Getting Your Practice Acquainted with 2013 CPT Code Changes in the New Year

By Liz Wilson,RT, CCS, RHIT, CEMC, CPMA
Director of Coding and Auditing
Compliance Officer

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”.

Operating Rules for Patient Insurance Eligibility Verification and Claim Status Inquiry

Transaction standards adopted under the Health Insurance Portability and Affordability Act of 1996 (HIPAA) enable electronic data interchange using a common interchange structure, thus significantly decreasing administrative burden on covered entities and reducing the amount of paper forms needed for transmitting data. However, due to the flexibility of the standards, each health plan used the transactions in very different ways, resulting in significant gaps which remain an obstacle to achieving greater administrative simplification.
These gaps spurred the creation of “companion” guides by health plans, which describe their unique implementation of HIPAA transactions and how they intend to work with business partners. Companion guides can vary widely in format and structure, which can be confusing both to health care providers and the trading partners who must implement them. It is estimated that there are currently over 1,200 such companion guides.
The abundance of health plan companion guides led to the development of voluntary operating rules, which aim to reduce costs and administrative complexities by fostering uniform standards and implementation guides across the health care industry. Specifically, they define the rights and responsibilities of all parties, security requirements, transmission formats, response times, liabilities and claims resolution tactics in order to facilitate successful administrative interoperability between health plans and providers. The CAQH CORE was charged the important task of gathering input from and building consensus among health care industry stakeholders to ultimately develop a set of universal operating rules.
The rules were released in two distinct phases. Phase I focused on the eligibility for a health plan transaction–electronically confirm patient benefit coverage, copays, coinsurance and base deductibles and allows providers to access needed patient information prior to or at the point of care via common internet protocols. Phase II adds rules for claim status transactions regarding patient matching, infrastructure requirements and prescriptive connectivity. It also expands on the first set of eligibility rules by adding a requirement for transaction recipients to send back patient remaining deductible amounts. Both the Phase 1 and Phase II rules were endorsed by MGMA.
Section 1104 of the Affordable Care Act of 2010 mandated operating rules for each of the HIPAA standard transactions and electronic funds transfer. The first set of mandated operating rules was released July 8, 2011 as an interim final rule by the Department of Health and Human Services. These operating rules adopted the CAQH CORE Phase I and II requirements and support and improve the insurance eligibility verification and claim status transactions. HHS finalized the rule on December 7, 2011.
The implementation date is set for January 1, 2013. By this time, health plans must become compliant with the operating rules for eligibility and claims status transactions. Additional operating rules will be implemented, with the next set (EFT and electronic remittance) next in line with a Jan. 1, 2014 compliance date. In the meantime, providers are strongly encouraged to reach out to their practice management system software vendors and clearinghouses to determine
if they will be supporting operating rules and how the practice can take advantage of these administrative simplification initiatives.
Penalties on Health Plans
December 31, 2013 is the first certification deadline whereby health plans must file a statement with HHS certifying that their data and information systems are in compliance with all new standards and operating rules. According to CMS, regulation detailing the health plan certification process is still under development. We expect additional regulations to be issued shortly. In April of 2014, penalties will begin to be assessed against health plans failing to meet certification and compliance requirements. The fee equals $1 per covered life each day until certification is complete.

8 Tips to Preserve Cash Flow

Have you ever heard “cash is king”? In current difficult economic times, a practice can never underestimate the importance of having a cash reserve in the bank. Cash flow is obviously a fundamental aspect of a practice – one you must treat with great care and seriousness.

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.

Medicare Update on Outpatient Therapy Claims

By Liz Wilson,RT, CCS, RHIT, CEMC, CPMA
Director of Coding and Auditing
Compliance Officer

“Revisions of the Financial Limitation for Outpatient Therapy Services – Section 3005 of the Middle Class Tax Relief and Job Creation Act of 2012,” were recently implemented. The Middle Class Tax Relief and Job Creation Act of 2012 (H.R. 3630) was signed into law on February 22, 2012. This law extends the Medicare Part B Outpatient Therapy Cap Exceptions Process through December 31, 2012. In response to this federal mandate, the Centers for Medicare and Medicaid Services (CMS) recently implemented a new process regarding the maximum allowable annual limits for Physical (PT),and for Occupational (OT) and Speech-Language Pathology Therapy (SLP). This process is directed at all Part B outpatient setting, including outpatient services at hospitals, private practices, skilled nursing facilities, home health agencies, outpatient rehabilitation facilities, and comprehensive outpatient rehabilitation facilities.

New System for Patients to Report Medical Mistakes

The Obama administration wants consumers to report medical mistakes and unsafe practices by doctors, hospitals, pharmacists and others who provide treatment.

In a flier drafted for the project, the government asks: “Have you recently experienced a medical mistake? Do you have concerns about safety of your healthcare?” And it urges patients to contact a new “consumer reporting system for patient safety.” Federal officials said the reports would be analyzed by researchers from the RAND Corporation and ECRI Institute, a nonprofit organization that has been investigating medical errors for decades.

In a reporting system envisioned by the Obama administration, patients and their relatives would report medical errors and near misses through a website and in telephone interviews.

For each incident, the government wants to know “what happened; details of the event; when, where, whether there was harm; the type of harm;contributing factors; and whether the patient reported the event and to whom.” The questionnaire asks why the mistake happened and lists possible reasons:
1. A doctor, nurse or other health care provider did not communicate well with the patient or the patient’s family.”
2. A health care provider did not respect the patient’s race, language or culture.”
3. A health care provider didn’t seem to care about the patient.”
4. A health care provider was too busy.”
5. A health care provider did not spend enough time with the patient.”
6. Health care providers failed to work together.”
7. Health care providers were not aware of care received someplace else.”

If the pilot project is cleared by the White House, health officials hope to start collecting information in May, 2013. Questionnaires would be available at kiosks in hospitals and doctor’s offices. Reporting is voluntary, and federal officials said they would keep the information confidential.

Top 10 OSHA Citations for Medical Offices

By Tiffani Hiudt Casey, attorney with Fisher & Phillips LLP

OSHA identified the following general industry standards as the top cited among doctors’ offices and clinics from October 2010 through September 2011: bloodborne pathogens, hazard communication, electrical wiring methods, respiratory protection, use of the proper recordkeeping forms, recordkeeping summaries, design and construction of exit routes, medical services and first aid, and general requirements for personal protective equipment.

A more detailed look at the specific standards is important, however, to identify where the most critical issues within those particular standards may be an issue in an employer’s office. In the last 6 months of 2011, as reported on the US Department of Labor website, the most frequently cited standards among doctors’ office and clinics are as follows:

Billing for Locum Tenens Services

By Liz Wilson, BS, RT, CCS, RHIT, CEMC, CPMA Director of Coding and Auditing Compliance Officer at HCSWNY

It is estimated that 40% of practices that utilize locum tenens neglect to bill for this service, losing out on an opportunity to recoup revenue. Most provider groups do not want to attempt to bill for the locum tenens because they feel that it is too difficult to do so. Often physician practices prefer to work understaffed (in the absence of a full-time provider) than to risk entanglement with the insurance companies.

Understanding how to properly bill for Locum Tenens services ensures that your practice continues to generate revenue while not disrupting your patients’ continuity of care.  The role of your locum and the duration of the assignment will dictate the appropriate billing method for your practice.

The locum tenens (one who “holds the place of”) traditionally covers for the provider that is on vacation, has taken a leave of absence, or has fallen ill for an extended period of time.  It is also customarily used for seasonal coverage and during practice expansion.

However surprising it may be for most of us—Medicare does allow you to bill for locum tenens services.  Medicare will pay for this service provided that the following conditions are met: