA has recently started an online outreach for Practice Management called the Practice Management Center.
The Center offers a variety of tools to assist providers navigate the the roadmap of today's practice. Be sure to sign up for the free Practice Management Alerts.
An example of the resources offered is a nice pocket guide to preventive service without patient cost share. The guide provides the CPT codes and the USPSTF Grade that insurance companies should pay under the Affordable Care Act.
The site also has a Take Action section that offers tools such as a tool to help you file a complaint against an insurance company.
Sexually Transmitted Infections and High Intensity Behavioral Counseling to Prevent STIs are now Preventive Services
March 7th, 2012
Medicare, Medicaid and most private insurors are now required to pay for screening for STIs and High Intensity Behavioral Counseling (HIBC) to prevent STIs. The tests are not subject to coinsurance or deductibles.
The tests must be ordered by a primary care provider; and the HIBC must be provided in primary care settings including family practice, internal medicine and ob-gyn offices. Hospital based care including emergency departments are not considered primary care settings for these services.
STIs included are Chlamydia (86631, 86632, 87110, 87270, 87320, 87490, 87491, 87810, 87800 (used for combined Chlamydia and gonorrhea testing), gonorrhea (87590, 87591, 87850, 87800 (used for combined Chlamydia and gonorrhea testing), syphilis (86592, 86593, 86780), and hepatitis B (hepatitis B surface antigen) 87340, 87341)).
Codes V74.5 or V73.89 and V69.8, denoting STI screening and high-risk behavior, respectively, and/or V22.0, V22.1, or V23.9, denoting pregnancy as appropriate must be included for the tests to be treated as preventive.
Bill new code G0445 (high-intensity behavioral counseling to prevent sexually transmitted infections, face-to-face, individual, includes: education, skills training, and guidance on how to change sexual behavior) for HIBC. CMS will cover semi-annual sessions, twenty to thirty minutes in length, per year. The code pays approximately $24 depending on your jurisdiction.
The visit must be linked to the correct diagnosis code. Per CMS in MLN Matters® Number: MM7610:
- The appropriate screening diagnosis code (ICD-9-CM V74.5 (screening bacterial – sexually transmitted) or V73.89 (screening, disease or disorder, viral, specified type NEC)), when used with the screening lab tests identified by Change Request (CR) 7610, will indicate that the test is a screening test covered by Medicare.
- Diagnosis code V69.8 (other problems related to life style) is used to indicate that the beneficiary is at high/increased risk for STIs. Providers should also use V69.8 for sexually active adolescents when billing G0445 counseling services.
- Diagnosis codes V22.0 (supervision of normal first pregnancy), V22.1 (supervision of other normal pregnancy), or V23.9 (supervision of unspecified high-risk pregnancy) are also to be used when appropriate.
This code may be paid on the same date of service as an annual wellness visit (AWV), evaluation and management (E&M) code, or during the global billing period for obstetrical care..
An E&M code should not be billed when the sole reason for the visit is HIBC to prevent STIs. If there is a different diagnosis, however, both may be billed on the same day.
Please review MLN Matters® Number: MM7610 for details on documentation requirements.
ERx - The Carrot and the Stick
March 2nd, 2012
A few of our clients received letters yesterday from CMS saying their reimbursement would be decreased by 1% because they had not complied with Medicare ERx guidelines. The letters also said that Medicare had not yet processed the requests for hardship exemptions that were due at the end of October, 2011.
Fortunately, Medicare has modified its rules for 2012 making it a little easier for providers to comply with ERx requirements and avoid 2013's 1.5% decrease for noncompliance.
Now, a provider can submit an ERx with ANY visit; not just with certain outpatient 90000 level codes. Thus, you may wish to include G8553 with charges for hospital claims where prescribing is done electronically. Hospital codes were not acceptable in 2012 for ERx compliance purposes.
Note, however, that using this option only avoids penalties; it does not satisfy requirements for ERx incentives. In order to receive the individual provider 2012 incentive payments, providers still must report ERxs primarily with office evaluation and management services.
To be a successful electronic prescriber for the 2012 eRx Incentive Program and earn a 1.0% incentive payment for the 2012, a provider must report the eRx measure for at least 25 unique electronic prescribing events during 2012. The measuring, however, is January 1 through June 30 so best practices would require 25 accepted claims before June 30 per practitioner.
To know if your ERx has been accepted by the National Claims History database, look for denial code N365 on your remittance advice. (KLA tracks these for our billing clients.) Yes, it is counter-intuitive to look for a denial code; but remember you are charging out 0 for this code. Thus, Medicare is paying nothing on the EOB.
Medicare issued a summary of the 2012 requirements in January 2012. The link is a good summary, but unfortunatly many of the links within the document aren't active. The correct link to the CMS section about ERx is: https://www.cms.gov/ERxIncentive/
A group practice may also potentially qualify to earn an eRx incentive payment equal to 1.0% of the group practice's total estimated Medicare Part B Physician Fee Schedule (PFS) allowed charges for covered professional services furnished during the 2012. Small groups must complete 625 ERxs to qualify. Large groups must complete 2,500.
To qualify for the group incentive you must self nominate for 2012. Nomination forms are available on the CMS ERx Incentive pages under Group Practice Reporting.
If you need a free method for ERx, feel free to sign up for Practice Fusion through KLA's link at: http://www.practicefusion.com/ccn/kla. KLA will not contact you if you take advantage of our link; but feel free to call us with questions.
You will need to fax Practice Fusion some information such as your DEA and proof of identity to get set up for ERx, but it is a free service. In fact, Practice Fusion had the more providers qualify for stimulus money in 2012 than any other EMR system.
Medicare, Secondary Insurance and Coordination of Benefits
March 1st, 2012
Medicare, Secondary Insurance and Coordination of Benefit problems may not be at the very top of our list of reimbursements issue, but it's very close.
- We see it when Medicare denies because it's not the primary payor,
- We see it when we get a denial from a secondary insurance company that the patient doesn't have, and
- We see it when, despite our providing all information via the new nightmarish 5010 standards, Medicare doesn't appropriately "crossover" to secondaries requiring arduous paper filing with Medicare eobs or online submission through the carrier with scanned attachments.
No wonder so many offices just give up on secondary dollars!
Medicare relies on the secondary insurance company to self report a new enrollee. If the secondary company does not, what can a provider do?
The brief answer is, provide proof of the patient's secondary insurance to the COBC (Coordination of Benefits Contractor).
Telephone: 1-800-999-1118 (8 AM to 8 PM Eastern Time)
Fax: 1-734-957-9598 (address the fax to Medicare Coordination of Benefits)
Mailing address: Medicare –Coordination of Benefits, P.O. Box 33847, Detroit, MI 48232
Because of the number of conflicts in the information CMC and COBC receives, CMS revised its data management "reporting hierarchy" process on December 7. The official document may be found at: http://www.cms.gov/MandatoryInsRep/Downloads/GHpHierarchy.pdf
Here are the highlights:
ONE TIME ONLY, a provider office may call the COBC when the patient is in the office and correct the information over the phone. After that, all proof must be sent by mail or fax.
To speed up your reimbursement process, train your front desk staff to always check secondary insurance. If there has been a change, be sure to retain proof of the secondary insurance such as an enlarged, legible copy of the secondary insurance card.
If you have an historical problem with a patient's secondary insurance, call the COBC while the patient is in the office and near the phone to attempt the ONE TIME ONLY option to correct over the phone.
CMS Issues Proposed Requirements for Stage 2 EHR
February 29th, 2012
On February 24, CMS released a Fact Sheet about its proposal for the Stage 2 meaningful use requirements of electronic health records (EHRs).
The new proposed rule primarily expands on Stage 1 requirements. For example, Providers will be required to report on 12 clinical quality measures (CQMs) in Stage 2. They were required to report on 6 in Stage 1. Other changes include making reporting which was optional in Stage 1, mandatory in Stage 2.
Per the Fact Sheet, proposed changes include:
- Changes to the denominator of computerized provider order entry (CPOE) (Stage 1 Optional, Stage 2 Required)
- Changes to the age limitations for vital signs (Stage 1 Optional, Stage 2 Required)
- Elimination of the “exchange of key clinical information” core objective from Stage 1 in favor of a “transitions of care” core objective that requires electronic exchange of summary of care documents in Stage 2 (Effective Stage 2)
- Replacing “provide patients with an electronic copy of their health information” objective with a “view online, download and transmit” core objective. (Effective Stage 2)
Specialists will be impacted more than primary care providers in Stage 2. Per the Fact Sheet meaningful use will require:
- Imaging results and information accessible through certified EHR technology
- Capability to identify and report cancer cases to a State cancer registry, except where prohibited, and in accordance with applicable law and practice
- Capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practice.
The proposed rule seeks to extend Stage 1 so that providers would have until 2014 to implement Stage 2. Per the Fact Sheet, the delay "would allow the needed time for vendors to develop Certified EHR Technology that can meet the Stage 2 requirements."
AMA Issues CPT Errata for 2012
February 27th, 2012
Remember...it's impossible to be perfect!
Despite the AMA's best efforts, 2012 CPT did have errors...so far 12 pages of them!
The errata may be found at:
http://www.ama-assn.org/resources/doc/cpt/cpt-corrections.pdf.
The page also offers a link to sign up for notifications about future errata.
Place of Service for Distant Site
February 13th, 2012
It's not always easy to know where services to a patient are rendered where the physician component of a diagnostic procedure is done at a site distant from the technical component.
CMS has clarified how to treat these types of claims in MLN Matters Number: MM7631.
The short answer is: the place of service is where the patient received face-to-face service.
The example given in the Medlearn article is:
A beneficiary receives an MRI at an outpatient hospital near his/her home. The hospital submits a claim that would correspond to the TC portion of the MRI. The physician furnishes the PC portion of the beneficiary’s MRI from his/her office location – POS code 22 will be used on the physician’s claim for the PC to indicate that the beneficiary received the face-to-face portion of the MRI, the TC, at the outpatient hospital.
There are just two exceptions to this rule that deal with a patients admission status in a hospital. If the patient is classified as inpatient but goes to an outpatient part of the facility to receive a test, the place of service would remain inpatient.
Compliance Tools for Beginners
February 6th, 2012
Failing to be "in compliance" is costing many providers' offices tens to hundreds of thousands of dollars. Regardless of how you feel about the politics of the overhead burden on providers, the penalties are real.
There are some tools available to help you. For example, visit CMS's archive of Quarterly Compliance Newsletters. This will help you key in to the primary areas of concern.
Or visit, CMS's Compliance page. It offers "Fast Facts" to help with compliance.
Overwhelmed with all the compliance material? Just plain tired of reading?
The OIG has made it a little easier for the TV/YouTube/IPad generations by addressing some of the more complicated compliance issues with podcasts.
The program began in December 2011 and the list of podcasts keeps growing. Some of our favorites include: Compliance Program Basics, Tips for Implementing an Effective Compliance Program and Importance of Documentation.
http://oig.hhs.gov/newsroom/podcasts/index.asp
Don't forget the popcorn!
2012 Welcomes New Waived Labs
January 27th, 2012
CMS updated it's list of waived laboratories on January 24. The entire list may be found at: https://www.cms.gov/CLIA/downloads/waivetbl.pdf.
Be sure to check with insurance carriers about coverage requirements. Just because you can perform a test in an office; does not mean you will be reimbursed for it.
Many of the new waived labs are associated with drug screening. There are state and federal laws associated with doing work-related drug screeing INCLUDING confirmatory screenings with a second method and allowing explanations as to why a test might be positive. Be sure to check with an authority before performing these tests.
Affordable Care Act & Preventive Services
January 9th, 2012
The first of the year is the time most providers are challenged by huge first of the year expenses and slow downs in cash flow because of deductibles.
As mentioned before, it's the perfect time to focus on preventive services. The Affordable Care Act requires that most NEW private insurance policies offer certain preventive services to patients without any cost share.
Cigna has published a very good Guide to Preventive Services that can be used as a blue print for most private insurance plans. Each company has slight nuances, but this is a very good place to start.
Alcohol Misuse Screening and Counseling Now Covered by Medicare In Primary Care Setting
December 5th, 2011
Effective October 14, 2011, Medicare is covering two new G codes, G0442 (Annual Alcohol Misuse Screening, 15 minutes), and G0443 (Brief face-to-face behavioral counseling for Alcohol Misuse, 15 minutes) are available for primary care providers. Payment for the service is approximately $16 for the screening and $24 for the 15 minutes behavioural counseling. As with most preventive services,deductibles and coinsurance do not apply.
Medicare uses a definition of alcohol misuse which includes risky/hazardous and harmful drinking which place individuals at risk for future problems.
In the general adult population, risky or hazardous drinking is defined as >7 drinks per week or >3 drinks per occasion for women, and >14 drinks per week or >4 drinks per occasion for men. Harmful drinking describes those persons currently experiencing physical, social or psychological harm from alcohol use, but who do not meet criteria for dependence.
Per MLN Matters Number MM7633:
Effective for claims with dates of service October 14, 2011, and later, CMS shall cover annual alcohol screening, and for those that screen positive, up to four, brief, face-to-face behavioral counseling interventions per year for Medicare beneficiaries, including pregnant women:
- who misuse alcohol, but whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence (defined as at least three of the following: tolerance, withdrawal symptoms, impaired control, preoccupation with acquisition and/or use, persistent desire or unsuccessful efforts to quit, sustains social, occupational, or recreational disability, use continues despite adverse consequences); and,
- who are competent and alert at the time that counseling is provided; and,
- whose counseling is furnished by qualified primary care physicians or other primary care practitioners in a primary care setting.
Each of the four behavioral counseling interventions must be consistent with the 5As approach that has been adopted by the USPSTF to describe such services:
- Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.
- Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.
- Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.
- Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.
- Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.
For the purposes of this covered service, the following provider specialty types may submit claims for G0442 and G0443:
- 01-General Practice
- 08-Family Practice
- 11-Internal Medicine
- 16-Obstetrics/Gynecology
- 37-Pediatric Medicine
- 38-Geriatric Medicine
- 42-Certified Nurse Midwife
- 50-Nurse Practitioner
- 89-Certified Clinical Nurse Specialist
- 97-Physician Assistant
For purposes of this covered service, the following place of service (POS) codes are applicable:
- 11-Physician’s Office
- 22-Outpatient Hospital
- 49-Independent Clinic
- 71-State or local public health clinic
Medicare To Pay for Behavioral Therapy for Obesity
December 5th, 2011
Medicare will now pay for Intensive Behavioral Therapy for patients with obesity.
According to Medicare, obesity is defined as a BMI of 30 kg/m2. This counseling is not subject to deductibles nor coinsurance.
Medicare will pay for:
- One face-to-face visit every week for the first month;
- One face-to-face visit every other week for months 2-6; and
- One face-to-face visit every month for months 7-12, if the beneficiary meets the 3kg (6.6 lbs) weight loss requirement during the first 6 months.
According to MLN Matters MM7641:
Effective for claims with dates of service on or after November 29, 2011, Medicare will recognize HCPCS code G0447, Face-to-Face Behavioral Counseling for Obesity, 15 minutes.
G0447 must be billed along with 1 of the ICD-9 codes for BMI 30.0 and over (V85.30-V85.39, V85.41-V85.45).
IBT for obesity consists of the following:
- Screening for obesity in adults using measurement of BMI calculated by dividing weight in kilograms by the square of height in meters (expressed kg/m2)
- Dietary (nutritional) assessment; and,
- Intensive behavioral counseling and behavioral therapy to promote sustained weight loss through high intensity interventions on diet and exercise.
Intensive behavioral intervention for obesity should be consistent with the 5-A framework:
- Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.
- Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.
- Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.
- Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.
- Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.
This service will only be paid to the following specialty types:
01 - General Practice
08 - Family Practice
11 - Internal Medicine
16 - Obstetrics/Gynecology
37 - Pediatric Medicine
38 - Geriatric Medicine
50 - Nurse Practitioner
89 - Certified Clinical Nurse Specialist
97 - Physician Assistant
Services, however, may be rendered by appropriate auxilliary personnel.
Payment for the 15 minute IBT session will be $22 to $25 dollars depending on jurisdiction and place of service.
Modifier 33?
November 14th, 2011
Having problems being paid for preventive testing? Medicare anticipated such problems when it added modifier 33 as a HCPCS II code to be effective January 1, 2011.
Modifier 33 should be used in addition to an allowed preventive diagnosis on procedures that are not preventive BY DEFINITION. Thus, you would add a modifier 33 for Cardiovascular Screening Tests; but not to an annual wellness exam.
Although it excludes some of the newly added preventive services, an excellent resource is Medicare's Quick Reference Card to Preventive Services.
Using Cardiovascular Screening Tests as an example, you would code:
Lipid Panel as 80061-33
Cholesterol as 82465-33
Lipoprotein as 83718-33, and
Triglycerides as 84478-33.
The diagnoses would be one or more of the following codes: V81.0, V81.1, V81.2.
Note that this will be paid as preventive only once every five years; so keep good records.
Follow these guidelines and you WILL get these items paid without your patient being responsible for any copay or deductible.
OIG Healthcare Targets for 2012
October 10th, 2011
On October 5, the Office of Inspector General released it's 2012 work plan.
Medicare Part B areas that will be investigated include:
- Incident to services--specifically for those that physicians that collect more than the norm for their speciality.
- Unrelated services provided during global surgery periods.
- Place of service errors.
- Compliance with assignment rules--specifically are providers writing-down or writing-off per Medicare determinations.
- Ambulatory service centers.
- Chiropractors.
- Sleep testing.
- Excessive payments for diagnostic radiology.
For the complete plan for Medicare Part B, visit http://oig.hhs.gov/reports-and-publications/archives/workplan/2012/WP01-Mcare_A+B.pdf.
Reminder: It's Against the Law to Bill Medicare QMB Patients
October 3rd, 2011
Dollars are tight. Many Medicaid programs are putting limitations on the number of visits they will pay in a year.
Confusion reigns as to whether or not you can balance bill a Medicaid patient who has exceeded the number of visits in a year. The short answer is probably no, but check with your Medicaid carrier to be sure.
One thing is for certain though: It is against federal law to balance bill a Medicare QMB patient, ie a patient with Medicare primary and Medicaid secondary.
This has become such an issue that CMS has published a reminder at: https://www.cms.gov/MLNMattersArticles/downloads/SE1128.pdf
Baffled by Preventive Services?
July 11th, 2011
Are you confused by the new Preventive Services offered by Medicare?
The Medicare Learning Network has recently updated several of their brochures to include changes from the Affordable Car Act.
Per CMS's press release, the following resources are now available:
“Quick Reference Information: Preventive Services” offers coverage, coding, and payment information on the wide variety of preventive services Medicare covers. View, download, or print at http://www.CMS.gov/MLNProducts/downloads/MPS_QuickReferenceChart_1.pdf.
“Quick Reference Information: The ABCS of Providing the Initial Preventive Physical Examination (IPPE)” offers a list of the elements included in the IPPE, along with some frequently asked questions. View, download, or print at http://www.CMS.gov/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf.
“Quick Reference Information: The ABCs of Providing the Annual Wellness Visit (AWV)” offers a list of the elements included in the AWV, along with some frequently asked questions. View, download, or print at http://www.CMS.gov/MLNProducts/downloads/AWV_Chart_ICN905706.pdf.
“Quick Reference Information: Medicare Immunization Billing” offers coverage, coding, and payment information for the seasonal influenza, pneumococcal, and hepatitis B vaccines. View, download, or print at http://www.CMS.gov/MLNProducts/downloads/qr_immun_bill.pdf.
The MLN® also offers these charts in a laminated, ring-bound booklet titled “Quick Reference Information Resources: Medicare Preventive Services.” This booklet contains all four of the preventive services charts listed above in a single, easy-to-use format. To order your free copy, visit the Preventive Services MLN page at http://www.CMS.gov/MLNProducts/35_PreventiveServices.asp, then scroll to “MLN Product Ordering Page” in the “Related Links Inside CMS” section.
Your Future and ACOs
March 31st, 2011
The proposed ACO guidelines were issued today. They remain extremely vague not even defining who will be in charge of administering the health care dollar in ACOs. The guidelines do say that payments will continue under a fee for service paradigm. However, there will be bonuses issued to providers for improving quality and decreasing cost.
In a related story, the Federal Trade Commission has issued a statement saying that EVERY ACO will fall under FTC scrutiny for antitrust violations. The FTC does say it is committed to assist in anything that will help lower the cost of healthcare; but also refers to the number of studies that show that ACOs will drive the cost of healthcare up not down.
A very good article may be found at: http://www.kaiserhealthnews.org/stories/2011/january/13/aco-accountable-care-organization-faq.aspx?referrer=search
The HHS statement may be found at: http://www.hhs.gov/news/press/2011pres/03/20110331a.html
CMS's New Waived Labs
March 2nd, 2011
Change request 7266 from Medicare adds some new waived labs and changes the codes on others. To view the change request, visit: http://www.cms.gov/transmittals/downloads/R2155CP.pdf.
If you scroll down to page 7 of the document, you will find a complete list of waived tests.
The new tests are:
- BTNX, Inc. Strep A Rapid Test
- Consult Diagnostics Mononucleosis Cassette {Whole Blood}
- BTNX Inc. Rapid Response Fecal Immunochemical Test (FIT)
- American IVD Biotechnology Services Inc. FOB/CRC Advanced+
- Amedica Biotech AmediCheck Instant Test Cup
- Confirm Biosciences Drugconfirm instant multi-drug test kit, Multi-Drug of Abuse Urine Test
- Insight Medical Multi-Drug of Abuse Urine Test
- Jant Pharmacal Corporation Accutest Drug Test Cup
- Micro Distributing II, Ltd Multi-Drug of Abuse Urine Test
- Millennium Laboratories Multi-Drug of Abuse Urine Test
- NexScreen LLC, NexScreen Cup
- On the Spot Drug Testing Multi-Drug of Abuse Urine Test
- Physicians’ Test Multi-Drug of Abuse Urine Test
- Total Diagnostic Solutions Multi-Drug of Abuse Urine Test
- UCP Biosciences, Inc. Drug Screening Test Cards
- UCP Biosciences, Inc. Multiple Drug Screen Cups
Codes and implementation dates are available at the link above.
In addition, the change request changes the code from the popular G0431 code, "Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class" TO G0434QW "Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter."
This change was necessary to align Medicare with the changes in 2011 CPT. The screens impacted are:
- Phamatech QuickScreen One Step Amphetamine Test,
- Accu-Stat Drugs of Abuse Home Test for Marijuana (THC),
- ADC CLIA Waived Marijuana (THC) Test,
- First Check Diagnostics LLC, First Check Home Drug Test Marijuana,
- Phamatech QuickScreen One Step THC Screening Test,
- Phamatech At Home Drug Test (Model 9078),
- Phamatech At Home Drug Test (Model 9078T),
- Worldwide Medical Corporation, First Check Home Drug Test (THC),
- Phamatech At Home Drug Test (Model 9073),
- Phamatech At Home Drug Test (Model 9073T),
- Phamatech QuickScreen One Step Cocaine Screening Test,
- Phamatech At Home Drug Test (Model 9068),
- Phamatech QuickScreen One Step Methamphetamine Test,
- DyanGen NicCheck II Test Strips,
- Mossman Associates, Inc. NicCheck I Test Strips,
- Phamatech At Home Drug Test (Model 9083),
- Phamatech QuickScreen One Step Opiate Screening Test, and
- Phamatech At Home Drug Test (Model 9133).
Do You Feel Bullied?
March 1st, 2011
Ok, this might not be the best medical office management topic.
Still, many of us who love kids have run into the dilemma of what to do about bullying. Sometimes, as adults we may face the same dilemma in the workplace.
HHS’ Health Resources and Services Administration has a campaign called Stop Bullying Now, which offers advice to Stop Bullying Now! See http://stopbullyingnow.hrsa.gov/kids/.
Patients turn to their doctors for all types of help. This may be a topic you are asked about. Having this reference on hand would be helpful.
HHS Report on ACA and State Funding
February 25th, 2011
HHS released a new report showing that the Affordable Care Act provides states with significant flexibility and resources to improve health care benefits and protect consumers. Per HHS, the law has provided or offered $2.8 billion in funding to states and more is available to help states implement new consumer protections, expand health coverage, and improve health care quality.
“The Affordable Care Act is built on the foundation of providing states with the resources and flexibility they need to build a better, more affordable health care system,” said HHS Secretary Kathleen Sebelius. “This report shows that states have what they need to continue putting comprehensive health insurance reforms in place.”
To access the entire report, visit: http://www.healthcare.gov/center/reports/states02252011a.pdf
Avoiding the eRx 2% Swing
February 24th, 2011
Time to get on board the eRx express. Even if you aren't fully sold on the advantages of electronic prescribing, failure to do so will cost you one percent of your Medicare dollars beginning in 2012. If you do participate in the program, you will get a bonus instead.
For 2012, that a two percent swing in your Medicare revenue.
CMS issued the following guidance today:
2011 Electronic Prescribing (eRx) Incentive Program Reminder-Avoiding the Adjustment
In November, the Centers for Medicare & Medicaid Services announced that, beginning in calendar year 2012, eligible professionals who are not successful electronic prescribers based on claims submitted between January 1, 2011 – June 30, 2011, may be subject to a payment adjustment on their Medicare Part B Physician Fee Schedule (PFS) covered professional services. Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorizes CMS to apply this payment adjustment whether or not the eligible professional is planning to participate in the eRx Incentive Program.
From 2012 through 2014, the payment adjustment will increase each calendar year. In 2012, the payment adjustment for not being a successful electronic prescriber will result in an eligible professional or group practice receiving 99% of their Medicare Part B PFS amount that would otherwise apply to such services. In 2013, an eligible professional or group practice will receive 98.5% of their Medicare Part B PFS covered professional services for not being a successful electronic prescriber in 2011 or as defined in a future regulation. In 2014, the payment adjustment for not being a successful electronic prescriber is 2%, resulting in an eligible professional or group practice receiving 98% of their Medicare Part B PFS covered professional services.
The payment adjustment does not apply if <10% of an eligible professional’s (or group practice’s) allowed charges for the January 1, 2011 through June 30, 2011 reporting period are comprised of codes in the denominator of the 2011 eRx measure.
Please note that earning an eRx incentive for 2011 will NOT necessarily exempt an eligible professional or group practice from the payment adjustment in 2012.
How to Avoid the 2012 eRx Payment Adjustment
Eligible professionals – An eligible professional can avoid the 2012 eRx Payment Adjustment if (s)he:
- Is not a physician (MD, DO, or podiatrist), nurse practitioner, or physician assistant as of Jun 30, 2011 based on primary taxonomy code in NPPES;
- Does not have prescribing privileges. Note: (S)he must report (G8644) at least one time on an eligible claim prior to June 30, 2011;
- Does not have at least 100 cases containing an encounter code in the measure denominator;
- Becomes a successful e-prescriber; and
- Reports the eRx measure for at least 10 unique eRx events for patients in the denominator of the measure.
Group Practices- For group practices that are participating in eRx GPRO I or GPRO II during 2011, the group practice MUST become a successful e-prescriber.
Depending on the group’s size, the group practice must report the eRx measure for 75-2,500 unique eRx events for patients in the denominator of the measure.For additional information, please visit the “Getting Started” webpage at http://www.cms.gov/erxincentive on the CMS website for more information; or download the Medicare’s Practical Guide to the Electronic Prescribing (eRx) Incentive Program under Educational Resources.
END OF CMS TRANSMITTAL
There are several free qualifying electronic eRx programs. If you would like to use Practice Fusion, you can signup through our link at http://www.practicefusion.com/ccn/kla. You will need to fax a form with copies of your DEA, etc. Instructions are available on the website.
(KLA is a certified consultant. Although this is our link for signup, we will not contact you directly. If you wish our assistance, please call or email us.)
Submitting the claims is not enough. You must also include proccedure code G8553 on your claim form with a NON HOSPITAL BASED evaluation and management code. For more details, unzip: https://www.cms.gov/ERxIncentive/Downloads/2011_eRxMeasure_ReleaseNotes_ClaimsBasedReportingPrinciples111010.zip
Charting With iPad, Android
February 22nd, 2011
For those of you that are using Practice Fusion, one of the most requested features is now available. You can now access your account from your iPhone or Android telephone/mobile device or iPad. You can now chart anywhere you have a SECURE WiFi device. In order to do this you need your free Practice Fusion account (sign up at http://www.practicefusion.com/ccn/kla) and the $29.95 LogMeIn Ignition app which is available in your App store.
RAC Auditors Approved Issue List
February 17th, 2011
Concerned about a visit from RAC auditors.
You can be a little better prepared by knowing what areas they are authorized to audit. A list of current approved issus may be found at:
http://www.connolly.com/healthcare/pages/ApprovedIssues.aspx
Each topic includes a list of states and types of providers that may be audited by topic; as well as other resources for further research.
In addition to following the education, review and reporting guidelines in your Compliance Plan, consider:
1. Print out the topics from the above website that apply to your practice,
2. Review the supporitng information,
3. Add to your compliance plan,
4. Self audit. Check our resources pages for a list of recommended external auditors,
5. Include results of audit in your Compliance notebook.
TennCare Cuts?
February 4th, 2011
Several of our Tennessee clients have expressed concerns over the TennCare cuts that may go into effect July 1.
For a summary of cuts, visit: http://www.tn.gov/tenncare/forms/tenncarewaiveramed12.pdf.
What concerns most of our clients is the eight day limit for hospital inpatient service, physician and nurse practitioner office visits and laboratory services.
Although we aren't fortune tellers, we think (and hope) the cut is unlikely.
The Affordable Care Act prohibits the reduction in eligibility for Medicaid between when the bill was passed in March 2010 and when the Act will be substantially implemented in 2014. Reducing eligibility = no federal funding. Although the amendments do not technically go to eligibility, the spirit of the Affordable Care Act was not just elibility but any reduction in benefits.
Per KHN: Governors are bristling against rules in the stimulus program and the health overhaul law that generally require them to maintain current Medicaid levels for adults until 2014, when much of the law kicks in, or risk losing federal matching funds. They say they need to be able to trim their Medicaid rolls now because their state budgets are in such dire straits – partly because stimulus funding that helped many prop up their health programs ends in June.
In Tennessee, cuts similar to those proposed for July were averted in 2010 when the hospitals agreed to a 3.5 percent fee on revenues. Hospitals will likely agree to continue the fee instead of facing the potential of no pay for Medicaid patients who exceed the eight days of inpatient visits.
Since Federal law requires Advance Notice of any change in Medicaid coverage, Tennessee put the public on notice about the proposed changes in case other funding options do not materialize.
Templates for Medicare Wellness Visits, CANS-MCI for Cognitive Impairment
January 21st, 2011
This one is going to be a long one; but it's important to your bottom line, so please take a minute to read.
Several of our primary care clients have told us that the reporting requirements for the Medicare wellness exams are so extensive they would probably elect not to do the exams.
To try to encourage our clients to conduct the exams, KLA has developed a Medicare Wellness Visit template that can be used for all your Medicare Wellness Visits from IPPE (Welcome to Medicare) to Subsequent Annual Wellness Visit.
For every primary care client for which we've run the numbers, performing the Medicare Wellness visits can mean $50,000 or more in annual income. Some of our clients would have in excess of $100,000 in additional income based on the number of Medicare patients seen by a single physician. PLUS, these visits are not subject to cost sharing, ie deductible or co-pays. By scheduling them early in the year, a practice can minimize the impact of the annual Medicare deductible on its cash flow.
Today, Family Practice Management issued a good digital article on the IPPE and Annual Wellness Visit. This article explains why, if you are a primary care provider, you NEED TO offer these services. The article includes another template for the Medicare Prevent Physical Exam. You may prefer it to the one KLA put together. It includes elements that the KLA template assumes are maintained elsewhere in your patient file such as history, allergy and medication lists.
For the official word from Medicare, visit: http://www.cms.gov/MLNMattersArticles/downloads/MM7079.pdf.
In the KLA template, there are two items that may need further explanation.
The first is a reference to Caring Connections under Advance Planning. We blogged about this site a few weeks ago. In a nutshell, it's a site that offers free, downloadable, state-specific advance planning directives.
The second is a reference to CANS-MCI under Cognitive Assessment. I borrowed the following (with permission of course) from reimbursement Guru Don Self's recent newsletter:
"...the fourth measure of the new annual Medicare exams is “Detect any Cognitive Impairment”. The Medicare program does not dictate to you HOW you detect it, but only that you do so.
There is a simple—yet very effective—method of Cognitive testing, that requires almost no staff time to accomplish, and takes away the “guesswork” that an MMSE involves. This Cognitive Testing is testing for memory, attention, response speed & processing speed and requires an average of 25 to 40 minutes of the patient’s time in your own office. This is so much easier on the patient than sending them across town, and it is very profitable for our clients.
We (Don Self) recommend and sell the Computer-Administered Neuropsychological Screen for Mild Cognitive Impairment (CANS-MCI®). This test was developed as an instrument for detection of mild cognitive impairment, that is not only self-administered (by the patient), but also is touch screen driven to practically eliminate you or your staff having to sit with the patient while they take the test. It is common knowledge that the earlier you detect the chronic disease process, the better chance you have of making a difference in the progression of the disease. Neuropsychological or imaging evaluations early enough in the pre-clinical phase of the disease enhance the effectiveness of treatments.
It is possible for you to provide this service to your patients and get the point-of-care information to make medical decisions, without having a capital outlay. One tool we have added to our arsenal in helping physicians is the CANS-MCI test and it does not require any capital investment. Medicare (as well as CIGNA, UHC, BCBS and every other carrier we have reviewed) pays for the following codes when done in a physician office, which is part of the CANS-MCI test:
96103: Psychological testing admin. by computer $57.44
96120: Neuro-psych test administered with computer $89.43
The average Medicare allowed in the country are shown, so this means that Medicare’s allowed in your area will be about $146.87."
If you want to learn more about CANS-MCI, please contact Don directly at: donself [at] donself [dot] com.
By 2015, Medicare is scheduled to transition to a patient managed rather than fee-for-service model. By keeping up each step of the way, your practice will be ready for the transition.
Please share this information with other primary care providers. Together, each one of us is stronger.
Are Your Informed Consent Forms Bullet Proof?
January 17th, 2011
Some patients are litigious.
It’s an unfortunate fact of a doctor’s life that they must look at every patient as a possible plaintiff in a malpractice suit.
And, juries like to compensate those with injuries whether or not the doctor has done anything wrong.
I’m often reminded of the story told by a friend who served on a jury a few years ago. The plaintiff had stepped off a well-marked curb and fell as she was leaving a restaurant. The elderly plaintiff broke her leg in several places and sued the restaurant.
Although the evidence was incontrovertible that the restaurant had marked the curb and provided a nearby ramp, my friend said she still was tempted to vote in favor of the plaintiff just because the restaurant “could afford to pay.”
How prepared are you if through no fault of your own a procedure has a negative outcome?
As part of your practice’s New Year’s resolutions, why not review your Informed Consent forms and accompanying handouts. Are they comprehensive?
Many of the specialty societies are now providing language that may be included for you procedures. Check the handouts you give your patients about procedures to ensure they include:
- A description of the procedure,
- Possible risks and benefits of the procedure,
- Alternatives to the procedure, if any,
- Aftercare instructions including contact information should the patient need assistance,
- Estimated cost of the procedure.
We have a rudimentary form for your use at:
http://www.klahealthcare.com/sites/240/uploaded/files/Authorization_for_Surgery.pdf
This form is designed to be accompanied with handouts explaining the above.
The form also includes permission to film the procedures.
Advance Care Directives
January 12th, 2011
Part of Medicare's requirements for its new Annual Wellness Visit is the opportunity for the patient to discuss advanced care planning with a provider.
Yes, it seems providers are now expected to be doctors and lawyers.
Thanks to caringinfo.org, the task need not be daunting. This website has many tools to assist your patient with advanced care planning including free downloadable state specific advance directives with comprehensive instructions on how to accurately complete it.
If your patient is computer-literate, you may provide him/her with a link to the site. If you patient needs a little help in the computer usage department, you can download the forms for the patient to complete.
The site offers many additional tools for your patient and caregivers such as brochures on how to choose an agent and on how to be an agent.
If your patient has an Advance Care Directive, please obtain a copy for the patient's file. Alternately, the patient my choose to use a free service such a Google Health that allows the directive to be stored securely online. Login information can be given to health care providers as needed.
In any case, a provider needs to know if there is and Advance Care Directive. If there is, who is the patient's agent for healthcare decisions.
National Safety Goals - Medication Reconciliation
January 7th, 2011
How long has it been since you've reviewed your medication reconciliation procedures?
Although most of us associate the Joint Commissions with the hospitals: their authority extends further. If you do surgery in your office, you too are subject to their review.
Before you stop reading, believing this doesn't apply to you, consider:
- Do you do injections?
- Do you do lesion removals?
- Do you sometimes sew up a cut?
Technically, all of the above are surgeries.
New medication reconciliation standards will go into effect July 1, 2011, The draft copy of the standards as well as other safety goals related to the office surgery practice may be found at:
http://www.jointcommission.org/obs_2011_npsgs/.
Even if a visit from the joint commissions to your practice is unlikely, keep in mind that standards such as these can and are used to show a reasonable standard of care in malpractice cases.
Day One for EHR Bonuses
January 3rd, 2011
Today is the first day providers may sign up for bonuses available for the meaningful use of EHR.
The final regs were published today about requirements to qualify for incentive bonsues for EHR. The 277 page document basically says stop gap measures will continue through 2011.
The rule describes the permanent certification program for electronic health records (EHR), and how organizations become authorized to test and certify EHR technology.
ONC plans to replace the temporary program currently in effect with the permanent version January 1, 2012, but it also say it will delay the date if necessary.
To learn more about the Medicare and Medicaid bonus program, as visit the CMS website at: https://www.cms.gov/EHRIncentivePrograms/.
To determine if you are eligible for either the Medicare or Medicaid EHR incentive programs visit: https://www.cms.gov/EHRIncentivePrograms/15_Eligibility.asp.
Changes for ESRD Capitation for 2011
December 30th, 2010
If your receive Medicare Monthly Capitation Payments (MCPs) to manage ESRD patients remember these requirements for ESRD beneficiaries to access ESRD-related drugs that go into effect January 1, 2011. It's important to follow the new rules in order for your patients to receive ESRD-related drugs.
MCP physicians and practitioners must:
- Indicate on an ESRD patient’s prescription when a medication is not ESRD-related so payment for these non-ESRD-related medications is made under Part D.
- If a lab is performed in office and is not related to ESRD, please append modifer AY and supply a non ESRD diagnosis.
ESRD facilities must:
- Instruct patients to obtain their ESRD-related medications from ESRD facility-contracted pharmacies to ensure that pharmacies receive payment from the ESRD facilities and patients receive their medications with no financial obligation.
- Instruct physicians and practitioners who receive MCPs to manage ESRD patients, to direct their patients to use ESRD facility-contracted pharmacies to ensure that pharmacies receive payment from the ESRD facilities and patients receive their medications.
- Indicate on ESRD claims each ESRD-related drug (except for composite rate drugs) furnished to an ESRD patient either directly or through a prescription filled by a pharmacy.
- Use the AY modifier on ESRD claims for each non-ESRD-related drug furnished to an ESRD patient.
- Instruct home dialysis patients currently under Method II about any changes in the arrangements for ESRD-related home dialysis supplies and that patients no longer have any financial obligation to suppliers for ESRD-related supplies on or after January 1, 2011.
ESRD patients may obtain covered Part D non-ESRD-related prescription drugs from a network pharmacy or an out-of-network pharmacy in accordance with Part D rules.
For more information visit: http://www.cms.gov/MLNMattersArticles/downloads/MM7064.pdf
Also, remeber beginning January 1, 2011 a home-based dialysis patient must have one face-to-face visit with a provider per month. Visit our prior blog post for details.
Are Practices Really Exempt from Red Flag Rules?
December 29th, 2010
We received this today from healthcare attorney, Charles Key.
Clients and Friends:
According to a recent posting by the American Medical Association, President Obama on December 18, 2010 signed into law the "Red Flag Program Clarification Act of 2010," passed by both houses of Congress December 8. According to the AMA summary, the law clarifies the application of the controversial Federal Trade Commission "Red Flags Rule" so as to apply only to creditors who, in the ordinary course of business, either (1) obtain consumer reports in connection with credit transactions, (2) furnish information to credit reporting agencies, or (3)make loans. Most medical practices (as well as law firms, accounting firms, and other professional practices) will thus not be subject to the Red Flags Rule as clarified by the new law. Those that are subject to the Rule must comply by this Friday, December 31, 2010.
The Red Flags Rule requires non-exempt creditors to adopt written policies designed to detect, prevent, and (where found) mitigate identity theft. For more information, see the AMA's full posting at http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/practice-management-center/data-security/red-flags-rule.shtml.
CharlesCharles Key | Wyatt, Tarrant & Combs, LLP | 1715 Aaron Brenner Drive, Suite 800 | Memphis, Tennessee 38120-4367 | Direct dial (901) 537-1133 | Mobile (901) 481-3321 | Fax (901) 537-1010 | www.wyattfirm.com
Debridement Codes "Excised" for 2011
December 27th, 2010
For 2011, the AMA has expanded the Integumentary System subsection to include new guidelines to define debridement. The Excision and Debridement subsection (11000-11047) went through extensive changes.
The familiar codes 11040 and 11041 are gone. In a parenthetical note under the codes' old location is a note reading, "For debridement of skin, i.e., epidermis and/or dermis only, see 97597, 97598.”
97597 and 97598 are wound care codes that require active wound care procedures to remove devitalized and/or necrotic tissue and promote healing. 97597 is for 20 square centimeters or less. 97598 is an add on code. 97598 is used in addition to 97597 for each additional 20 square centimeters or part thereof. These codes are not to be used in addition to codes 11042 through 11047.
The documentation to support selective 97597 and 97598 should include the following:
- Types of instruments used for selective debridement (i.e. high-pressure waterjet, scissors, scalpel, forceps);
- Assessment of the wound including drainage, color, texture, temperature, vascularity, condition of surrounding tissue, and size of the area to be targeted for debridement.
If the provider treats with a nonselective method (such as a whirlpool) prior to using selective debridement, for the wound during the same visit, then only the selective debridement is reimbursable. A modifier 59 should only be used 59 if two different wounds are treated with the different modalities. Clearly note the location of each wound and the treatment associated with each wound.
CPT code 11042 has been revised to read “debridement, subcutaneous tissue (includes epidemis and dermis, if performed); first 20 square centimeters or less.” Add on code 11045 is new and covers each additional 20 square centimeters of part thereof.
11043 is used for the first 20 square centimeters muscle and/or fascia. 11046 is the add on code for each additional 20 square centimeters of part thereof.
Note that the add on codes are frequently out of numerical order.
Debridement of burn wounds remain 16020-16030.
Changed Requirements for Home Health Care Certification for 2011
December 20th, 2010
Beginning January 1, 2011 a physician who certifies Medicare home health services must see the patient within 90 days before or 30 days after the home health certification. Although a NPP still cannot certify a patient for home health services, the required exam may be provided by a NPP who works incidental to or in collaboration with the physician.
The physician will be required to document when he had a face-to-face encounter with the patient and to document how the patient’s clinical condition supports the need for skilled home health services as part of the certification form. Attachments to the form are also acceptable. Thus a physician may wish to include the required elements in his note for the date of service to support the certification. The note could then be attached to the certification form.
The new requirements does have some positives for physicians:
- A NPP may provide the face-to-face encounter,
- A hospitalist may certify the need for home health care based on their face to face contact with the patient in the hospital, establish and sign the plan of care the transfer care to another physician, and
- In rural areas, the law allows the face-to-face encounter to occur via telehealth, in an approved originating site.
To learn more visit the Medicare Learning Network website at: http://www.cms.gov/MLNMattersArticles/downloads/SE1038.pdf.
Home health care certifications and recertifications is an area frequently missed by physicians. Care
In order to bill for managing patients in home health care, you simply use code G0180 for initial certification, and G0179 for each follow up. Certification and recertification pays approximately $30 to $40.
If you document phone calls and faxes, and keep copies of the certifications in the chart, you can bill for these services. The payment for managing these patients is approximately $70 per month.
Of course, always document.
Care Plan Oversight activities that are BILLABLE include as part of Care Plan Oversight include:
- Communication with interdisciplinary team and pharmacist, including phone calls or other verbal communication.
- Review of patient status reports.
- Modification of plan of care, including the review and signing of modification orders.
- Review of lab results, reports, and records.
Care Plan Oversight billing criteria:
- Patient must be receiving Medicare covered home health services.
- Physician must document that 30 minutes or more of supervision to the patient’s care has occurred
- Physician must have seen the patient at least once during the six-month period prior to Care Plan Oversight billing.
- Physician is the only physician billing for Care Plan Oversight for the particular patient.
- The physician billing for Care Plan Oversight must be the physician who signed the home health plan of care or the physician who was received the "hand off" for monitoring the care..
Other considerations:
- Always retain the home care Plan of Treatment in the patient’s medical record.
- Minimum billable time is 30 cumulative minutes dedicated to the patient’s care over a 30-day period. Document the time in the patient's medical record.
- Care Plan Oversight activities cannot relate to post-op periods in global surgery packages UNLESS patient is being monitored for an unrelated condition.
To help you capturing Home Health Care Plan Charges, KLA has developed a tracking form for your use.
Services With Waived Deductibles and Coinsurance for 2011
December 15th, 2010
Yes, we're starting to sound like a broken record...but this is so important to your bottom line.
If you want to avoid a little of the cash flow crunch in early 2011, book and bill services with waived coinsurance and deductible.
We've found a list CMS sent to its Contractors about implementing this. Yes, we will eventually see a MLN Matters release on it; but we haven't yet.
To see the COMPLETE list of services for which Medicare will be waiving deductibles and coinsurance, visit:
Deductible and Coinsurance for Preventive Services
This is good information to share with your provider friends.
Annual Wellness Visit (AWV), Including Personalized Prevention Plan Services (PPPS)
December 14th, 2010
We waited and waited on a Medicare Learning Network publication on the annual wellness visits before publishing yesterday's newsletter. Guess what? Today one was finally published!
Two new HCPCS codes, G0438 - Annual wellness visit, includes a personalized prevention plan of service (PPPS), first visit, (Short descriptor – Annual wellness first) and G0439 - Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit, (Short descriptor – Annual wellness subseq) will be implemented January 1, 2011
You can view the official "word" from Medicare on the new wellness exam benefits at: http://www.cms.gov/MLNMattersArticles/downloads/MM7079.pdf.
The article details nicely what is required to be documented for the visit. Remember, the wellness visits begin after a patient has completed one year with Medicare. The first year the patient should be given the IPPE exam. For information on documenting that exam visit: http://www.cms.gov/MLNProducts/Downloads/MPS_QRI_IPPE001a.pdf.
A patient's first Annual Wellness Visit pays approximately $115 and is not subject to either coinsurance or deductibles. Subsequent Annual Wellness Visits pay about $77.
Remember too that this is a requirement of the Affordable Care Act. Unless an insurance company has applied for or falls under an exception, similar benefits should be available for ALL PATIENTS!
Health Care Law Found Unconstitutional by Federal Judge
December 13th, 2010
Today's New York Times reports:
"A federal district judge in Virginia ruled on Monday that the keystone provision in the Obama health care law is unconstitutional, becoming the first court in the country to invalidate any part of the sprawling act and insuring that appellate courts will receive contradictory opinions from below." Judge Henry Hudson declined "the plaintiff's request to freeze implementation of the law pending appeal, meaning that there should be no immediate effect on the ongoing rollout of the law."
Judge Hudson sought to sever those portions of the health care law that violated the Constitution rather than striking down the entire statute. The provision in question would require everyone to have health insurance or pay a fine.
The opinion states: "'Neither the Supreme Court nor any federal circuit court of appeals has extended Commerce Clause powers to compel an individual to involuntarily enter the stream of commerce by purchasing a commodity in the private market. In doing so, enactment (of the mandate to purchase insurance) exceeds the Commerce Clause powers vested in Congress under Article I (of the Constitution)"
To date, two other District Courts, one also in Virginia and another in Michigan, have upheld the law.
Contradicting opinions from different districts paves the way for a hearing in the U.S. Supreme Court.
There are more suits pending.
Congress Passes One Year SGR Fix. President Obama Promises to Sign
December 9th, 2010
The House of Representatives passed legislation this morning that prevents a 24.9 percent Medicare payment cut to providers that was scheduled to take effect on January 1, 2011 under the SGR formula. The measure unanimously passed the Senate yesterday. There was bipartisan support for the bill.
The extension will allow Congress and the White House to revisit the SGR formula responsible for the budgeted cuts. With the first of the Baby Boomers reaching Medicare age during 2011, the way physicians are paid must be addressed or even more substantial cuts than those forecast are inevitable.
Per the AMA, "The joint efforts of AARP, the military community, AMA and other physician groups helped make this one year delay a reality for patients and their physicians.”
The President supports the bill and it should be signed into law shortly.
Finally - Medical Practices Aren't Creditors
December 7th, 2010
It's not completely official yet, but On December 7, the House passed the Red Flag Program Clarification Act of 2010. The Red Flags Rule requires financial institutions and creditors to develop and implement a written identity theft program.
Several Physician organizations have lobbied to have medical providers exempted from the definition of Creditor. This legislation would exempt health care providers from the Red Flags Rule requirements that go into effect January 1, 2011.
The Senate passed similar legislation on November 30. This legislation will now be sent to the President for signature.
Despite the exemption, most providers are still required to verify the patients identity under the policies of third party payor contracts. It remains good policy to obtain picture identification of new patients.
New Q Codes Required For Billing Flu Vaccines to Medicare
December 6th, 2010
CMS has created specific HCPCS codes and payment rates for Medicare billing purposes for this flu season. Effective for claims with dates of service on or after January 1, 2011, CPT code 90658 will no longer be paid by Medicare. As of October 1, 2010, the following new influenza Q codes became payable by Medicare: Q2035 (Afluria), Q2036 (Flulaval), Q2037 (Fluvirin), Q2038 (Fluzone), and Q2039 (Not Otherwise Specified flu vaccine).
However, providers using these codes will not be paid for using these codes immediately. The Medicare contractors’ have until February 7, 2011 to program their software to accept the codes. Medicare institutional providers also have the option to hold their claims containing the new influenza Q codes until February 7, 2011. Best advice: vaccinate before the end of the year and use the old, still accepted codes. After January 1, use the new Q codes.
For further information, please see http://www.cms.gov/Transmittals/2010Trans/list.asp.
For 2011 Home Dialysis Patients Must Have Face to Face Visit
December 1st, 2010
Effective January 1, 2011, the dialysis monthly capitation payment requires the provider to have at least one face-to-face patient visit per month with the patient for the home dialysis MCP service as described by CPTs 90963, 90964, 90965, and 90966.
Medicare contractors may waive the requirement for a monthly face-to-face visit for the home dialysis MCP service on a case by case basis; for example, when the nephrologist’s notes indicate that the physician actively and adequately managed the care of the home dialysis patient throughout the month.
For the Medicare Learning Matters article on topic visit:
PreAuthorizations Impact Care Negatively
November 26th, 2010
The AMA has recently published findings from a survey querying over 2,400 physicians on the impact preauthorizations with an insurance company had on overall patient care. For those endlessly frustrated by obtaining such preauthorizations, the results were no surprise.
According to the story at http://www.ama-assn.org/ama/pub/news/news/survey-insurer-preauthorization.shtml:
- More than one-third (37%) of physicians experience a 20 percent rejection rate from insurers on first-time preauthorization requests for tests and procedures. More than half (57%) of physicians experience a 20 percent rejection rate from insurers on first-time preauthorization requests for drugs.
- Nearly half (46%) of physicians experience difficulty obtaining approval from insurers on 25 percent or more of preauthorization requests for tests and procedures. More than half (58%) of physicians experience difficulty obtaining approval from insurers on 25 percent or more of preauthorization requests for drugs.
- Nearly two-thirds (63%) of physicians typically wait several days to receive preauthorization from an insurer for tests and procedures, while one in eight (13%) wait more than a week. More than two-thirds (69%) of physicians typically wait several days to receive preauthorization from an insurer for drugs, while one in ten (10%) wait more than a week.
Three New Subsequent Observation Codes for 2011
November 22nd, 2010
CPT 2011 has a new section for Subsequent Observation Codes in the Hospital Care sections. Observation Codes are a hot topic with the OIG. It's not enough for the patient to be in the observation unit, the provider must also document the level of care appropriately.
The new codes are similar to the inpatient subsequent care codes, in that they include an interval history, a history that “focuses on the period of time since the physician last performed an assessment of the patient” according to the CPT Assistant.
The new codes are defined by the AMA's CPT as follows:
- 99224 -- Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: Problem focused interval history; problem focused examination; medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit.
- 99225 -- Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient’s hospital floor or unit.
- 99226 -- Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; a detailed examination; medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/ or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient’s hospital floor or unit
A Little New, More Old for Sleep Studies for 2011
November 17th, 2010
There are two new codes for unattended sleep studies for 2011 that pay significantly more than attended sleep studies by CMS.
According to the AMA’s 2011 CPT Code Handbook the full narrative for the new CPT Codes are:
95800: Sleep Study, unattended simultaneous recording, heart rate, oxygen saturation, respiratory analysis (eg by airflow or peripheral arterial tone), and sleep time.
95801: Sleep study unattended minimum of heart rate, oxygen saturation and respiratory analysis (eg by airflow or peripheral arterial tone).
The codes differ slightly. For example, 95800 includes recording sleep time. 95801 captures a minimum heart rate.
The National CMS rates for these codes is high. Currently 95800 allows $1,000 and 95801 allows $1,700. Professional societies, including the AMA, are questioning these reimbursement rates and have asked for clarification. Expect a correction.
Beware before using these codes with private insurers. Many Blue Cross carriers, for example, have already announced the will not pay these codes and will consider these codes to be excluded by contract.
We still only have temporary code for home study tests. The codes remain:
G0398: Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG/heart rate, airflow, respiratory effort and oxygen saturation. Approximate 2011 Reimbursement: $115.
G0399: Home sleep study test (HST) with type II portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation. Approximate 2011 Reimbursement: $115.
G0400: Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels. Approximate 2011 Reimbursement: $115.
As for the traditional sleep lab codes, some will increase. Others, decrease. There is decrease in the physician value of sleep studies and an increase in the malpractice component. The technical component went up in some cases and down in others.
Following are the additional sleep lab codes for 2011 and their 2011 “national” reimbursement amount and the change from 2010 to 2011.
2011 National Rate/Change
95803 Actigraphy testing $176.25, +$55.68
95803-TC Actigraphy testing $125.74, +$55.31
95803-26 Actigraphy testing $ 50.52, +$ 0.37
95805 Multiple sleep latency test $ 446.90, +$51.25
95805-TC Multiple sleep latency test $379.79, +$77.06
95805-26 Multiple sleep latency test $ 67.11, -$25.81
95806 Sleep study unattend & resp effort $198.38, -$ 5.90
95806-TC Sleep study unattend & resp effort $130.16, +$ 8.11
95806-26 Sleep study unattend & resp effort $ 68.21, -$14.02
95807 Sleep study attended $511.80, +$32.45
95807-TC Sleep study attended $443.21, +$45.35
95807-26 Sleep study attended $ 68.58, -$12.91
95808 Polysomn 1-3 channels $707.59, +$38.72
95808-TC Polysomn 1-3 channels $609.88, +$71.90
95808-26 Polysomn 1-3 channels $ 97.71, -$33.19
95810 Polysomnograph 4 or more $756.26, -$12.91
95810-TC Polysomnograph 4 or more $619.83, +$23.23
95810-26 Polysomnograph 4 or more $136.43, -$36.14
95811 Polysomnography w/cpap $816.00, -$32.08
95811-TC Polysomnography w/cpap $673.67, +$10.70
95811-26 Polysomnography w/cpap $142.33, -$42.77
Sleep studies, particularly hospital based sleep studies, have become a push-button topic for the Office of Inspector General (OIG). So far during 2010, the OIG has issued three advisories regarding sleep studies. These deal primarily with the relationship between the provider of sleep studies and the hospital.
Also RAC auditors have been charged with identifying improper place of service and improperly billed services. Thus, knowing which code properly represents the sleep study you perform is important.
New Coding for Administration of Immunization for 2011
November 15th, 2010
Effective January 1, 2011, immunization codes 90465-90468 will be gone.
Replacing them are new codes 90460 and add-on code 90461. The new codes recognize the counseling given to pediatric patients and their families concerning the risks and possible side effects of the immunizations.
Counseling may be given by the physician or qualified health care professional such as a nurse practitioner or a physician assistant at the time of service. Registered nurses and medical assistants are not qualified health care professionals. Counseling provided by them do not qualify for 90460 and 90461.
Compliance Alert: Be sure to record a note about the counseling component associated with immunization as these are component of the CPT code definition. Also, avoid charging a separate evaluation and management code for the visit unless significant, medically necessary services are provided.
Per CPT, the new codes are defined as:
90460 - Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component.
+90461 each additional vaccine/toxoid component (List separately in addition to code for primary procedure)
If counseling is NOT provided, codes 90471 through 90474 should be used instead.
Codes 90460 and add-on code 90461 are reported per vaccine or toxoid component. Per CPT notes a component is a single antigen in a vaccine that prevents disease caused by a single organism. Thus if a vaccine contains multiple antigens, the vaccine is a combination vaccine.
Multiple units of code 90460 may be reported for each first vaccine or toxoid component administered. No modifier should be required when reporting multiple first components. 90460 applies to combination vaccines and to single component vaccines such as influenza. Code 90461 is an add-on code reported for each additional vaccine component administered.
Modifiers are not required for multiple vaccines.
Coding Example:
The following example of the use of the new administrative codes is from the AAFP website:
An 11-year old girl presents for a preventive visit (99393). In addition, the child and her mother are counseled by the physician on risks and benefits of HPV (90649), Tdap (90715) and seasonal influenza administers each vaccine, completes chart documentation and vaccine registry entries, and verifies there is no immediate adverse reaction.
CPT Codes reported are:
99393 - Preventive Service
90649 - HPV vaccine
90460 - Administration first component (1 unit)
90715 - Tdap vaccine
90460 - Administration first component (1 unit)
90461 - 2 additional components (2 units)
90660 - Influenza vaccine, live, for intranasal use
90460 - Administration first component (1 unit)
2011 CPT Introduces New Ophthalmological Codes, Revises Others
November 12th, 2010
The following new and revised codes will be listed in the 2011 CPT Coding Manual and are effective January 1, 2011.
Code 92135 was one identified by the AMA as subject to misuse. Further, the use of this testing has grown substantially. Thus the code has been deleted and replaced with the following:
- 92132 - Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral (Replaces 0187T)
- 92133 - Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve
- 92134 - Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina
The Ophthalmoscopy codes have also been revised to include the following codes to report remote imagining for screening retinal disease and management of active retinal disease. Per AMA's Changes: An Insider's View: "These codes are required to meet the needs of diabetic retinopathy screening programs, which provide remote imaging and data sumission to a centralized reading center."
- 92227 - Remote imaging for detection of retinal disease (e.g., retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral. Do not report this code with 92002-92014, 92133, 92134, 92134, 92250, 92228 or with an E&M based on a single organ system.
- 92228 - Remote imaging for monitoring and management of active retinal disease (e.g., diabetic retinopathy) with physician review, interpretation and report, unilateral or bilateral. Do not report this code with 92002-92014, 92133, 92134, 92134, 92250, 92228 or with an E&M based on a single organ system
Additional ophthalmological coding changes/revisions include:
- 66174 - Transluminal dilation of aqueous outflow canal; without retention of device or stent (Replaces 0176T)
- 66175 - Transluminal dilation of aqueous outflow canal; with retention of device or stent (Replaces 0177T)
- 65778 - Placement of amniotic membrane on the ocular surface for wound healing; self-retaining
- 65779 - Placement of amniotic membrane on the ocular surface for wound healing; single layer, sutured
- 65780 - Ocular surface reconstruction; amniotic membrane transplantation, multiple layers
- 66761 - Iridotomy / iridectomy by laser surgery (e.g., for glaucoma) (per session)
New CLIA Waived Labs for 2010
November 8th, 2010
CMS has issued an MLN Matters article about new CLIA Waived Labs for 2010. You may view the article at:
http://www.cms.gov/MLNMattersArticles/downloads/MM7184.pdf.
The new labs which may be reported by waived labs by adding the modifer QW are:
CPT Code Effective Date Description
G0430QW January 1, 2010 American Screening Corp. OneScreen Drug Test Cups
84443QW March 2, 2010 Aventir Biotech LLC, Forsure TSH Test {Whole Blood}
84443QW March 4, 2010 BTNX, Inc Rapid Response TSH Test Cassette
G0430QW April 21, 2010 CLIAwaived, Inc. Rapid Drug Test Cup {OTC}
G0430QW April 21, 2010 Millennium Labs Clinical Supply Multi-Drug Pain Med Screen Cup
G0430QW May 10, 2010 US Diagnostics ProScreen Drugs of Abuse Cup {OTC}
G0430QW July 1, 2010 Ameditech, Inc ImmuTest Drug Screen Cup
G0430QW July 4, 2010 Quik Test USA, Inc. Multi-Drug of Abuse Urine Test
G0430QW July 4, 2010 Screen Tox Multi-Drug of Abuse Urine Test
82274QW,G0328QW July 8, 2010 Consult Diagnostics iFOBT
G0430QW July 19, 2010 Alfa Scientific Designs Drug of Abuse Urine Cassette Test
G0430QW July 19, 2010 Alfa Scientific Designs Drug of Abuse Urine Cup Test
G0430QW August 18, 2010 American Screening Corp. Reveal Multi-Drug Test Cup
87880QW August 18, 2010 PSS Consult Diagnostics Strep A Dipstick
Many of these drug testing kits are available over the counter should a parent wish to perform drug tests in the privacy of the home.
For a complete list of waived tests visit: https://www.cms.gov/CLIA/downloads/waivetbl.pdf
2011 CPT Changes
November 5th, 2010
This excellent recap of 2011 changes is from http://codingahead.blogspot.com/2010/11/2011-cpt-code-changes.html
2011 CPT CODE CHANGES
Evaluation and Management – 3 New Codes
99224 - Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: Problem focused interval history; Problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient’s hospital floor or unit.
99225 - Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient’s hospital floor or unit
99226 - Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient’s hospital floor or unit.
Integumentary System – 3 New & 2 Deleted codes
New CPT codes (Add-on Codes)
11045 - Debridement Subcutaneous Tissue, each additional 20 sq cm
11046 - Debridement Muscle/Fascia, each additional 20 sq cm
11047 - Debridement Bone, each additional 20 sq cm
Deleted codes
11040 & 11041 Debridement; skin; partial & full thickness
Musculoskeletal System – 5 New Codes
22551 - ARTHRD ANT INTERBODY DECOMPRESS CERVICAL BELW C2
22552 - ARTHRD ANT INTERDY CERVCL BELW C2 EA ADDL NTRSPC
29914 - ARTHROSCOPY HIP W/FEMOROPLASTY
29915 - ARTHROSCOPY HIP W/ACETABULOPLASTY
29916 - ARTHROSCOPY HIP W/LABRAL REPAIR
Respiratory System – 4 New Codes
31295 - NSL/SINUS NDSC SURG W/DILAT MAXILLARY SINUS
31296 - NSL/SINUS NDSC SURG W/DILAT FRONTAL SINUS
31297 - NSL/SINUS NDSC SURG W/DILAT SPHENOID SINUS
31634 - BRONCHOSCOPY BALLOON OCCLUSION
Cardiovascular System – 20 New & 23 Deleted
New CPT codes
33620 - APPLICATION RIGHT & LEFT PULMONARY ARTERY BANDS
33621 - TTHRC CATHETER INSERT FOR STENT PLACEMENT
33622 - RECONSTRUCTION COMPLEX CARDIAC ANOMALY
37220 - REVASCULARIZATION ILIAC ARTERY ANGIOP 1ST VSL
37221 - REVSC OPN/PRQ ILIAC ART W/STNT PLMT & ANGIOP UNI
37222 - REVASCULARIZATION ILIAC ART ANGIOP EA IPSI VSL
37223 - REVSC OPN/PRQ ILIAC ART W/STNT & ANGIOP IPSI VSL
37224 - REVSC OPN/PRG FEM/POP W/ANGIOPLASTY UNI
37225 - REVSC OPN/PRQ FEM/POP W/ATHRC/ANGIOP SM VSL
37226 - REVSC OPN/PRQ FEM/POP W/STNT/ANGIOP SM VSL
37227 - REVSC OPN/PRQ FEM/POP W/STNT/ATHRC/ANGIOP SM VSL
37228 - REVSC OPN/PRQ TIB/PERO W/ANGIOPLASTY UNI
37229 - REVSC OPN/PRQ TIB/PERO W/ATHRC/ANGIOP SM VSL
37230 - REVSC OPN/PRQ TIB/PERO W/STNT/ANGIOP SM VSL
37231 - REVSC OPN/PRQ TIB/PERO W/STNT/ATHR/ANGIOP SM VSL
37232 - REVSC OPN/PRQ TIB/PERO W/ANGIOPLASTY UNI EA VSL
37233 - REVSC OPN/PRQ TIB/PERO W/ATHRC/ANGIOP UNI EA VSL
37234 - REVSC OPN/PRQ TIB/PERO W/STNT/ANGIOP UNI EA VSL
37235 - REVSC OPN/PRQ TIB/PERO W/STNT/ATHR/ANGIOP EA VSL
38900 - INTRAOP SENTINEL LYMPH ID W/DYE NJX
Deleted Codes
35454 – 35474 Transluminal balloon angioplasty
35480 - 35495 Transluminal peripheral atherectomy
39520 - 39531 Repair, diaphragmatic hernia
Digestive System – 18 New & 4 Deleted
New CPT codes
43283 - LAPS ESOPHAGEAL LENGTHENING ADDL
43327 - ESOPG/GSTR FUNDOPLASTY W/LAPT
43328 - ESOPG/GSTR FUNDOPLASTY W/THORCOM
43332 - RPR PARAESOPH HIATAL HERNIA W/LAPT W/O MESH
43333 - LAPT RPR PARAESOPH HIATAL HERNIA W/ MESH
43334 - RPR PARAESOPH HIATAL HERNIA W/THORCOM W/O MESH
43335 - RPR PARAESOPH HIATAL HERNIA W/THORCOM W/MESH
43336 - RPR PARAESOPH HIATAL HERNIA THORCOABDOM W/O MESH
43337 - RPR PARAESOPH HIATAL HERNIA THORCOABDOM W/MESH
43338 - ESOPHAGUS LENGTHENING
43753 - GASTRIC TUBE PLMT W/ASPIR & LAVAGE
43754 - GASTRIC TUBE DX PLMT W/ASPIR 1 SPECIMEN
43755 - GASTRIC TUBE DX PLMT W/ASPIR MULT SPECIMENS
43756 - DUODENAL TUBE DX PLMT W/IMG GID 1 SPECIMEN
43757 - DUODENAL TUBE DX PLMT W/IMG GID MULT SPECIMEN
49327 - LAPS W/INSERTION NTRSTL DEV W/IMG GID 1+
49412 - PLMT INTRSTL DEV OPN W/IMG GID 1+
49418 - INSJ INTRAPERITONEAL CATHETER W/IMG GID
Deleted Codes
43324 - Esophagogastric fundoplasty (eg, Nissen, Belsey IV, Hill procedures)
43325 - Esophagogastric fundoplasty; with fundic patch (Thal-Nissen procedure)
43600 - Biopsy of stomach; by capsule, tube, peroral (1 or more specimens)
49420 - Insertion of intraperitoneal cannula or catheter for drainage or dialysis; temporary
Urinary System – 1 New Code
53860 - Transurethral Radiofrequency Treatment for Stress Incontinence
Female Genitourinary System – 1 New Code
57156 - Insertion of Vaginal Brachytherapy Device
Nervous System – 8 New & 2 Deleted codes
New CPT Codes
61781 - Stereotactic Computer Assisted PX IDRL CRNL
61782 - Stereotactic Computer Assisted PX XDRL CRNL
61783 - Stereotactic Computer Assisted PX SPINAL
64566 - POST TIB NEUROSTIMULATION PRQ NEEDLE ELECTRODE
64568 - INC IMPLTJ CRNL NRV NSTIM ELTRDS & PULSE GENER
64569 - REVISION/REPLMT NSTIM CRNL ELTRDS
64570 - REMOVAL CRNL NRV NSTIM ELTRDS & PULSE GENERATOR
64611 - CHEMODENERV PAROTID & SUBMANDIBL SALIVARY GLANDS BI
Deleted CPT codes
61795 - Stereotactic computer-assisted volumetric (navigational) procedure, intracranial, extracranial, or spinal (List separately in addition to code for primary procedure)
64573 - Incision for implantation of neurostimulator electrodes; cranial nerve
Eye and Ocular Adnexa – 4 New Codes
65778 - PLACE AMNIOTIC MEMB OCULAR SURFACE SELF RETAIN
65779 - PLACE AMNIOTIC MEMBRANE OCULAR SURFACE SUTURED
66174 - TRLUML DILAT AQUEOUS CANAL W/O DEV/STNT
66175 - TRLUML DILAT AQUEOUS CANAL W/DEV/STNT
Radiology – 5 New Codes
74176 - CT ABD & PELVIS W/O CONTRAST
74177 - CT ABD & PELVIS W/CONTRAST
74178 - CT ABD & PELVIS W/O CONTRST 1+ BODY REGNS
76881 - US EXTREMITY NON-VASC REAL-TIME IMG COMPL
76882 - US EXTREMITY NON-VASC REAL-TIME IMG LMTD
Pathology & Laboratory–15 New & 13 Deleted codes
New CPT codes
80104 - DRUG SCRN QUAL 1+ CLASS NONCHROMOTOGRAPHIC EA
82930 - GASTRIC ACID ANALYIS W/PH EA SPECIMEN
83861 - MICROFLUID ANALYSIS TEAR OSMOLARITY
84112 - PLACENTAL ALPHA MICROGLOBULIN C/V QUAL
85598 - PHOSPHOLIPID NEUTRALIZATION HEXAGONAL
86481 - TB ANTIGEN RESPONSE GAMMA INTERFERON T-CELL SUSP
86902 - BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA
87501 - INFECTIOUS AGENT DNA/RNA INFLUENZA EA TYPE
87502 - INFECTIOUS AGENT DNA/RNA INFLUENZA 1ST 2 TYPES
87503 - NFCT AGENT DNA/RNA INFLUENZA 1+ TYPES EA ADDL
87906 - NFCT GEXYP DNA/RNA HIV 1 OTHER REGION
88120 - CYTP INSITU HYBRID URINE SPEC 3-5 PROBES EA MNL
88121 - CYTP INSITU HYBRID URNE SPEC 3-5 PROBES CPTR EA
88177 - CYTP C/V AUTO THIN LYR PREPJ ADEQUACY EA EVAL
88363 - EXAM & SELECT ARCHIVE TISSUE MOLECULAR ANALYSIS
88749 - UNLISTED IN VIVO LAB SERVICE
Deleted codes
82926 - Gastric acid, free and total, each specimen
82928 - Gastric acid, free or total, each specimen
86903 - Blood typing; antigen screening for compatible blood unit using reagent serum, per unit screened
89100 - Duodenal intubation and aspiration; single specimen (eg, simple bile study or afferent loop culture) plus appropriate test procedure
89105 - Duodenal intubation and aspiration; collection of multiple fractional specimens with pancreatic or gallbladder stimulation, single or double lumen tube
89130 - Gastric intubation and aspiration, diagnostic, each specimen, for chemical analyses or cytopathology;
89132 - Gastric intubation and aspiration, diagnostic, each specimen, for chemical analyses or cytopathology; after stimulation
89135 - Gastric intubation, aspiration, and fractional collections (eg, gastric secretory study); 1 hour
89136 - Gastric intubation, aspiration, and fractional collections (eg, gastric secretory study); 2 hours
89140 - Gastric intubation, aspiration, and fractional collections (eg, gastric secretory study); 2 hours including gastric stimulation (eg, histalog, pentagastrin)
89141 - Gastric intubation, aspiration, and fractional collections (eg, gastric secretory study); 3 hours, including gastric stimulation
89225 - Starch granules, feces
89235 - Water load test
Medicine – 39 New & 41 Deleted codes
New CPT codes
90460 - IMADM THROUGH 18YR ANY ROUTE 1ST VAC/TOXOID
90461 - IMADM THROUGH 18YR ANY ROUTE EA ADDL VAC/TOXOID
90644 - MENINGOCOCCAL & HIB CONJ VACCINE 4 DOSE IM
90664 - INFLUENZA VAC PANDEMIC FORMULA LIVE INTRANASAL
90666 - INFLUENZA VACCINE PANDEMIC SPLT PRSRV FREE IM
90667 - INFLUENZA VACCINE PANDEMIC SPLT ADJUVANT IM
90668 - INFLUENZA VACCINE PANDEMIC SPLT IM
90867 - TRANSCRANIAL MAG STIMJ TX PLANNING
90868 - TRANSCRANIAL MAG STIMJ TX DLVR & MGMT
91013 - ESOPHGL MOTILITY STD W/I&R STIM/PERFUSION
91117 - COLON MOTILITY STDY MIN 6 HR CONT RECORD W/I&R
92132 - CMPTR OPHTHALMIC DX IMG ANT SEGMT W/I&R UNI/BI
92133 - COMPUTERIZED OPHTHALMIC IMAGING OPTIC NERVE
92134 - COMPUTERIZED OPHTHALMIC IMAGING RETINA
92227 - REMOTE IMG DX RETINL DIS W/ALYS & REPORT UNI/BI
92228 - REMOTE IMG MGT RETINL DIS W/I&R UNI/BI
93451 - RIGHT HEART CATH O2 SATURATION & CARDIAC OUTPUT
93452 - L HRT CATH W/NJX L VENTRICULOGRAPHY IMG S&I
93453 - R & L HRT CATH W/NJX L VENTRICULOG IMG S&I
93454 - CATH PLMT & NJX CORONARY ART ANGIO IMG S&I
93455 - CATH PLMT & NJX CORONARY ART/GRFT ANGIO IMG S&I
93456 - CATH PLMT R HRT & ARTS W/NJX & ANGIO IMG S&I
93457 - CATH PLMT R HRT/ARTS/GRFTS W/NJX&ANGIO IMG S&I
93458 - CATH PLMT L HRT & ARTS W/NJX & ANGIO IMG S&I
93459 - CATH PLMT L HRT/ARTS/GRFTS WNJX & ANGIO IMG S&I
93460 - R & L HRT CATH WINJX HRT ART& L VENTR IMG S&I
93461 - R&L HRT CATH W/INJEC HRT ART/GRFT&L VENT IMG S&I
93462 - LEFT HEART CATH BY TRANSEPTAL PUNCTURE
93463 - MEDICATION ADMIN & HEMODYNAMIC MEASURMENT
93464 - PHYSIOLOGIC EXERCISE STUDY & HEMODYNAMIC MEASURE
93563 - NJX SEL HRT ART CONGENITAL HRT CATH W/S&I
93564 - NJX SEL HRT ART/GRFT CONGENITAL HRT CATH W/S&I
93565 - NJX SEL L VENT/ATRIAL ANGIO HRT CATH W/S&I
93566 - NJX SEL R VENT/ATRIAL ANGIO HRT CATH W/S&I
93567 - NJX SUPRAVALV AORTOG HRT CATH W/S&I
93568 - NJX PULMONARY ANGIO HRT CATH W/S&I
95800 - SLP STDY UNATND W/HRT RATE/O2 SAT/RESP/SLP TIME
95801 - SLP STDY UNATND W/MIN HRT RATE/O2 SAT/RESP ANAL
96446 - CHEMOTX ADMN PRTL CAVITY PORT/CATH
Deleted Codes
Immunization Administration
90465 - Immune admin 1 inj,
90466 - Immune admin addl inj,
90467 - Immune admin o or n, 1 inj,
90468 - Immune admin o/n, addl inj,
91000 Esophageal intubation
Manometry
91011 - Esophagus motility study w mechoyl
91012 - Esophagus motility study w acid perfusion studies 91052 - Gastric analysis test
91055 - Gastric intubation for smear
91105 - Gastric intubation treatment
91123 - Irrigate fecal impaction
92135 - Ophth dx imaging post seg
Electrocardiographic services
93012 - Transmission of ecg
93014 - Report on transmitted ecg
Ambulatory ECG Monitoring
CPT codes 93230 - 93237
Heart Catheterization and Injection procedure Codes
93501 - Right heart catheterization
93508 - Cath placement, angiography
93510 - Left heart catheterization; percutaneous
93511 - Left heart catheterization; by cutdown
93514 - Left heart catheterization by ventricular puncture
Combined Heart Catheterization
CPT codes 93524 - 93529
Injection procedures
CPT codes 93539 - 93545
Imaging Supervision
CPT codes 93555 - 93556
Chemotherapy Administration
96445 - Chemotherapy administration into peritoneal cavity, requiring and including peritoneocentesis
E-Prescribing Incentive Checks ALMOST in the Mail
October 22nd, 2010
E-prescribing incentive program are currently being processed, and should be wrapped up by the end of October. incentive payments will be paid as lump-sum to the TIN or the taxpayer ID under which the eligible professional’s claims were submitted.
It’s not too late to start participating in the e-prescribing program for 2010. You can receive an incentive payment of two percent for participating in the program. There are several FREE e-prescribing programs available online. Check our resources pages for more information.
For 2010, there is a single code to report e-prescriptions:
G8553: At least one prescription created during the encounter was generated and transmitted electronically using a qualified eRx system.
Simply append the code to your claims to report that you used a qualified system to transmit one or more prescriptions electronically during the encounter. You only need to report 25 non hospital claims for the year to qualify.
If you could use two percent more of your Medicare dollar, e-prescribing is an easy first option.
Interim Relief for Reporting Cost of Group Healthcare Costs on W-2s
October 15th, 2010
A provision of the Patient Protection and Affordable Care Act requires employers to report the cost of healthcare coverage paid by the employer on their employees on Form W-2 beginning in tax years on or after January 1, 2011. The cost to be reported would be the "aggregate cost." Per the IRS, the aggregate cost is "the 'applicable premium' under the rules providing for COBRA continuation coverage instead of the out of pocket cost paid by the employer.
The Treasury Department and IRS have extended interim relief from this requirement for 2011 to allow employers more time to update their payroll procedures to capture the "aggregate cost" data.
For more information visit: http://www.irs.gov/pub/irs-drop/n-2010-69.pdf
Are You Capturing Nebulizer Education Codes?
October 8th, 2010
We admit it. We're on a quest.
We want to help you increase your reimbursement by capturing all the dollars you are entitled to but leave on the table.
Earlier this week, I saw a nurse teaching a patient how to use a nebulizer. And yes, nebulizer education is a billable code. It does not need to be done by the provider, but must be done subject to a provider's orders. This particular office had never billed for nebulizer education.
The CPT Code is 94664: Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device.
When may you bill the code?
94664 requires that education be given seperate from a nebulizer treatment. There must be a signed, written order in the chart for the education which documents medical necessity. For example, a House episode showed a clinic patient using the inhaler as if it were perfume. Dr. House could have easily written an order explaining the medical necessity of education.
Other more common reasons could be training for new nebulizer user or for a prescription for a new type of device.
If a medically necessary E/M service is provided on the same day as the nebulizer education, append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on the office visit code (99201-99215).
Also beware that CCI edits bundle 94664 into inhalation treatment code 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device). However you may use modifier 59 to override the edit if the treatment and education are two SEPERATE events.How about reimbursement?
The national Medicare Allowed on the procedure is $14.38. Considering Medicare allows $14.01 for the nebulizer treatment itself, if the practice demostrates the use of the nebulizer with the treatment, billing for education instead results in better reimbursement. Of course, materials codes should also be included.
If nebulizer education is part of your routine practice, be sure to capture this frequently overlooked code.
Legal and Practical Issues of Billing and Collection Practices
September 25th, 2010
One of my favorite resources for staying up to date is the Med Law Blog published by Tucker Arsenberg Attorneys. Michael Cassidy does a very nice job of keeping the blog updated with the practical impact of law changes. Yesterday's post is applicable to everyone in private practice. As such, I'm including it in full.
Legal and Practical Issues of Billing and Collection Practices Posted on September 24, 2010 by Michael Cassidy
Contributed by Michael Cassidy & Donna Kell
mcassidy [at] tuckerlaw [dot] com, djk [at] kellgroup [dot] com
An overlooked byproduct of health care reform and the general economic recession is the “multiplier” effect of larger deductibles and co-pays and the reduced ability of patients to make those payments, resulting in more collection problems and the perhaps unintended creation of consumer financing issues. This article is intended to address both the legal and practical issues of your billing and collection practices.
I. Legal Issues
Two legal issues that are often overlooked are the federal Truth in Lending Act (TLA) and the federal Fair Debt Collection Practice Act (Fair Debt Act).
Most physicians jump to the conclusion that the TLA does not apply to them because they are not engaged in consumer financing. However, TLA applies to any person who regularly extends consumer credit and the definition of consumer credit characterizes the transaction as one in which the party to whom the credit is extended is an actual person and the services which are the subject of the transaction are primarily for personal, family or household purposes -- this definition applies directly to the extension of credit for medical services and the TLA will apply if your practice meets either of these thresholds:
1. You regularly extend credit, which is defined as extending credit more than 25 times per year; and
2. The credit is either subject to a finance charge, or payable and subject to a written agreement in more than four installments.
Interest, or “the finance charge,” does not include charges for actual, but unanticipated late payment, for exceeding a credit limit, or for events of default or delinquency such as checks returned for insufficient funds.
If you are extending credit and subject to TLA, then you should consult with your lawyer to prepare the necessary disclosure documents necessary for the Truth in Lending Disclosures, which are basically the same documents you receive in any of the lending transactions in which you may have been involved.
The Fair Debt Act makes it unlawful for anyone to give a consumer, in this case the patient, the false belief that the person other than the creditor is participating in the collection process. For example, if you threaten to turn patients over to a collection agency, but actually have no arrangements to do so, you are violating the Act. Therefore, you should follow the following guidelines with regard to compliance with the Fair Debt Collection Practice Act:
1. Do not threaten to refer a bill to a collection agency or take any other action unless you plan to do so or regularly do so with others;
2. Do not disclose to any third party, over the phone or otherwise, that you are attempting to collect a debt from a patient;
3. Do not send correspondence which reveals collection activities, such as post cards, envelopes with “past due” stamped on the outside;
4. Do not call patients before 8:00 a.m. or after 9:00 p.m. or at work if you know they are not permitted to take personal calls; and
5. You may not call a patient directly if the patient has advised you they are represented by counsel.
II. Practical Issues
In order to ensure that your medical practice is compliant, it is prudent to create a self-pay financial policy. A written financial policy not only helps your office support staff to be consistent in how self-pay collections are implemented, but also allows your patients who have self-pay balances to know what to expect from your practice.
Consider including the following elements into your policy:
1. How and when your practice verifies patient insurance coverage. The person who verifies insurance should be instructed to document co-payment amounts by specialty and/or type of service into the patient chart so that office staff knows exactly what to collect from the patient on the date of service.
2. Specifics about what the patient can expect for collection of other patient-responsible balances such as deductibles and co-insurance amounts. Explain the billing cycle to every patient. Inform them about your patient invoicing procedures; such as, the frequency of invoicing and the types of collection activities your practice employs.
3. Patient Due Statements. Design a statement that is readable, that clearly identifies the balance due, specifies the due date, and clearly states how patients can contact your office.
4. Bad Addresses. Create a procedure to quickly investigate patient statements that are returned to you due to a bad address. If you are unable to correct it, the patient chart should be flagged so that any future contact with the patient, including subsequent appointments and invoices, are halted until the address is updated.
5. Reporting Bad Debt. If you determine that you want to affect a patient’s credit score, you may chose to sign-up with a credit bureau. Patients’ concerns about bad debt reporting may prompt them to pay you promptly.
6. Financial hardship. What criteria does your practice utilize to reduce a patient-due balance? If your practice participates with Medicare, you need to be certain that you are charging all payers equally. This means that co-payments, deductibles and coinsurance amounts are not be written off subjectively. Developing standard discounts that are based upon income guarantees that self-pay reductions are handled equitably and objectively.
7. Payment methods that are accepted by the practice. For example: cash, checks, payment plans, debit cards, and credit cards.
i. Cash – Collect co-payments on the date of service, preferably at patient check-out. Practices that collect at check-in may miss co-payments that are assessed by type of service. If you accept cash, be sure to have procedures in place for daily reconciliation.
ii. Payment Plans – Your policy should specify acceptable payment thresholds, with the goal being to collect all balances in three months or less. Determine if your practice management system has functions that can easily create payment coupons. This can help your patients to keep their payment commitment. If your financial policy allows for assessing interest, make sure that the system is set-up to follow TLA guidelines.
iii. Debit and Credit Cards - Think about ways to make it easy for your patients to pay their balances; including giving patients an online payment option.
After you’ve established your policy, take the time to train your front desk and billing staff. Practices can be exposed to legal liability simply due to an employee who is not appropriately trained or who is uncomfortable or incapable of accurately communicating with patients who are delinquent.
Complete understanding of a well-designed financial policy, combined with frequent staff training and refresher seminars - especially with regard to the Fair Debt Act guidelines, patient communications, and conflict resolution techniques – can assure legal compliance, patient satisfaction and a steady cash flow regardless of the many economic changes that you face.
2011 Neurology CPT Code Changes
September 24th, 2010
Sleep Studies
CPT 2011 replaces the temporary G codes used for unattended sleep studies with new permanent codes:
95800 Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (eg, by airflow or peripheral arterial tone), and sleep time
95801 Sleep study, unattended, simultaneous recording minimum of heart rate, oxygen saturation, and respiratory analysis (eg, by airflow or peripheral arterial tone)
The codes differ by whether or not sleep time is included. Assuming the SGR cut does not go into effect later this year, Medicare allowed for global 95800 will be about $925, and for global 95801, $1550.
CPT notes also advise Providers not to report ECG or sleep study services seperately when using 95800 or 95801.
Muscle, Range of Motion Testing
The term "Tensilon" has been removed from CPT Code 95857. The description is now: Cholinesterase inhibitor challenge test for myasthenia gravis.
The change was necessary because the drug Tensilon is no longer available.
Intraoperative Neurophysiology
Following the description of the add-on code 95920, CPT 2011 adds a note that discusses how to count time.
Do not report 95920 if recording lasts 30 minutes or less. For procedures that last beyond midnight, report services using the day on which the monitoring began.
More on Counting Time
Count every 24 hours: 95950-95953 and 95956. For recording 12 hours or less, use modifier 52.
Count every hour of physician attendance: 95961 and 95962. Report 95961 for the first hour of physician attendance. Use modifier 52 with 95961 for 30 minutes or less. Report 95962 for each additional hour of physician attendance.
EEGs
The AMA requested that 95953 and 95956 be revised to clarify attendance and unattendance. The terminology of both were changed.
Code 95953 is for an ambulatory EEG, which is not attended by a technologist or nurse.
Code 95956 is used now for monitoring without video. It requires attendendance during the recording. The code descriptors now read:
95953 Monitoring for localization of cerebral seizure focus by computerized portable 16 or more channel EEG, electroencephalographic (EEG) recording and interpretation, each 24 hours, unattended
95956 Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, electroencephalographic (EEG) recording and interpretation, each 24 hours, attended by a technologist or nurse
Smoking Related Disease No Longer Required For Tobacco Cessation Counseling
September 6th, 2010
On August 25 CMS announced a change in reimbursement policy for tobacco cessation counseling. In the past, to bill for Tobacco Cessation Counseling, a smoking related disease diagnosis had to be linked to codes 99406 (three to ten minutes) and 99407 (more than ten minutes).
Medicare alloweds for these codes are approximately $13 and $25, slightly more or less depending on your jurisdiction.
CMS announced that “under new coverage, any smoker covered by Medicare will be able to receive tobacco cessation counseling from a qualified physician or other Medicare recognized practitioner who can work with them to help them stop using tobacco.” Thus, the only diagnosis now required is 305.1, tobacco use disorder.
The new tobacco cessation counseling coverage expansion applies to services under Medicare Part B and Part A. “The new benefit will cover two individual tobacco cessation counseling attempts per year.Each attempt may include up to four sessions, with a total annual benefit thus covering up to eight sessions per Medicare patient who uses tobacco.”
“For too long, many tobacco users with Medicare coverage were denied access to evidence based tobacco cessation counseling,” said Kathleen Sebelius, HHS secretary, the August 25 statement. “Most Medicare beneficiaries want to quit their tobacco use. Now, older adults and other Medicare beneficiaries can get the help they need to successfully overcome tobacco dependence.”
Tobacco counseling must be done according to a plan. The websites http://www.smokefree.gov/ and http://www.cdc.gov/tobacco/quit_smoking/index.htm both have programs that may be adopted and used for counseling. Simply telling a patient to quit smoking is not sufficient.
CMS Expands Covered Telehealth Services for 2011
September 6th, 2010
CMS is adding the following requested services to the list of Medicare telehealth Services for 2011:
• Individual and group KDE services (HCPCS codes G0420 and G0421, respectively);
• Individual and group DSMT services, with a minimum of 1 hour of in-person instruction to be furnished in the initial year training period to ensure effective injection training (HCPCS codes G0108 and G0109, respectively);
• Group MNT and HBAI services (CPT codes 97804, and 96153 and 96154, respectively);
• Subsequent hospital care services, with the limitation of one telehealth visit every 3 days (CPT codes 99231, 99232, and 99233); and
• Subsequent nursing facility care services, with the limitation of one telehealth visit every 30 days (CPT codes 99307, 99308, 99309, and 99310).
CMS also limited the use of telehealth in two ways. First, for hospital care services, CMS limited the patient’s admitting physician or practitioner to one telehealth visit every 3 days. For subsequent nursing facility care services, CMS limited the patient’s admitting physician or non-physician practitioner to one telehealth visit every 30 days. Also, for DSMT, CMS required a minimum of 1 hour of in-person instruction to be furnished in the year following the initial training to ensure effective injection training.
For more information, visit: http://www.cms.gov/MLNMattersArticles/downloads/MM7049.pdf.
Outstanding Review of Meaningful Use Published by NEJM
August 6th, 2010
The New England Journal of Medicine has published an outstanding description of the requirements for Meaningful Use in Electronic Health Records. The article itemizes the objectives and the means of measuring a practice's compliance.
The article and chart may be read by clicking here:
The “Meaningful Use” Regulation for Electronic Health Records
"Meaningful Use" For EHR Now Defined
July 14th, 2010
Yesterdary (July 13, 2010) CMS and ONC announced the final rules on Meaningful Use and Standards and Certification under the HITECH Act’s Electronic Health Records (EHR) incentive program.
You may find the final rule for meaningful use at: http://www.ofr.gov/OFRUpload/OFRData/2010-17207_PI.pdf.
The final rule on standards, implementation specifications, and certification criteria for EHR technology may be found at http://www.ofr.gov/OFRUpload/OFRData/2010-17210_PI.pdf.
No Signature Means No Order for Medicare Auditors
June 21st, 2010
One of the areas Medicare auditors are instructed to review during audits is the signatures of medical records. In fact, if a required physician's signature is missing from an order that requires a signature, auditors have been instructed to completely ignore the medical record or order.
CMS has recently updated MLN Matters Number MM698 to define what is a legible signature. On pages six and seven of the bulletin, a chart that summarizes signature and legibility requirements is included. See:
https://www.cms.gov/MLNMattersArticles/downloads/MM6698.pdf
There are some surprises in the publication. For example, signature by attestation is allowed. A suggested format for the attestation is provided within the article.
Initials are only acceptable is over a typed name or accompanied by a signature log or attestation statement.
A dictated and typed medical report even if initialed is insufficient unless the physician initials over a typed name (or there is an accompanying signature log or attestation statement.)
Surprisingly, some items do not require a signture. For example, orders for clinical diagnostic tests are not required to be signed. But if the order for the clinical diagnostic test is unsigned, there must be some form of documentation by the treating physician (e.g., a progress note) that he intended for the clinical diagnostic test to be performed. This documentation must be signed.
Not knowing and applying signature requirements could be a costly mistake. The MLN Matters cited above should be mandatory reading.
ICD-9 Changes for 2011 Released
June 14th, 2010
The ICD-9 2011 codes will take effect October 1, 2010. For diagnosis codes CMS does NOT allow a grace period to the first of 2011. The codes must be used beginning October 1, 2010.
The proposed changes include 122 new codes thatl reflect CMS’s continued drive for greater specificity in diagnosis coding. There are 11 deleted and nine revised diagnoses codes. 54 of the 122 new codes are V codes.
Some of the new changes include:
New V Codes
V Codes compose the largest single group of changes..
V11.4 is a new history of code for Combat and operational stress reaction (COSR), for a past acute reaction to stress that might have been called combat fatigue or catastrophic stress in former years.
Codes V13.23, Personal history of vaginal dysplasia, and V13.24, Personal history of vulvar dysplasia, were created at the request of the American College of Obstetricians and Gynecologists for patients with dysplasia that required follow-up visits to ensure the condition had resolved.
Codes V25.11–V25.13, Encounter for insertion or removal or removal and reinsertion of intrauterine contraceptive device (IUD), was added. The current code V25.42, Intrauterine contraceptive device (surveillance), is limited to checking the presence of the IUD.
Codes V13.61–V13.69, Personal history of (corrected) congenital conditions, recognize that many congenital conditions can be completely repaired.
The intent of new code V49.86, Do not resuscitate status, is to identify the patient who has a physician's order for "do not resuscitate" status.
Code V49.87, Physical restraint status, identifies patients who had restraints in place during their healthcare services. This code excludes the use of restraints due to procedures.
Code V62.85 was created to identify homicidal ideation.
New codes V85.41–V85.45, Body mass index 40 and over, adult, were added to provide greater specificity regarding BMI 40 and over for adults.
Two new codes (V88.11–V88.12, Acquired absence of pancreas) provide information about the acquired total absence and acquired partial absence of the pancreas organ.
Specific codes (V90.01–V90.9, Retained foreign bodies) were created to identify patients who have retained foreign fragments within their bodies, such as radioactive, metal, magnetic, plastic, organic, and other and unspecified fragments.
New codes (V91.00–V91.99, Multiple gestation placenta status) for use with pregnancy codes for multiple gestations (twin, triplet, quadruplet, and other specified multiples) to indicate the number of placentas and amniotic sacs present have been added.
The V91 category codes are used in addition to category 651 codes to describe the female's multiple gestation condition.
External Cause Status
E000.2 was added as a new External Cause Status to indicate the patient was acting as a volunteer when the event occurred that caused the patient to seek medical attention.
Acute Idiopathic Pulmonary Hemorrhage in Infants
The Centers for Disease Control and Prevention requested a specific code for acute idiopathic pulmonary hemorrhage in infants (AIPHI). This condition causes pulmonary hemorrhage in a previously healthy infant with a gestational age over 32 weeks and no prior medical problems. Subcategory 786.3, Hemoptysis, was expanded to include unspecified hemoptysis (786.30), AIPHI (786.31), and other hemoptysis (786.39).
Aortic Ectasia
New codes were created to classify aortic ectasia at different sites, including thoracic aortic ectasis (447.71), abdominal aortic ectasia (447.72), thoracoabdominal aortic ectasia (447.73), and ectasia of unspecified site of aorta (447.70). Aortic ectasia is a dilation of the aorta that may develop into an aneurysm over time.
Blood and Blood Products Transfusion Related Conditions
Several codes were added to capture different blood transfusion-related conditions. Code 275.02, Hemochromatosis due to repeated red blood cell transfusions, was added to recognize iron overload caused by repeated red blood cell transfusions. In addition, codes 275.01, Hereditary hemochromatosis; 275.03, Other hemochromatosis; and 275.09, Other disorders of iron metabolism were created to identify patients with hemochromatosis that may result in organ damage, including heart, kidney, and liver dysfunction.
A new code for transfusion-associated circulatory overload, or TACO (276.61), identifies patients with circulatory overload following a blood or blood component transfusion. The circulatory overload may follow large volumes of infusion that cannot be processed by the recipient or underlying cardiac or pulmonary pathology. Elderly patients and infants are at an increased risk for TACO, even with small transfusion volumes.
Code 287.41 was added to identify post-transfusion purpura (PTP), which produces a sudden severe thrombocytopenia (platelet count less than 10,000/µL) usually five to 12 days following transfusion of blood components. This reaction is associated with the presence of antibodies directed against the human platelet antigen system. Code 287.49 was also added to subcategory 287.4, Secondary thrombocytopenia, for other secondary thrombocytopenia conditions, such as those due to massive blood transfusions.
Code 780.66 was added for febrile nonhemolytic transfusion reaction (FNHTR), which may be referred to as a "post-transfusion fever." This condition, which can occur within four hours of a transfusion, includes fever, chills, and rigors. It may be a reaction between recipient antibodies and transfused leukocytes.
Numerous codes were created to classify hemolytic transfusion reactions (HTRs), an increased destruction of red blood cells due to incompatibility between blood donor and recipient. It can be acute or chronic depending on the timing of the occurrence. HTRs can be caused by either ABO or non-ABO incompatibility and can be fatal.
New codes were created in the following ranges:
- 999.60–999.69, ABO incompatibility reaction due to transfusion of blood or blood products
- 999.70–999.79, Rh and other non-ABO incompatibility reaction due to transfusion of blood or blood products
- 999.80–999.89, Other and unspecified infusion and transfusion reaction
A simple diagnosis of "transfusion reaction" is coded to 999.80; however, requesting more specific information from the physician will produce more accurate coding and provide better information to report transfusion-related complications.
The Food and Drug Administration, Center for Biologics Evaluation and Research, requested the new codes for better tracking to decrease transfusion complications.
Cocaine Poisoning
A unique code for poisoning by cocaine or crack cocaine (970.81) was added to the table of drugs and chemicals for FY 2011.
Fecal Incontinence
Fecal incontinence can be caused by problems with the rectal and anal sphincters. It may first present with symptoms like fecal smearing, urgency, and incomplete defecation. Incomplete defecation is not synonymous with fecal impaction.
New codes were created for fecal impaction (560.32), fecal incontinence (787.60), incomplete defecation (787.61), fecal smearing (787.62), and fecal urgency (787.63).
Fluency Disorders
Code titles have been modified and new codes added to distinguish childhood onset fluency disorder, adult onset fluency disorder, and fluency disorder subsequent to brain lesion or disease.
The title of code 307.0 was changed from "stuttering" to "adult onset fluency disorder." Code 315.35 was added for reporting childhood onset fluency disorder. New code 784.52, Fluency disorders in conditions classified elsewhere, is used as an additional code with conditions such as Parkinson's disease that produce the fluency problem.
Influenza
Subcategories 488.0, Influenza due to identified avian influenza virus, and 488.1, Influenza due to novel H1N1 influenza virus, were expanded to the fifth-digit level to identify pneumonia, other respiratory manifestations, and other manifestations that occur as a result of the virus infection. Codes 488.01, Influenza due to identified avian influenza virus with pneumonia, and 488.11, Influenza due to identified novel H1N1 influenza virus with pneumonia, require an additional code to identify the type of pneumonia.
Jaw Pain
Jaw pain may be a symptom of a myocardial infarction. For this reason, new symptom code 784.92 was created for jaw pain to classify the patient who presents with this complaint.
Neurofibromatosis
Code 237.73 was added to subcategory 237.7, Neurofibromatosis, to recognize Schwannomatosis, a genetic disorder that causes multiple tumors to grow on cranial, spinal, and peripheral nerves. Code 237.79 was also added to capture other neurofibromatosis conditions.
Neurogenic Claudication
Neurogenic claudication is associated with significant lumbar spinal stenosis, leading to compression of the cauda equine or lumbar nerves. It may require corrective surgery. Patients can have lumbar spinal stenosis without neurogenic claudication.
Code 724.03, Spinal stenosis, lumbar region, with neurogenic claudication, was created. Code 724.02, Spinal stenosis, lumbar region, without neurogenic claudication, was revised to distinguish between patients with and without neurogenic claudication.
Neurological Conditions
Six new signs and symptoms codes involving cognition were created to better classify traumatic brain injury (TBI) and its associated conditions (799.51–799.59). These codes describe cognitive impairments such as memory, concentration, attention, communication, and executive function.
The new codes can also be used to classify patients presenting with the same symptoms due to a neurological condition. The codes can be used as additional codes when the cause is known, such as TBI, and before a definitive diagnosis is made.
Obesity Hypoventilation Syndrome
Code 278.03 was added for obesity hypoventilation syndrome (OHS), also called Pickwickian Syndrome. OHS is a breathing problem that causes hypoventilation and produces decreased oxygen levels and elevated carbon dioxide.
Post-traumatic Seizures
New code 780.33 was created for post-traumatic seizures that are acute symptomatic seizures following a head injury. Post-traumatic seizures are not the same as post-traumatic epilepsy. Patients with post-traumatic seizures require follow-up to ensure complete resolution and prevent complications.
Reproductive Organ Congenital Anomalies
Congenital anomalies of the uterus, cervix, and vagina are collectively known as Müllerian anomalies. Vaginal and cervical anomalies are less common than uterine anomalies.
Seven new codes in the 752.31–752.39 range were created to identify uterine anomalies of
agenesis, hypoplasia, unicornuate, bicornuate, septate, arcuate, and other anomalies of the uterus. Codes 752.43–752.45 were created to identify cervical and vaginal anomalies, specifically cervical agenesis, cervical duplication, vaginal agenesis, transverse vaginal septum, and longitudinal vaginal septum.
To see the new, deleted and revised codes visit:
https://www.cms.gov/ICD9ProviderDiagnosticCodes/07_summarytables.asp#TopOfPage
This site will be updated as revisions are made in the code set.
June 1 - Red Flag Warning!
May 27th, 2010
For over a year, we've been told by major medical associations that Red Flag Rules shouldn't apply to medical practices. After all, most medical practices aren't very aggressive with their collection practices. How often have you known a doctor to put a lien against someone's home because of an unpaid claim? Thus why should a medical office be grouped with financial institutions as a purveyor of credit.
Still, identity theft is REAL in a medical office setting. The oddity in a medical practice is that the theft is frequently done to the provider; not by him.
Physicians and other providers run the very real risk of their identity being stolen. Most providers have encountered their DEA numbers being fraudulently used to obtain prescriptions. Also most providers have experienced treating a patient for which Medicare already has a date of death.
It has long been a rule by many Medicaid carriers that a provider's office should verify identity BEFORE rendering treatment. The use of Medicaid cards by those other than the patient covered is a major problem for most state plans.
A provider's office should have HIPAA policies in place that will go far to satisfying the Red Flag Rules. Adding procedures such as obtaining a picture i.d. or reasonable substitute thereof will likely protect the provider more than it will the patient.
Free resources are available online to help prepare the required written policies. The FTC itself has an online template for low risk businesses available at: http://www.ftc.gov/bcp/edu/microsites/redflagsrule/RedFlags_forLowRiskBusinesses.pdf.
The American Medical Association also has a template available. If you are a member, you can access a Word document that may be easily modified. Everyone can access a pdf version. See http://www.ama-assn.org/ama1/pub/upload/mm/368/red-flags-rule-policy.pdf
The American Medical Association and others have filed a lawsuit to prevent the Red Flag Rules from applying to medical offices. To read about the lawsuit, visit: http://www.ama-assn.org/ama/pub/news/news/lawsuit-red-flags-rule.shtml.
But honestly, with all the tools available, why not waive the white flag and comply.
Evaluating a Billing Company
May 26th, 2010
I received an email today from Chris Thorman of Software Advice about "How to Evaluate a Billing Company." It was well done. My only criticism was his failure to recognize HBMA as a billing company certification. When Medical Economics did a similar article several years ago, HBMA's certification was the one recommended.
KLA is a longtime member of HBMA and has found its services, particularly those in Washington, to be invaluable. To learn more about HBMA, visit: http://www.hbma.org/.
You may read the article itself at http://www.softwareadvice.com/articles/medical/how-to-evaluate-medical-billing-services-1042610/.
Always willing to learn something new, KLA will be looking at AMBA membership.
Online Appointment Scheduling
May 7th, 2010
A few weeks ago, I needed to make an eye appointment. When doing a Google search to find my eye doctor's phone number, I found she had an online scheduler. The scheduler showed available appointments only. There was not detail on the web view about who had what appointments. I was thrilled that I could book my appointment online.
Several days before the appointment, I was sent an email reminder. The day before the appointment I was sent another email reminder.
When I got to the doctor's office, I asked her wonderful receptionist about the software. She said it worked great. She used the same software to book the appointment in the office. If you add a patient's email address, reminders will be sent. It also includes a feature where the physician can make notes about the patient.
There's a little setup involved. You need to define your visits. For example, you could have new patient, established patient, laboratory only.
The program can handle multiple providers and multiple sites.
If you'd like to try it out, go to the website instant-scheduling.com. There's no charge for the first 30 days. If you're a KLA client, the service will be free to you under our license. Just give me a call for the "promotional code."
Let me know what you think!
Sharon
Our Updated Website
May 5th, 2010
KLA Healthcare Consultants is excited about our new website designed by the extraordinary RocketFuel. The Rocket Fuel team is what they promise: Intergalactic Web Experts In Our Neighborhood.
With our newly designed site we will be able to quickly post new resources and blog entries for the use of our clients and friends. With the easy to use web interface, we can make these changes ourselves, from our desktops, as needed.
The Rocket Fuel animal lovers always include a picture of Bowtie the cat when launching a new website.
The employees of KLA share a love of animals. Our combined pets include cats, dogs, birds and fish. We even have a nest of baby finches on a lightpost outside our office.
Thank you Rocket Fuel. We appreciate you. In homage, we'll keep Knox in his bowtie for luck. We'll drink our champagne instead of breaking it over the bow of our new website.
