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Newsletter 2015 Q1

Introducing Andrea Devlin, New Consultant at Alta Partners

Alta Partners, LLC is pleased to announce the addition of Andrea Devlin, CPC as Healthcare Consultant to our team. Andrea has over twenty years of experience in healthcare, working within the Northeast Ohio healthcare community in various capacities. She began her career with Sheffield Lake Family Care Center where she worked as a medical billing specialist for five years before the practice merged with Westshore Primary Care Associates. During the merger, Andrea worked as a site manager to ensure a smooth transition. After the merger she worked at Westshore for thirteen years in various positions including Physician Referral Specialist, Reimbursement Specialist, and Accounts Receivable Supervisor. She supervised a billing staff of five and coordinated six office sites with a standardized referral process among all offices.

After becoming a Certified Professional Coder (CPC), Andrea joined the Cleveland Clinic Foundation as a medical coder and auditor. Her responsibilities included conducting audits for the orthopedic and rheumatology departments which consisted of over 45 medical professionals. Before joining Alta Partners, Andrea was working as a billing manager at a local OB/GYN practice. Andrea is certified and proficient in CPT, HCPCS, ICD-9, and ICD-10 coding and is currently working on her Certified Professional Medical Auditor certification.

Andrea specializes in medical chart coding and auditing. She will be working with the Alta Partners’ consulting team to perform medical chart reviews and coding education and training. To learn more about the medical chart review services Alta Partners offers, click here.

Contact information:
Email: amd@altapartnersllc.com
Phone: (440) 808-3710


Changes for the 2015 Medicare Physician Fee Schedule

Sustainable Growth Rate (SGR)

Permanent legislation to prevent the reduction in physician fee schedule rates was not included in the 2015 final fee schedule ruling. CMS did comment that Congress, in years prior, has taken action to avoid the reductions. If legislation is not passed by March 31, 2015 to postpone or correct this, physicians risk a 21.2% reduction in rates. In its ruling, CMS stated that it supports legislation to permanently change SGR to “provide stability for Medicare beneficiaries and providers while promoting efficient, high quality care.”

Physician Fee Schedule Reimbursement Changes

The 2015 Physician Fee Schedule Final Rule included changes to reimbursement rates for Medicare Part B. These changes were based on changes to the Relative Value Units (RVU's) which include the Work, PE, and Malpractice RVU's. As part of the final rule, the Centers for Medicare & Medicaid Services (CMS) included a reimbursement impact analysis to assess the overall impact these RVU changes would have on allowed charges.

In previous years, the estimated impact has varied among specialties, ranging in 2014 from a positive 12% to negative 11% impact. In 2015, the estimated impact has only a slight variation between the different specialties.

The chart below summarizes the specialties estimated to be positively impacted by the RVU changes.

The chart below summarizes the specialties estimated to be negatively impacted by the RVU changes.

For all other specialties (those not listed in the charts above) the estimated impact is 0%.

Chronic Care Management

In the CY 2014 final rule CMS discussed many of the parameters surrounding chronic care management. The details for this service were finalized in the CY 2015 ruling. While previously expected to create a G-code for chronic care management services, CMS created CPT code 99490 for these services with the following description:

Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored.

The code was assigned a Work RVU value of 0.61 and payment rate of $42.60 that can be billed up to once per month for 20 minutes of chronic care activity per qualified patient.

Enhanced Transparency in PFS Rate Setting

CMS created a new process for determining fee schedule payment rates in an effort to improve transparency. The new process will allow payment rates to go through a notice and comment period prior to being adopted. CY 2015 was used as a transition year while the process is finalized. CY 2016 will serve as a transition year once the process has been further refined with full implementation in CY 2017.

Global Surgery

In the CY 2015 proposed rule, CMS proposed transitioning 10- and 90- day global codes to 0-day global codes by 2017. The changing of global surgery packages stems from a concern that the codes are valued incorrectly, with fewer visits actually occurring than are accounted for in the global codes. After reviewing comments, CMS decided in its final rule to spread the transition over CY 2017 and CY 2018. 10-day global services will be transitioned in 2017; 90-day services will be transitioned in 2018. During this time, CMS plans to assess whether there is a better to construct bundled payments for surgical services that incentivizes care coordination and care redesign across an episode of care.

Telehealth Services

CMS added the following services to the list of covered telehealth services:

  • Annual wellness visit

  • Psychoanalysis

  • Psychoanalysis

  • Prolonged E/M services requiring direct patient contact

Off-Campus Provider-Based Departments

CMS will begin collecting data on off-campus provider-based departments in an effort to better understand the growing trend of hospital acquisition of physician offices and treatment of those locations as off-campus, provider-based, outpatient departments. Data collection will be accomplished by requiring hospitals to use a modifier for services performed in these settings and a new place of service code on professional claims. This reporting will be voluntary for hospitals in 2015, required beginning January 1, 2016. CMS is currently working to finalize its proposal to create a HCPCS modifier for hospitals to use. The new place of service code will be required for professional claims as soon as it is available, but not before January 1, 2016.


OIG Focus in 2015 – Highlights from the 2015 Work Plan

On October 31, 2014 the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) released its Work Plan for Fiscal Year 2015. The work plan outlines new and ongoing reviews and projects the OIG plans to pursue with respect to HHS programs and operations during the current fiscal year. The plan includes projects for the major departments of HHS including the Centers for Medicare and Medicaid Services (CMS), public health agencies, and the Administrations for Children and Families.

Below are highlights of initiatives addressing CMS operations, specifically Medicare Part A and Part B programs.  

New Inpatient Admission Criteria

The OIG will be reviewing the effects of the inpatient admission criteria (known as the “two midnight policy”) to determine the impact on hospital billing, Medicare payments, and beneficiary copayments. Variations among hospitals’ billing in 2014 will also be reviewed.

Medicare Oversight of Provider-Based Status

Provider-based facilities are facilities owned and operated by hospitals, typically located off-site, that are operated as outpatient departments. Services at these facilities are reimbursed both a technical fee (hospital) and professional fee (physician). The OIG will review the extent to which provider-based facilities meet CMS’s criteria to qualify for this status.

Comparison of Provider-Based and Free-Standing Clinics

Medicare payments for physician office visits in provider-based clinic and free-standing clinics will be compared to determine payment differences. The OIG would like to assess the potential impact on the Medicare program of hospitals’ claiming provider-based status for its facilities.

Outpatient Evaluation and Management Services Billed at the New Patient Rate

Medicare outpatient payments made to hospital for evaluation and management (E/M) services for clinic visits billed at new patient rates will be reviewed. The goal is to determine whether or not the billing of these visits as new patients was appropriate based on Federal regulations. According to Federal regulations, the meaning of “new” and “established” pertains to whether the patient has been seen as a registered inpatient or outpatient of the hospital within the past 3 years. Based on preliminary work, overpayments have occurred due to established patients being billed as new patients.

Ambulatory Surgical Centers: Payment System

Medicare’s methodology for setting ambulatory surgical center (ASC) payment rates will be reviewed for appropriateness. The rates will also be reviewed to determine whether a disparity exists between ASC and hospital outpatient department payment rates for similar surgical procedures provided in both settings.

Anesthesia Services: Payments for Personally Performed Services

Medicare Part B claims for personally performed anesthesia services will be reviewed to determine whether they follow Medicare guidelines. Personally performed anesthesia services (modifier AA) are reimbursed at higher rates than those services where the anesthesiologist provided medical direction but did not personally perform the services.

Physicians: Place-of-Service Coding Errors

Medicare Part B claims for services performed in ASC’s and hospital outpatient departments will be reviewed to determine whether the place of service was coded correctly. Physician payments differ depending on where the service is performed.

Enhanced Enrollment Screening Process for Medicare Providers

In an effort to prevent fraud, waste and abuse resulting from the Medicare enrollment process, CMS has begun to implement new screening processes including site visits, fingerprinting, background checks, and an automated provider screening process. OIG will work to review the extent to which and the way in which CMS and its contractors have implemented these screening procedures. The effects of these processes will also be assessed by reviewing initial enrollment and enrollment revalidations approved and denied before and after the new processes implementation.

State Use of Provider Taxes to General Federal Funding

State health-care-related taxes imposed on various Medicaid providers will be reviewed to determine whether the taxes comply with applicable Federal requirements. The focus will be on the mechanism States use to raise revenue and the amount of Federal funding generated. Federal regulations define and set forth the standard for permissible health-care-related taxes.


Proper Documentation is a MUST When Using Modifier 25 & E/M Time Based Coding

Documentation in the medical record is an important aspect of providing medical care that also affects billing. Proper documentation to support the level of procedure billed helps to reduce denials and can offer protection in the event of a payer audit. The general philosophy of payers, including Medicare, is “if it’s not documented, you didn’t do it”, which can lead to not being reimbursed for work performed.

Modifier 25

Modifier 25 is used when a “significant, separately identifiable evaluation and management (E/M) service by the same physician on the day of a procedure” is performed. In short, you performed an E/M service above and beyond the other service provided. 

Example: A patient comes in for a preventative exam and is also complaining about a rash. Modifier 25 would be used to record that not only was a healthy check done, but the provider also treated the patient for the rash. When billing Medicare for this, the E/M service must be distinguished as separate from the preventive service provided.

Best practice is for two separate notes to be entered. However, this requires additional work for the provider. The next best solution is to clearly document that two separate exams were conducted. When in doubt, ask whether there is enough documentation to support each claim separately; whether each claim could stand on its own. “Double dipping” is not allowed on history, exam and assessment. Therefore, the exam and assessment of the acute condition must be clearly listed.

In conclusion, if the provider does not clarify that the additional service was above and beyond the routine exam, brought up by the patient and not discovered during the exam, both codes cannot be billed. Remember to verify your documentation is adequate before submitting the claim. 

Time Based Coding

When a patient comes in for a visit but an exam is not really necessary and counseling and/or coordination of care dominates the encounter, face-to-face time is considered the key or controlling factor to qualify for a particular E/M service level. Whether counseling and/or coordination of care dominated the encounter is determined by the “greater than 50% rule”, that is, was 50% of more of the encounter spent on performing these services including discussing the plan of care, test results, and patient options. If this applies, then the level of E/M service will be dependent on the face-to-face time of the encounter. To support this, it is important that the documentation in the medical record include a statement that describes (1) the total time of the encounter, (2) that 50% or more of the time was spent counseling the patient, and (3) what the counseling was pertaining to.


Allscripts User Tips

Our staff is here to help make sure your claims are processed efficiently. Below are some tips when working in the Allscripts system that will help to ensure your claims are processed quickly and help to reduce denials.

  • When entering a patient’s demographics, punctuation and special characters cannot be used. This includes periods, dashes, asterisks, and forward slashes. Only letters and numbers should be entered into this field.

  • If a patient is covered under both Medicare and a Medicare supplement policy, the supplemental policy should be entered as a commercial insurance product. Entering two Medicare policies would be incorrect since the supplemental policy is sold and administered by a private commercial insurance company.

  • When entering a patient’s insurance, it is important to include the effective date and termination date, if applicable, to ensure that the claim is billed to the correct payer based on the patient’s coverage on the date of service. If a patient presents new insurance coverage, letting your A/R person know through email can help ensure other claims are sent to the correct insurance based on the new insurance’s effective date.

  • Patients under the age of 18 years old are typically not their own responsible party; the responsible party tends to be a parent and/or guardian.

  • Medicare does not allow payment for code 99211 (with or without Modifier 25) when billed with a drug administration service code. Separately identifiable evaluation and management services billed performed may be billed using modifier -25 but must meet a higher complexity level of care than the service represented by CPT code 99211.


Medicare Updates and Resources

Throughout the course of the year, Medicare updates its policies and procedures and publishes provider resources. Below are some recent changes and useful resources currently available.

Pneumococcal Vaccinations

Prior to September 19, 2014, Medicare Part B only covered pneumococcal vaccinations for persons at high risk of serious pneumococcal disease (including all people 65 and older; immunocompetent adults at increased risk of pneumococcal disease or its complications because of chronic illness; and individuals with compromised immune systems) with revaccination for only those persons at highest risk of serious infection or likely to have a rapid decline in antibody levels, provided at least 5 years had passed since their previous vaccination. Effective September 19, 2014, Medicare will cover:

  • An initial pneumococcal vaccine to all Medicare beneficiaries who have never received the vaccine under Medicare Part B; and

  • A different, second pneumococcal vaccine one year after the first vaccine was administered (that is, 11 full months have passed following the month in which the last pneumococcal vaccine was administered).

This policy change occurred to better align Medicare pneumococcal vaccination coverage requirements with new recommendation issued by the Advisory Committee on Immunization Practices (ACIP). Click here for more information regarding the updates.

Telehealth Services

Effective January 1, 2015, the following services have been added to the list of telehealth services that can be furnished to Medicare beneficiaries under the telehealth benefit:

  • Annual wellness visits,
  • Psychoanalysis
  • Psychotherapy
  • Prolonged evaluation and management services

A full listing of covered telehealth services can be found here

CMS Creates the Office of Enterprise Data and Analytics (OEDA)

In November 2014, CMS announced the creation of the Office of Enterprise Data and Analytics to be led by Niall Brennan as the agency’s Chief Data Officer (CDO). As more data becomes available and the focus of healthcare shifts from volume driven to outcomes driven, the need to analyze and provide access to data is expected to continue to grow. The OEDA is expected to help CMS to better utilize its data resources to guide decision-making and develop frameworks to promote external access to the information. The full press release is available here.

Web-Based Training On Avoiding Medicare Fraud and Abuse Now Available

The “Avoiding Medicare Fraud and Abuse: A Roadmap for Physicians” Web-Based Training Course (WBT) was revised and is now available. This WBT is designed to provide education on the federal laws that combat fraud and abuse. It includes the identification of "red flags" that could lead to potential legal liability, compliance recommendations for physicians, real-life fraud and abuse case examples, and helpful online resources about fraud and abuse. Continuing education credits are available to learners who successfully complete this course. See course description for more information.

To access the WBT, go to MLN Products, scroll to the bottom of the web page and under “Related Links” click on “Web-Based Training Courses.”

To access the PDF version, click here.