Main  |  Next »

Monday Sep 18, 2017

New details as we get closer to CMS replacing current Medicare cards

As I announced in June, the Centers for Medicare & Medicaid Services plans to issue new Medicare identification cards that no longer carry Social Security numbers as a way to prevent fraud and fight identity theft. Last week, CMS unveiled the new cards.


[Read More]


Posted at 02:45PM Sep 18, 2017 by Kent Moore | Comments[0]

Tuesday Sep 05, 2017

Ask beneficiaries to designate you their primary clinician online

If you treat Medicare patients, you and your patients likely value the relationships you’ve formed. As Medicare continues to change how it reimburses physicians for beneficiary care, it would be helpful if the program knew about and honored those relationships, right?


[Read More]


Posted at 11:45AM Sep 05, 2017 by Kent Moore | Comments[0]

Wednesday Aug 23, 2017

CMS: health plans can't force you to take virtual credit cards

Physicians who have been confused or concerned about health plans wanting to use virtual credit cards to pay them for patient care are learning they have more say in the matter than they thought.


[Read More]


Posted at 04:14PM Aug 23, 2017 by Kent Moore | Comments[0]

Monday May 22, 2017

How to avoid the unpaid Medicare annual wellness visit

One of the challenges of getting paid for Medicare annual wellness visits (AWVs) is that Medicare reimburses only one AWV a year per Medicare patient – and your patient may get that visit elsewhere without you knowing it. Even worse, you will not discover that fact until after you have provided the service and received a claim denial from Medicare. What’s a practice to do?


[Read More]


Posted at 09:51AM May 22, 2017 by Kent Moore | Comments[0]

Monday Nov 28, 2016

New code required in 2017 for telehealth services

Beginning Jan. 1, the Centers for Medicare & Medicaid Services (CMS) is creating a new place of service (POS) code for physicians who provide telehealth services from a distant site. POS code 02 is described as “The location where health services and health related services are provided or received, through telecommunication technology.”

Under HIPAA, non-medical code sets, such as POS, are paid based on what code set was in effect on the date of the transaction, not the date of service. So even if the date of service was in 2016, if you initiate the claim on or after Jan. 1, you should use the new POS code.

Note that you must still use modifiers GT (via interactive audio and video telecommunications systems) and GQ (via an asynchronous telecommunications system) when billing Medicare for telehealth services. If you bill POS code 02 but without the GT or GQ modifier, your Medicare administrative contractor (MAC) will deny the service. Your MAC will also deny the service if you bill for telehealth services with modifiers GT or GQ but without POS code 02.

CMS has provided additional information on this change through the Medicare Learning Network(www.cms.gov).

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians


Posted at 12:23PM Nov 28, 2016 by David Twiddy | Comments[0]

Tuesday Nov 15, 2016

New influenza vaccine code delayed until Jan. 1

If you are dispensing influenza vaccines under a new CPT code this fall, the Centers for Medicare & Medicaid Services (CMS) is suggesting that you do not send those claims in for payment right away.

This summer, CMS was scheduled to accept a new CPT code for influenza vaccine. The code, 90674, describes “Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use.” The CPT Editorial Panel accepted the code at its February meeting, and it will appear in the 2017 CPT book. CMS previously disclosed(www.cms.gov) a payment allowance of $22.936 for code 90674, beginning for services provided on or after Aug. 1.

But CMS recently announced(www.cms.gov) that Medicare claims processing systems will not be able to accept code 90674 until Jan. 1.

In the meantime, CMS advises that you hold claims containing that code until then. Also, if you bill institutional claims, CMS says that code 90674 will be implemented on Feb. 20.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians


Posted at 10:33AM Nov 15, 2016 by David Twiddy | Comments[0]

Thursday Nov 10, 2016

New pay increases in the 2017 Medicare physician fee schedule

The Centers for Medicare & Medicaid Services (CMS) has released its final rule on the 2017 Medicare physician fee schedule(www.cms.gov). Some of the several increases for care management services in 2017 will interest family physicians. For example, CMS next year will begin paying for:

• Non-face-to-face prolonged evaluation and management services

• Comprehensive assessment and care planning for patients with cognitive impairment

• Primary care practices to use interprofessional care management resources to treat behavioral health conditions

• Chronic care management (CCM) for patients with more complex conditions

In addition, CMS is trying to encourage more practices to offer and bill for CCM services by reducing the administrative burden associated with those codes.

CMS also will revalue existing codes describing face-to-face prolonged services. For 2017, CMS has set the Medicare conversion factor at $35.8887, which is slightly higher than the 2016 conversion factor of $35.8043. CMS expects that the provisions of the final rule will generate an estimated 1 percent increase in Medicare allowed charges for family physicians.

CMS has provided additional information in a fact sheet on the final rule(www.cms.gov).

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians


Posted at 12:07PM Nov 10, 2016 by David Twiddy | Comments[0]

Monday Jul 11, 2016

CMS releases proposed rule on 2017 Medicare physician fee schedule

Earlier this month, the Centers for Medicare & Medicaid Services (CMS) released its proposed rule(www.cms.gov) on the 2017 Medicare physician fee schedule. Primary care physicians should be interested that the rule includes several proposed increases for care management services. Specifically, CMS is proposing to pay for:

•    Non-face-to-face prolonged evaluation and management services
•    Comprehensive assessment and care planning for patients with cognitive impairment
•    Primary care practices to use interprofessional care management resources to treat behavioral health conditions
•    Resource costs of furnishing visits to patients with mobility-related impairments
•    Chronic care management (CCM) for patients with more complex conditions

In addition, CMS proposes to reduce the administrative burden associated with the CCM codes to encourage more practices to furnish and bill for these services. CMS also will revalue existing codes describing face-to-face prolonged services.

For 2017, CMS estimates the conversion factor to be $35.7751, which is slightly lower than the 2016 conversion factor of $35.8043. However, CMS expects that the provisions of the proposed rule will generate an estimated 3 percent increase in Medicare allowed charges for family physicians. That would be the largest estimated update for a given specialty.

For individuals who don’t want to read the proposed rule itself, CMS has provided an abbreviated fact sheet(www.cms.gov) and press release(www.cms.gov). CMS is accepting comments on its proposals through Sept. 6.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians


Posted at 10:25AM Jul 11, 2016 by David Twiddy | Comments[0]

Thursday Jul 07, 2016

JW modifier allows physicians to get paid for some discarded drugs

The Centers for Medicare & Medicaid Services (CMS) recently revised its guidance(www.cms.gov) on how to use the JW modifier. Specifically, the revision will make it easier for physicians to get paid for leftover medication or biologicals that are properly thrown out.

Beginning Jan. 1 of next year, physicians must use the JW modifier for claims with unused drugs or biologicals from single-use vials or single-use packages that are appropriately discarded (except those provided under the Competitive Acquisition Program for Part B drugs and biologicals). The physician must also document the discarded drug or biological in the patient's medical record when submitting Part B claims.

For example, imagine you administer 95 units of a drug from a single-use vial that is labeled to contain 100 units and discard the remaining five units. You bill the 95-unit dose on one line of the claim and bill the discarded five units on another line by using the JW modifier. Both line items would be processed for payment. You apply the JW modifier only to the amount of drug or biological that is discarded.

You may not use the JW modifier when the billing unit is equal to or greater than the total actual dose and the amount discarded. For example, if one billing unit for a drug is 10 mg in a single-use vial and you administer 7 mg and discard the remaining 3 mg, you can bill the 7 mg dose as one 10 mg unit. You could not also bill the discarded 3 mg on a separate line item with the JW modifier because that would result in overpayment.

Medicare administrative contractors currently have discretion over whether to require the JW modifier for any claims with discarded drugs or biologicals, and how the discarded drug or biological information should be documented. CMS is revising this policy to create more uniformity for these types of claims.

For additional information on billing Medicare for discarded drugs and biologicals, see section 40 of chapter 17 of the Medicare Claims Processing Manual(www.cms.gov).

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians


Posted at 12:10PM Jul 07, 2016 by David Twiddy | Comments[0]

Tuesday Jun 28, 2016

CMS places some limits on review of Medicare claim denials

If you’ve ever appealed a Medicare claim denial only to see it struck down for new reasons that the reviewers found in the course of their review, help may be coming.

The Centers for Medicare & Medicaid Services (CMS) recently told its Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs)(www.cms.gov) to change how they review certain claim denials. Specifically, CMS says they should limit their review of redeterminations and reconsiderations of claims denied following a complex prepayment review, a complex post-payment review, or an automated post-payment review to the reason or reasons the claim or line item was denied in the first place. 

CMS acknowledged that MACs and QICs generally have discretion while conducting appeals to develop new issues and review all aspects of coverage and payment related to the claim or line item. As a result, while the original reason for the denial may be resolved, this expanded review may result in a denial of the appeal for new reasons. The revised instructions prohibit the contractors from doing that in certain situations, which is good news for physicians and others who initiate such appeals.

However, MACs and QICs will still have the discretion to develop new issues and evidence for claims denied as a result of automated pre-payment review. MACs will also continue to follow existing procedures for adjusting claims after successful appeals, meaning CMS will process the adjustments and may suspend them because of system edits. Claim adjustments that remain unpaid because of additional system-imposed limitations (e.g., frequency limits or Correct Coding Initiative edits) may result in new denials with full appeal rights.

In addition, if a MAC or QIC conducts an appeal of a claim or line item that was denied on pre- or post-payment review because of insufficient documentation, the contractor will review all applicable coverage and payment requirements for the item or service at issue, which means the claim could subsequently be denied for lacking medical necessity. If you receive requests for additional documentation, please be careful to respond quickly and completely to prevent the possibility of expanded review of the whole claim.

Finally, CMS is applying the new guidance only to appeals received by a MAC or QIC on April 18 or later. Prior denials based on expanded evidence will not be reopened.

As noted, the CMS guidance provides some good news to physicians and other providers of Medicare services. But CMS has placed a number of limits on this guidance, and you will need to be aware of the phase and type of review (e.g., pre- or post-payment, automated or complex) to which a claim is subject and consider the possibility of subsequent system edits and denials when determining whether to appeal.  

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians


Posted at 12:24PM Jun 28, 2016 by David Twiddy | Comments[0]

Main  |  Next »

CURRENT ISSUE

RECENT POSTS

SEARCH THIS BLOG


TOPICS

DISCLAIMER

The views expressed here do not necessarily reflect the opinions of FPM or the AAFP. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. All comments are moderated and will be removed if they violate our Terms of Use.

FEEDS