The Centers for Medicare & Medicaid Services (CMS) recently announced they will move forward with Phase 2 of the ordering/referring edits effective May 1. As previously reported, these requirements apply to ordered/referred items and services including DMEPOS, clinical laboratory and imaging services, and home health claims billed by Medicare Part B suppliers. For these claims, ordering/referring providers must be eligible to order or refer in Medicare, their legal name and NPI must be listed on the claim, and they must have an enrollment record in Medicare. The requirements vary slightly for medical interns and residents who order or certify these items and services.

Currently in Phase 1, CMS is issuing warnings for claims that fail to meet the requirements. These claims will be denied in Phase 2. Practices should look for the following messages on the remittance advice for provider and supplier Part B claims:

N264: Missing/incomplete/invalid ordering physician provider name
N265: Missing/incomplete/invalid ordering physician primary identifier

Since most medical practices depend on insurance reimbursements for a majority of their income, it’s important to view payors as key partners to help you grow your business. In fact, a solid relationship with your payors is essential to the smooth operation and profitability of your practice. While most practices are content with the relationships they have, there are times when it makes sense to reevaluate the payors a practice currently participates with to add new partners or eliminate some. Below are some key considerations when evaluating your payor participation.

Launching your practice
When first launching your practice it is important to participate with the plans that have the highest number of subscribers in the area you practice. A practice should diversify its payor mix so it is not heavily concentrated in any demographic area or with a particular carrier.

Join physician organizations in your area
Since there is always strength in numbers, contact your state medical society to see if there are any organizations that physicians can join to enhance their ability to negotiate with payors. Often times physician organizations can take your concerns to the payor or a representative of that payor and are able to negotiate favorable reimbursement rates on behalf of its members.

Look at the payor’s network
It is also important to make sure to examine your current referral providers and whether your current payor mix fits with providers. While it’s important to ensure that your payors already contract with your affiliated hospital, be sure that they are also contracted with ancillary services such as rehab facilities, skilled nursing facilities, speech therapy, occupational therapy, and other homecare needs. You should be looking at more than just whether your affiliated hospital is contracted with a payor.

How well are the payors rated
Do you know how well rated each of your payors are? It is recommended to occasionally check on health insurance plan rankings through places such as the National Committee for Quality Assurance (NCQA). Not only examine their rating on an annual basis, but also find out what type of support that plan provides to your practice.

Ease of use
Is your staff spending too much time following up with the payor on the following activities:
• Credendialing/provider enrollment into the plan network
• Following up on outstanding claims and denials
• Obtaining prior authorization
• Is there a Provider Relations Representative assigned to your practice who is responsive to your questions

Finally, communication between the payor and practice is vital so it doesn’t get to the point where you need to constantly look for new payors. You want to sit down with your provider relations representative to outline what your concerns are and map out your strategy and then follow through. Healthcare Solutions WNY billing staff meets with the payors on their client’s behalf frequently to address issues of reimbursement and other problems that may be occurring.

Before deciding to participate with a new plan or terminate an existing relationship, which may reduce reimbursement and increase out of pocket expenses for your patients for non-participation with a payor, there are key components to the decision making process to consider. All of these considerations should be discussed with your Provider Relations Representative first.

Effective July 1, 2013, all Occupational (OT), Physical (PT) and Speech Therapy (SLP) services will have new coding requirements when submitting Medicare beneficiary claims.

To recap recent developments since our last newsletter article on therapy coding and billing: The American Taxpayer Relief Act of 2012 was signed into law by President Obama on January 2, 2013. This legislation extends the Medicare Part B Outpatient Therapy Cap Exceptions Process through December 31, 2013. The statutory Medicare Part B outpatient therapy cap for Occupational Therapy (OT) is $1,900 for 2013, and the combined cap for Physical Therapy (PT) and Speech-Language-Pathology Services (SLP) is also $1,900 for 2013. This is an annual per beneficiary therapy cap amount determined for each calendar year. Medicare Allowable charges, which include Medicare Payments to providers and beneficiary coinsurance, are both counted toward the therapy cap. In the outpatient setting, Medicare pays for 80% of allowable charges and the beneficiary is responsible for the remaining 20% of the amount.

Effective July, Medicare will now require that 42 non-payable reporting G-codes be assigned and 7 new modifiers be appended when billing for CPT codes for the purpose of data reporting. Claims processed for dates of service after June 30th will require these HCPCS 11 G-codes and modifiers on all Medicare Part B Outpatient therapy claims, regardless of whether the beneficiary has exceeded the therapy cap. If these requirements are not met, the claims will be denied.

Non-payable Function-Related G-codes
The HCPCS II G-codes have no Relative Value Units assigned and therefore are not reimbursable codes. The G-codes and related severity/complexity modifiers describe the functional limitation status of the patient. These should be reported on the following claims:
• At the initial therapy encounter
• At every 10 treatment days throughout execution of the treatment plan
• On the same date of service that an evaluation or re-evaluation is submitted on the claim [CPT codes 92506, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 96125, 97001, 97002, 97003, 97004]
On the same DOS the reporting of a particular functional limitation is ended, in cases where the need for further therapy is necessary
• At the time of discharge from therapy

Whereas the former requirement stated that the progress reporting was due every 10th treatment day or every 30 calendar days, whichever was less, the new requirement states services related to the progress reports be furnished on or before every 10th treatment day.

Generally two G-codes will be required unless the beneficiary is under more than one plan of care at the same time furnished by the same therapist or provider. Multiple G-codes may be appropriate under these circumstances. If the therapy is a one-time visit and will be discontinued due to lack of medical necessity or because the care will be transferred to another provider, then three G-codes (current status, goal status, and discharge status) should be reported. The following is a list of these required codes for reporting function:

Mobility G-code set:
•G8978, Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals. Short descriptor: Mobility current status
•G8979, Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting. Short descriptor: Mobility goal status
•G8980, Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting. Short descriptor: Mobility D/C status

Changing & Maintaining Body Position G-code set:
•G8981, Changing & maintaining body position functional limitation, current status, at therapy episode outset and at reporting intervals. Short descriptor: Body pos current status
•G8982, Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting. Short descriptor: Body pos goal status
•G8983, Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end reporting. Short descriptor: Body pos D/C status

Carrying, Moving & Handling Objects G-code set:
•G8984, Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at reporting intervals. Short descriptor: Carry current status
•G8985, Carrying, moving & handling objects functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting. Short descriptor: Carry goal status
•G8986, Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end reporting. Short descriptor: Carry D/C status

Self Care G-code Set:
•G8987, Self care functional limitation, current status, at therapy episode outset and at reporting intervals. Short descriptor: Self care current status
•G8988, Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting. Short descriptor: Self care goal status
•G8989, Self care functional limitation, discharge status, at discharge from therapy or to end reporting. Short descriptor: Self care D/C status

Other PT/OT Primary G-code Set:
•G8990, Other physical or occupational primary functional limitation, current status, at therapy episode outset and at reporting intervals. Short descriptor: Other PT/OT current status
•G8991, Other physical or occupational primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting. Short descriptor: Other PT/OT goal status
•G8992, Other physical or occupational primary functional limitation, discharge status, at discharge from therapy or to end reporting. Short descriptor: Other PT/OT D/C status

Other PT/OT Subsequent G-code Set:
•G8993, Other physical or occupational subsequent functional limitation, current status, at therapy episode outset and at reporting intervals. Short descriptor: Sub PT/OT current status
•G8994, Other physical or occupational subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting. Short descriptor: Sub PT/OT goal status
•G8995, Other physical or occupational subsequent functional limitation, discharge status, at discharge from therapy or to end reporting. Short descriptor: Sub PT/OT D/C status

Swallowing G-code Set:
•G8996, Swallowing functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals. Short descriptor: Swallow current status
•G8997, Swallowing functional limitation, projected goal status, at initial therapy treatment/outset and at discharge from therapy. Short descriptor: Swallow goal status
•G8998, Swallowing functional limitation, discharge status, at discharge from therapy/end of reporting on limitation. Short descriptor: Swallow D/C status

Motor Speech G-code Set: (Note: These codes are not sequentially numbered)
•G8999, Motor speech functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals. Short descriptor Motor speech current status
•G9186, Motor speech functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy. Short descriptor Motor speech goal status
•G9158, Motor speech functional limitation, discharge status at discharge from therapy/end of reporting on limitation. Short descriptor: Motor speech D/C status

Spoken Language Comprehension G-code Set:•G9159, Spoken language comprehension functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals. Short descriptor: Lang comp current status
•G9160, Spoken language comprehension functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy. Short descriptor: Lang comp goal status
•G9161, Spoken language comprehension functional limitation, discharge status at discharge from therapy/end of reporting on limitation. Short descriptor: Lang comp D/C status

Spoken Language Expressive G-code Set:
•G9162, Spoken language expression functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals. Short descriptor: Lang express current status
•G9163, Spoken language expression functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy. Short descriptor: Lang express goal status
•G9164, Spoken language expression functional limitation, discharge status at discharge from therapy/end of reporting on limitation. Short descriptor: Lang express D/C status

Attention G-code Set:
•G9165, Attention functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals. Short descriptor: Atten current status
•G9166, Attention functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy. Short descriptor Atten goal status
•G9167, Attention functional limitation, discharge status at discharge from therapy/end of reporting on limitation. Short descriptor: Atten D/C status

Memory G-code Set:
•G9168, Memory functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals. Short descriptor: Memory current status
•G9169, Memory functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy. Short descriptor: Memory goal status
•G9170, Memory functional limitation, discharge status at discharge from therapy/end of reporting on limitation. Short descriptor: Memory D/C status

Voice G-code Set:
•G9171, Voice functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals. Short descriptor Voice current status
•G9172, Voice functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy. Short descriptor Voice goal status
•G9173, Voice functional limitation, discharge status at discharge from therapy/end of reporting on limitation. Short descriptor: Voice D/C status

Other Speech Language Pathology G-code Set:
•G9174, Other speech language pathology functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals. Short descriptor: Speech lang current status
•G9175, Other speech language pathology functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy. Short descriptor: speech lang goal status
•G9176, Other speech language pathology functional limitation, discharge status at discharge from therapy/end of reporting on limitation. Short descriptor: speech lang D/C status

Severity/Complexity Modifiers
For each of the above-listed nonpayable G-codes, a modifier must be used to report the severity/complexity for
that functional measure. The beneficiary’s current status, the anticipated goal status, and the discharge status are reported via the appropriate severity modifiers. The seven severity modifiers are defined below:

Modifier Impairment Limitation Restriction
CH: 0% impaired, limited or restricted
CI: At least 1% but less than 20% impaired, limited or restricted
CJ: At least 20% but less than 40% impaired, limited or restricted
CK: At least 40% percent but less than 60% impaired, limited or restricted
CL: At least 60% but less than 80% impaired, limited or restricted
CM: At least 80% but less than 100% impaired, limited or restricted
CN: 100% impaired, limited or restricted

Therapy Modifiers
The GP, GO, GN, and KX modifiers (when applicable) are still required for the therapy services denoted by CPT codes. All claims containing a procedure code from the following list of “Applicable Outpatient Rehabilitation HCPCS Codes” should contain one of the therapy modifiers to distinguish the discipline of the plan of care under which the service is delivered, regardless of the therapy limit status of the patient:

• GN Services delivered under an outpatient speech-language pathology plan of care;
• GO Services delivered under an outpatient occupational therapy plan of care; or,
• GP Services delivered under an outpatient physical therapy plan of care
• KX Services delivered in which the clinician attests that services are medically necessary and justification is documented in the medical record, despite the beneficiary having exceeded the calendar therapy cap

Aside from billing these G-codes with severity/complexity modifiers, they must always be billed on a claim that bills for therapy services with therapy modifiers. Non-payable G-codes should be entered as a charge of $0.01 for proper MAC claim processing.

For more information and examples of the new requirements, read the following Medicare MLN Article and CMS Transmittal:

Outpatient Therapy Functional Reporting Non-Compliance Alerts: Change Request (CR) 8166, from which supplemental information regarding your claims June 30, 2013.
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8166.pdfCMS Pub 100-04 Medicare Claims Processing Transmittal 2622 (replaces 2603)
“Implementing the Claims-Based Data Collection Requirement for Outpatient Therapy
Services — Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) of 2012”
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2622CP.pdf

In the hotel industry, hospitality in its purest form is the friendly treatment of guests. Practicing hospitality helps hotel owners and operators gain loyal, repeat customers – something that all industries desire. The hotel industry excels at providing hospitality, and there are a number of things that healthcare can learn from this industry. In particular, the hotel industry often uses alliteration to communicate important concepts to its employees. Read on to see how the letter E explains how the hotel industry provides hospitality and how healthcare providers can use these tips to improve patient experience.

Empathy

Empathy should not be confused with sympathy. The hotel industry takes a great deal of time teaching our associates how to understand and share the feelings of others. An empathetic associate does not feel sorry for a guest who has had a traumatic travel day, but they do understand what it feels like and they take steps to mitigate that guest’s stress by empathizing with them.

Some examples of this would be speeding up the check-in process so they can get quickly to their room, offering the guest a cold beverage, assisting with luggage or offering directions to a nice, quiet restaurant. A well trained, empathetic associate can read the body language of a guest that has had a bad day and tailor their recommendations based on the guest’s verbal and non-verbal clues.

The very best of associates do this so seamlessly the guest doesn’t even realize the associate is trying. They just feel a little better at the end of the conversation than they did at the beginning. Please notice, none of the suggestions above cost the company more money or took the associate away from helping other guests.

Exceeding expectations

Exceeding expectations is the anticipation of the guest’s needs before the guest even understands their own needs. Hotel associates are the masters of this. Because our industry operates on low overhead margins we don’t have a plethora of extra associates waiting around to handle every guest’s whim.

Sound familiar to you? Instead, we teach our associates communication skills that go beyond verbal skills. Hospitality associates are trained on how to initiate a conversation, how to “make a connection with a guest,” and to be observant of the guests’ environmental clues (another E word).

For example, an associate sees a guest in swimming trunks wandering around the lobby looking in all directions. It is a relatively safe bet the guest is looking for the swimming pool. An associate trained in exceeding expectations, would quickly grab a pool towel, some sun screen and approach the guest, making eye contact (another E word) and introduce themselves to the guest. That is exceeding the guests’ expectations, without providing more service than the guest needs.

Empowerment

Empowerment is granting every associate in the building the power to “make it right for the guest,” which is an advancement on the old adage the “guest is always right.” What we didn’t understand until recently was this requires a lot of training and guidelines.

Previously leaders in the hotel industry thought if we put the structure of guidelines around it, then it wasn’t truly empowerment. We have since learned that a guest usually doesn’t want or require as much compensation or attention as we previously thought we should be giving.

A huge part of empowerment is training every associate how to hold a conversation in a difficult situation and come to a mutually agreeable compromise, leaving the guest satisfied and ideally a loyal customer. For example, is it as simple as granting the associate the ability to switch a guest to another room without obtaining permission from a supervisor.

Engagement

An engaged associate will lead to an engaged, loyal and repeat guest. In the hotel business, it is no longer standard practice to measure associate opinions.

The hotel industry for the most part now measures associate engagement. An engaged associate is fully involved and enthusiastic about their responsibilities to the hotel and the guest’s needs.

Engaged associates require less training, have less turnover, are more productive and committed to improving the financial performance of the company. A company needs to create an environment where the employees feel compelled to work for an organization.

Focus on quality of work relationships, values of the organization, and the associate’s connection to the company’s outcomes. A company also has to progressively remove disengaged associates that refuse to engage.
Remember the old saying, one bad apple spoils the whole basket? Remember again, engaged associates lead to engaged guests.

Effect

In the hotel business, effect is the measure of how well we satisfied the guest –in other words, follow up. Our business measures guest satisfaction.

We have learned that satisfied guests return. We have also learned that the best way to have an effect on a guest’s satisfaction is to follow up and resolve any communicated or hidden issues before the guest leaves the building.

We do this by correcting any known guest issues in a timely manner, then following up with the guest to make sure the issue was truly resolved. Our industry also has a best practice of interacting with the guest as much as possible while they are in building and asking simple open ended questions to make sure we completely understand if the guest’s experience (another E word) was everything the guest wanted it to be.

Here is hoping to see you in one of our hotel’s one day. We would be elated (our last E-word)!

Many of us recall that as early as 2010, the clinical community was first introduced to the National Committee for Quality Assurance (NCQA) concept of the Patient-Centered Medical Home (PCMH) healthcare delivery model. By 2011, NCQA had initiated the “Patient-Centered Medical Home (2011)” as a model of healthcare that steers away from episode-focused care and instead coordinates long-term care for a more cohesive and greatly improved standard of patient care. This system of healthcare delivery was based on the Wagner Chronic Care Model and was designed so that each patient’s entire health needs are addressed, monitored, and treated at one location. The concept is founded on coordinating the efforts of a team of qualified healthcare professionals that is led by the patient’s personal physician. The personal physician takes the responsibility for the patient’s care collectively while coordinating all services among other involved clinicians. This system optimizes communication of diagnostic results and treatment plans among providers for an efficient and effective quality healthcare. The results are a cost-effective method of offering the patient an active participation in his/her own care. As of the date of this publication, there are 5,429 PCMH in the country.

The implementation of this healthcare system proved so effective and successful, that on March 25, 2013, the NCQA introduced a new plan that extends from this concept. It is called the “Patient-Centered Specialty-Practice Recognition Program” (PCSP). The NCQA recognizes the importance of developing effective communication and supporting care between the primary physician care and the specialty practices. The goals of the newest initiative is to: provide timely access to care; reduce diagnostic test orders duplication; improve communication among caregivers involved in the patient’s care; improve coordination of multiple specialty care; track patients’ care with systems, and; include the patient, family, and caregiver in the decision-making, where appropriate. The outcomes include less facility re-admissions, less ED visits, lower mortality rates, and increased healthcare availability, continuous high-quality care, and increased patient satisfaction).

In addition to the benefit of this model to the patient, medical practices that would achieve the NCQA PCMH Recognition stood to gain financial incentives available to all eligible providers who seek to obtain recognition. The incentives are offered by health plans and employers, as well as federal and state-sponsored pilot programs—such as CMS and some private payors. Federally Qualified Health Center providers who submit claims electronically may be eligible to receive care management payments. Providers on board with Meaningful Use requirements are eligible for incentives as well. Excellus Blue Cross Blue Shield reported that nearly 60 percent of physician groups participating in 2011 earned financial incentives based on the attainment of savings and quality performance.

Effective March 25th, all eligible providers who have their own panel of patients can obtain PCSP recognition. Eligible providers include MDs, DOs, NPs, PAs, CNMs, and state-licensed MS or PhD: psychologists, clinical social workers and counselors.

Currently, the PCSP standards align with CMS Meaningful Use Stage 1 and Stage 2 criteria. However, since MU Stage 2 collection of data will not begin until October 2014 with January 1, 2015 data submission, only the MU Stage 1 criteria will be used to evaluate the medical practice. The NCQA has released a crosswalk between the PCSP and Stage 1 and 2 MU standards. http://www.ncqa.org/Portals/0/Public%20Policy/HITPC_Stage3_NCQAfinal.pdf

There are six requirements for this new model. The Patient-Centered Specialty Practice (PCSP) Recognition standards include:

1. Track and Coordinate Referrals: Specialty practice collaborates effectively with PCPs and other specialists to coordinate testing and care of shared patients. The content of the referral communications supports the needs of all clinicians.

2. Provide Access and Communication: Timely access to appointments, timely responses to telephone and secure electronic messages during and after office hours, addressing patients’ cultural and language needs, explaining the roles of PCPs, specialists, and the patients in the relationship. In addition the standards include development of a specialty practice team where each team member is trained to be patient-centered and contribute to the top of their license or role.

3. Identify and Coordinate Patient Populations: Capture key clinical and administrative data to facilitate reporting on specific populations. Demonstrate that the specialty practice is using evidence-based tools for managing care for those populations and following up proactively when care is needed.

4. Plan and Manage Care: Development of a patient-centered care plan by specialty practice alone, or in collaboration with PCP or other specialists, and assessment of barriers and progress in that care plan. Specialist practice manages patients’ medications, and provides educational resources or refers patients to community services as needed.

5. Track and Coordinate Care: Specialty practice coordinates use of lab, imaging, and other specialty referrals with PCP practices or other specialists caring for a patient. These are tracked proactively from the point of request through receipt and patient notification. Patients are also tracked as they move through transitions of care such as hospitalizations.

6. Measure and Improve Performance: Measurement of a number of clinical processes or outcomes and patient experience, showing improvement over time. Practice demonstrates transparency by sharing data within the practice and with external organizations.

The web-based PCSP tool includes the Standards and Guidelines, explanations and examples The Survey Tool also includes all the information and the electronic data collection tool needed to prepare and submit materials to apply for recognition and is available on the NCQA website:

http://www.ncqa.org/PublicationsProducts/RecognitionProducts/PCSPProducts.aspx

The NCQA offers an eligibility-application-recognition process flowchart to assist interested providers in having a clear vision of the goals that need to be met to attain and to retain recognition:

The NCQA offers an eligibility-application-recognition process flowchart to assist interested providers in having a clear vision of the goals that need to be met to attain and to retain recognition:

http://www.ncqa.org/Portals/0/Programs/Recognition/PCSP/PCSP%20start%20to%20finish%20full%20image.jpg

For more information, visit the NCQA website:

http://www.ncqa.org/Programs/Recognition/PatientCenteredSpecialtyPracticeRecognition.aspx

Political battles from 2012 spill into 2013

As new Representatives and Senators are sworn in and incumbents return to Washington, there will be close scrutiny on whether the 113th Congress will be more productive and better able to work together to address contentious issues of raising the debt ceiling again and revisiting the delayed sequestration cuts. Additionally, this may be the first time in decades that Congress considers significant entitlement reform in an attempt to address the nation’s long-term fiscal health and concerns about program solvency. As part of a broader deficit reduction package, we will advocate that Congress finally repeal the SGR.

March sequestration showdown to include 2 percent Medicare provider cuts

The fiscal cliff legislation (the American Taxpayer Relief Act of 2012) delays the “sequester” cuts for two months, which prevents various defense and other automatic cuts from occurring at that time. These cuts include an across the board, 2 percent cut for all Medicare providers. It’s expected Congress will revisit issues related to the sequester in the near future.

States prepare for 2014 healthcare reform implementation

States have their work cut out for them as they get ready for the 2014 implementation of numerous aspects of healthcare reform, such as preparing to open healthcare Exchanges and potentially expanding their Medicaid programs. Additionally, insurers are preparing to meet new requirements; employers are evaluating how to avoid certain fines for not providing insurance coverage; and the healthcare industry is making necessary changes in order to provide coverage to millions of newly insured Americans.

New Medicare Physician Fee Schedule in effect

Although Congress averted the SGR cut for 2013, other payment changes from the final 2013 Medicare Part B Physician Fee Schedule are now in effect. The fee schedule includes a number of policies impacting Part B payments for physician services furnished on or after Jan. 1, 2013, such as RVU changes and an expansion of the Multiple Procedure Payment Reduction (MPPR). MGMA created an analysis exclusively for members to help them understand the key changes to Medicare Part B for 2013.

Also see the new MGMA fee schedule analysis tool that allows you to compare the new fee schedule to last year’s fee schedule. Upload CPT codes for the providers in your practice, and the tool will calculate the changes in work and total RVU values.

Key year to avoid future quality reporting penalties (PQRS, MU, eRx)

2013 is a critical year for eligible professionals (EPs) and practices to avoid penalties under three of Medicare’s biggest quality reporting programs: e-prescribing, Physician Quality Reporting System (PQRS) and the EHR incentive program Meaningful Use. Successfully meeting various program criteria in 2013 can allow EPs to avoid the following penalties on future Medicare payments:

2013 Program Participation Penalty / year levied

e-prescribing 2% penalty / 2014

PQRS 1.5% penalty / 2015

Meaningful Use 1.0% penalty / 2015

Payment increases for primary care

The growing emphasis on care coordination and primary care results in opportunities such as the new Medicare transitional care management services. Additionally, beginning in 2013 there will be higher payment for Medicaid primary care services furnished by certain providers via the Medicaid/Medicare primary care payment parity program. Learn more about this in our member resource outlining key points of the final rule.

Implementation of key administrative simplification provisions

Jan. 1 is the compliance date for the first set of mandated administrative simplification operating rules improving the electronic transaction for patient insurance eligibility verification and the electronic transaction that requires health plans to identify the status of a claim. Although CMS recently announced a 90 day enforcement delay, practices should check with their practice management system vendors and health plans to take advantage of these administrative improvements.

Countdown to ICD-10

The healthcare industry prepares to transition from the current ICD-9 diagnosis code set to the vastly more complicated ICD-10 code set. In 2012, CMS finalized another ICD-10 delay from Oct. 1, 2013 to Oct. 1, 2014. Transitioning to the expanded code set will have a significant impact on medical practices, in terms of implementation costs, workflow modifications and cash flow disruption. MGMA strongly advocates that the government not transition to ICD-10 unless it demonstrates that the benefits of the new code set outweigh the costs. Access MGMA ICD-10 resources to learn more about the requirements.

Large groups must act to avoid value-based payment modifier penalty, potential bonuses available

Groups with 100 or more eligible professionals need to participate in 2013 PQRS GPRO to avoid a 1 percent Medicare penalty in 2015. Some groups may choose to participate in a voluntary value modifier “quality tiering” program and have their practice evaluated based on the quality and cost of the care they deliver. Under this optional program, groups may earn a bonus or be penalized based on their performance. Learn more in the 2013 final physician fee schedule analysis.

CMS emphasizes Medicare payment reform demonstrations and pilots to explore fee-for-service alternatives

The Centers for Medicare and Medicaid Innovation (CMMI) continues to implement new programs designed to explore alternatives to fee-for-service payment. CMMI opportunities include voluntary programs focused on concepts like accountable care, patient engagement and care coordination. This year practice executives will be able to assess the results of whether the first accountable care organizations in the Medicare Shared Savings Program (MSSP) were able to meet, or exceed, their initial target benchmarks and share savings with the government. These initial results will enable practice executives to evaluate whether the MSSP would be a worthwhile program for their practice. Additionally, these results will give insight on the feasibility of expanding this and similar programs.

Expansion of government audits to curb Medicare fraud, waste and abuse

Dramatic increases in Recovery Audit Contractor (RAC) payment corrections in 2012 reflect a heightened CMS focus on addressing improper Medicare payments. The Department of Health and Human Services (HHS), along with the Department of Justice, have raised concerns about the use of EHRs to increase coding intensity and signaled that CMS would initiate more extensive medical reviews of evaluation and management (E/M) services. Despite MGMA’s objections, CMS has thus far allowed one of its RACs to perform a limited number of complex reviews of level 5 E/M services. Practices may see more audits and a greater focus on documentation issues in 2013, and members are encouraged to review the Medicare coding guidelines and ensure documentation accuracy. Visit our RAC Resource Center for the latest updates on RACs.

Release of long-awaited key compliance regulations

HHS is expected to finalize further details regarding requirements on reporting and returning all Medicare and Medicaid overpayments to CMS within 60 days of being identified. Additionally, HHS will likely release a final rule outlining the “Sunshine Act” provisions, which require drug, device, biological and medical supply manufacturers to report to CMS any payments or other value transferred to physicians or teaching hospitals. This may also be the year that HHS finalizes long-awaited privacy and security regulations that address extending HIPAA requirements to business associates, providing patients with an accounting of disclosures of patient information, and notifying patients and the government when a breach occurs.

SGR cuts loom for 2014

Congress must act by the end of 2013 to avert the 2014 physician payment cut resulting from the flawed SGR formula. Because of the extensive scope of issues related to deficit reduction, 2013 represents the best opportunity in years for Congress to address the SGR in any grand bargain. MGMA continues to fight for repeal of the SGR to finally end the cycle of increasing Medicare physician payment cuts and the growing SGR debt.

Healthcare providers and organizations must be highly vigilant in an atmosphere of stricter scrutiny and regulatory enforcement by the federal government. In particular, they must preserve their participation rights in Medicare and Medicaid.

As Medicare has experienced cuts in funding – with potentially more on the horizon – the Centers for Medicare and Medicaid Services (CMS) has stepped up enforcement activities to combat fraud in the delivery of health care services. Fraud takes many forms, from submitting claims for services not performed to “upcoding” for services that were provided.

Even if these errors are a result of unintentional mistakes, there is cause for concern. That’s because one of the more significant civil penalties that CMS, in partnership with the Office of Inspector General (OIG), imposes is excluding providers from participating in federal health care programs.

Consequences of Exclusion

Some conduct (such as a felony conviction for fraud) gives rise to mandatory exclusions, while others (such as failing to undertake corrective action in response to an incident) may or may not result in exclusion. This is determined by OIG.

Exclusion results being placed on the list of excluded individuals and entities (LEIE), which is maintained and searchable online. The consequences of being placed on the LEIE can be far-reaching.

In addition to not being able to participate in Medicare, placement on the LEIE will likely:

1. Result in the individual or entity also being barred as a participating provider with private health insurers.

2. Trigger breaches of employment agreements, and may jeopardize a provider’s clinical privileges.

3. Result in the individual or entity being terminated from Medicaid programs.

Steps to Present Exclusion

Organizations can take steps to minimize the likelihood of ending up on the LEIE. While the OIG has posted extensive guidance on this, the key strategy is developing and implementing an effective compliance program. According to the OIG, there are seven hallmarks of an effective plan:

Audits. An effective program will include periodic audits to monitor compliance with, and the effectiveness of, the plan. This will include auditing charts to confirm that services being provided are reasonable and necessary, as well as auditing coding and billing to ensure proper billing for services. This needs to be done periodically.

Written standards. The plan should be written, and include readily identifiable standards and procedures. This will include identifying potential areas of risk to the organization, and then identifying the standards to be followed (whether they relate to proper billing or identifying what are reasonable and necessary medical services).

Oversight. An effective plan will be overseen by one or more persons designated as compliance officers. The organization should provide a detailed description of the officer’s duties and conduct periodic evaluation of the officer’s performance.

Education. Ongoing training and education is critical to ensuring that providers and staff understand the plan, its standards, and the protocols that are in place to ensure compliance. Training will encompass not only the plan, but also the key areas of the organization’s operations (for example, training on proper coding/billing protocols). As with other aspects of the plan, the organization should review and update its training and education.

Responsiveness. An effective plan includes procedures to timely and effectively investigate and respond to incidents of fraud, including notifying the appropriate governmental agency(ies) of such incidents. An organization may want to consider identifying in its plan red flags that may indicate fraud, as well as specific timelines for investigating incidents.

Communications. Open lines of communication within an organization will ensure that providers/staff remain aware of the plan and its requirements, and also foster an environment where members of the organization feel comfortable sharing information about potential fraudulent conduct.

Discipline. Well-defined standards for how discipline will be meted out will help impress upon the organization’s members the serious repercussions should there be non-compliance. Discipline can include a multi-step approach, from warnings to (in serious cases) immediate termination.

It is up to each organization to incorporate these features into its plan. Smaller organizations, given their limited resources, have more flexibility. Larger organizations, on the other hand, are expected to have a more comprehensive plan in place.

Petitioning the OIG

If, for any reason, a health care organization faces placement on the LEIE, it should petition OIG to not be included. If that fails, the organization should, at the end of the exclusion period, request reinstatement in the federal payor programs.

This is done by written request to the OIG. If reinstatement is granted, the organization should then request reinstatement in Medicaid and private payor programs. These should be made in writing, although a hearing may be required before reinstatement is granted.

However, with the proper planning and implementation, healthcare organizations and providers can develop plans that reduce the risk of fraud and ensure they remain out of the cross hairs of the OIG. Even if your organization already has a plan, you should periodically review that plan to ensure it contains the appropriate elements and that your organization’s members are following it.

Currently, there are three primary laws that the federal government is using to prosecute fraud claims: False Claims Act (FCA), the Anti-kickback statute (AKS), and the Physician self-referral law (Stark). Violations of the FCA and AKS can result in the imposition of criminal penalties on health care providers, while violation of any of the three can also result in civil penalties. If you are uncertain about your current rights and obligations under these laws, consult legal counsel that is well versed in the complexities and changing nature of federal health care law.

Michael J. Daray is a shareholder at Law Weathers in Grand Rapids, Mich., with a diverse healthcare and business law practice that represents health care providers on regulatory, compliance and business issues such as electronic medical record licensing agreements.

The American Medical Association (AMA) has revamped its Current Procedural Terminology (CPT) codes for 2013. These changes are effective as of January 1st. The key to reducing claim denials is to examine your chargemaster. The deletions and additions of CPT codes will require that your practice closely re-examine your providers’ encounters/superbills. Even the new language in some of these new codes requires particular documentation to support billing for each service. It’s imperative that your group review the changes to ensure a prosperous New Year!

The most critical changes were the ones that affect each provider, regardless of specialty or place of service—the Evaluation and Management codes (E/M). Among the many different types of changes, CPT 2013 revised the description of 82 of its E/M codes within the range 99201-99467. The majority of the revisions are advantageous in the description of each code by now specifying that these E/M services are no longer limited to use by a physician. The descriptors that once read “physicians” now read as “qualified health care professionals”.

The 2013 AMA CPT book also introduced seven new codes among these three new Evaluation and Management categories: 1) Supervision by a control physician of interfacility transport care of the critically ill or critically injured pediatric patient; 2) Complex chronic care coordination services, and; 3) Transitional care management services. The last 2 of these 3 new E/M categories will mostly affect Family Practice, General Practice and Internal Medicine providers. The following guidance was paraphrased from the AMA CPT ® 2013 guidelines:

E/M: Pediatric Critical Care Patient Transport (99485-99486)
These two new, time-based codes are intended for reporting the non face-to-face work of a control physician directing care during interfacility transport. The patient’s age and medical condition (critical illness or critical injury), and the total time, must be documented. When determining time, do not include pre-transport communication with the referring or accepting facility. Only the time spent directly by the transport team may be used to determine reportable time. The controlling provider cannot code for any of the procedures performed by the team performing the transport. Do not report 99485 or 99486 with 99466 or 99467 for the same patient.

E/M: Complex Chronic Care Coordination Services (99487-99489)This new E/M category reports coordination of care for patients with chronic illnesses. Effective coordination of services among providers to manage complex conditions requires significant staff and provider time. Patients with one or more chronic illnesses expected to last at least 12 months, acute exacerbation of an illness, or functional decline qualify for the use of these codes. The coordination activities are detailed in the coding guidelines preceding 99487–99489. Codes are reported per calendar month. At least one hour must be documented to claim the services. Documentation templates to record the date, time spent on chronic care coordination, and the care coordinated will facilitate proper documentation to support the services.

E/M: Transitional Care Management Services (99495-99496)This new E/M subsection reports transitional care management for patients discharged from an inpatient hospital, observation, or a skilled nursing facility. The goal of transitional care is to provide services needed to transition the patient from a facility to his or her home, domiciliary, rest home, or assisted living. Such care helps to prevent readmissions and lowers the cost of health care (outpatient care is less expensive then inpatient care). To qualify for these codes, the medical decision-making must be of moderate to high complexity. The services include one face-to-face visit and non face-to-face services (e.g., arranging home health agencies for patient care). Coding guidelines preceding this subsection list the services performed for transitional care. Codes are selected based on medical decision-making associated with the patient’s condition, when the communication is initiated with the patient, and when the face-to-face encounter occurs following discharge. The first face-to-face encounter is included. The codes may be reported only once per 30 calendar days.

Each of the other six major CPT sections has had changes made to them also. The smallest CPT section of Anesthesia only underwent descriptor revisions for 2 of its codes, whereas many new codes were introduced to the most voluminous of the six CPT sections: the Surgery Section. For example, the Integumentary System subsection changed the requirement for Island pedicle flap code 15740. The Musculoskeletal System subsection revised 3 of its codes, added 5 new codes (pre-sacral anterior arthrodesis technique and 4 shoulder arthroplasty codes), and deleted 29590 (Denis-Browne splint strapping). The Respiratory subsection of Surgery introduced bronchoscopy and bronchial thermoplasty codes to replace several previous codes. Codes for thoracocentesis and pneumocentesis have been replaced with more current procedures. The Cardiovascular subsection of Surgery brings about over twenty new codes including transcatheter heart valve replacement codes, cardiac assist devices, and vascular injection procedures—for which the catheterization, contrast, fluoroscopy, supervision and interpretation and arteriotomy closure and now included in each of the vascular injection codes. The Digestive system introduced 2 new procedures: esophagoscopy with optical endomicroscopy (43206), and; upper GI endoscopy with optical endomicroscopy (43252). The Urinary subsection of Surgery introduced a new cystourethroscopy with bladder denervation procedure (52287). The Nervous system code changes were mostly code descriptor revisions with only one new code added for chemodenervation of the muscles innervated by facial, trigeminal, cervical spinal and accessory nerves (64615).

Another large section of CPT–the Radiology section, underwent 15 description revisions and 19 code deletions. The Nuclear Medicine subcategory had 7 thyroid imaging procedures deleted and replaced by 5 new codes for thyroid and parathyroid imaging. Bronchography and carotid and cerebral angiography codes were deleted. Four new codes for injection thrombolysis were introduced (37211-37214). The rest of the changes were made to the language in order to include either post-processing imaging, or to denote that a “qualified healthcare professional” could perform the service, no longer limited to a physician, only.

The Pathology and Laboratory Section of CPT now includes over 40 new lab codes and many existing code descriptor revisions. Over 20 DNA or RNA identification, amplification, isolation, lysis, gel separation, and interpretation codes have now been permanently deleted.

The Medicine Section underwent numerous changes. Three vaccines were deleted, and 2 new flu and 1 new Hepatitis B prophylactics were added. The psychiatry subsection of Medicine had a complete overhaul done: Two new codes for diagnostic evaluation were added as well as one new add on code for interactive complexity, and; a total of twenty eight former codes for individual, group psychotherapy and medical evaluation and management services were deleted and replaced by the 12 new codes that accompany the 18 remaining existent codes from 2012. Hemodialysis and ESRD services only had the code language altered. Gastroenterology introduced a code for GI transit and pressure measurement of a capsule from stomach to colon, including the interpretation and report (CPT 91112). Under Coronary Therapeutic Services and Procedures, percutaneous coronary angioplasty, artherectomy and revascularization codes were deleted and replaced by new code numbers and descriptions. The Intracardiac EPS subcategory introduced 5 new codes. Neuromuscular procedures introduced 7 nerve conduction study codes, 2 intraoperative monitoring add-on codes, and 2 sympathetic/parasympathetic function test codes.

Seven new Category II supplemental tracking codes were added for the purpose of performance measurement. A total of 28 new Category III temporary codes were added for emerging technology, services and procedure billing.

While the changes may seem overwhelming at first, they do provide your healthcare professionals with more advantages. State laws and carrier policies permitting, more of your PAs, NPs, CNSs, CNMs, and other specialty therapists will be permitted to use the E/M codes that were once exclusive to physicians.

Navigating the turbulent waves can be challenging for individual practioners and even large multispecialty groups. Our newsletter articles are written to familiarize your practice with important changes in the industry and provide you with the knowledge and the confidence that will keep your business afloat. Healthcare Solutions WNY provides many business services designed for your practice’s success. Contact us today and let us guide you towards smooth sailing throughout 2013.

Since generating cash to meet overhead, payroll and other monthly expenses can quickly become difficult, Healthcare Solutions is offering some tips to help avoid one of the most common fiscal afflictions facing practices and businesses today – insufficient cash flow. Cash flow is notoriously difficult to predict and slow paying customers, insurers, unexpected expenses and seasonal dips can quickly turn a positive outlook gloomy.

1. Know where you stand

When it comes to cash flow, knowledge is power. Cash flow crunches do not appear out of nowhere and they can often be spotted- and avoided- if you know exactly where you stand by using a cash flow statement.

2. Actively manage outflows

You are in control of accounts payable. When cash is tight, delay payments as much as possible, but without paying late to avoid late fees. Using charge cards to cover purchases is one option, but avoid carrying balances from month to month and incurring interest charges.

3. Streamline monthly expenses

The most obvious way to balance receivables with payables is to simply reduce expenses. Take a look at recurring costs. Even a small reduction can add up to a significant savings over the course of a year.

4. Create plan B

Every practice needs to find cash for unexpected expenses or for important investments, such as a new office or medical equipment. In these cases, it’s important to have several sources of financing lined up before a practice needs it, such as a line of credit. Don’t overlook special lending programs a practice may qualify for, such as those designated for small businesses owned by women or minorities.

5. Stay on top of receivables

There are many steps a practice can take to maximize receivables. If the practice has outlined payment terms to patients for self pay amounts, it is important to stick to them as much as possible. If the policy indicates payment is due at time of service, make sure your staff is trained to ask for payment at the time of service. If your practice makes calls to remind patients of their appointments, also remind them of payment responsibilities.

6. Offer a variety of payment options

If a practice is not willing to take the risk of offering an early-payment discount, another possibility is to encourage the use of debit and credit cards. Patients may be more willing to pay while they’re still in the office if they are using a credit card because it allows them to delay the expense or pay over time. There are bank transaction fees incurred by the practice with accepting credit cards but the payment at time of the visit may outweigh the expense of trying to collect from the patient later on.

7. Revamp collections

Stay on top of collections well before they are overdue. Begin by making sure all billing information is up to date. By maintaining current telephone numbers and address information, a practice can speed collections work and reach patients promptly. Wrong contact information or missing information will only add more time to the collection cycle.

8. Outsource receivables

If your practice cannot keep up with all of the billing functions, consider outsourcing the receivable function to devote the time and diligence it takes to make phone calls, receive payments and make deposits needed to maintain a practice cash flow.

Source: Medical Office Today