A major Electronic Prescribing (eRx) Incentive Program deadline is approaching for both individual eligible professionals (EPs) and group practices participating in the Group Practice Reporting Option (GPRO).  Physicians who are Eligible Providers  must successfully report as an electronic prescriber before June 30, 2013 or they will experience a payment adjustment in 2014 for professional services covered under Medicare Part B's Physician Fee Schedule (PFS.)

 

The 2013 eRx Incentive Program 6-month reporting period (January 1, 2013 to June 30, 2013) is the final reporting period available to you if you wish to avoid the 2014 eRx payment adjustment.

 

If you do not successfully report, a payment adjustment of 2.0% will be applied, and you will receive only 98.0% of your Medicare Part B PFS amount for covered professional services in 2014.

 

Avoiding the 2014 eRx Payment Adjustment 

 

Individual EPs and eRx GPRO participants who were not successful electronic prescribers in 2012 can avoid 2014 eRx payment adjustment by meeting specified reporting requirements between January 1, 2013 and June 30, 2013. Below are the 6-month reporting requirements:

 

 

Exclusions and Hardships Exemptions

 

Exclusions from the 2014 eRx payment adjustment only apply to certain individual EPs and group practices, and CMS will automatically exclude those individual EPs and group practices who meet the criteria. More information on exclusion criteria and hardship exception categories can be found on the Electronic Prescribing (eRx) Incentive Program: 2014 Payment Adjustment Fact Sheet.

 

If you have questions regarding the eRx Incentive Program, eRx payment adjustments, or need assistance submitting a hardship exemption request, please contact the QualityNet Help Desk at 866-288-8912 (TTY 1-877-715-6222) or via email qnetsupport@sdps.org. The Help Desk is available Monday through Friday from 7am-7pm CT.

 

To learn more about the eRx Incentive Program and program alignment under the CMS eHealth initiative, please visit www.CMS.gov/eHealth.

 

(information provided by Palmetto GBA)

 

 

Selection of Level of E/M Service Based on Duration of Coordination of Care and/or Counseling

 

Time is the key factor in selecting the level of service when counseling and/or coordination of care dominates (more than 50 percent) the face-to-face physician/ patient encounter or floor time (in the case of inpatient services). There are three key components when selecting the appropriate level of E/M service provided: history, examination, and medical decision making. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim.

 

Example: 

 

A cancer patient has had all preliminary studies completed and a medical decision to implement chemotherapy. At an office visit the physician discusses the treatment options and subsequent lifestyle effects of treatment the patient may encounter or is experiencing. The physician need not complete a history and physical examination in order to select the level of service. The time spent in counseling/coordination of care and medical decision-making will determine the level of service billed.

 

Office/Other Outpatient Setting:
 

Counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported. Face-to-face time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service. The code used depends upon the physician service provided. 

 

Patient is not present in the office: 
 

Counseling/coordination of care with the patient’s family alone (i.e. patient is at home) is not a billable service. 

 

Patient is present in the office:
 

If the family members/provider needs to perform counseling/coordination of care away from the patient they may leave the room and go to the hallway/private room. Time with the family may be included in the selection of the CPT code. 

 

Inpatient Setting: 
 

Counseling and/or coordination of care must be provided at the bedside or on the patient’s hospital floor or unit that is associated with an individual patient. Time spent counseling the patient or coordinating the patient’s care after the patient has left the office or the physician has left the patient’s floor or begun to care for another patient on the floor is not considered when selecting the level of service to be reported.

The duration of counseling or coordination of care that is provided face-to-face or on the floor may be estimated but that estimate, along with the total duration of the visit, must be recorded when time is used for the selection of the level of a service that involves predominantly coordination of care or counseling. 

 

Documentation must include the following:
 

Duration of counseling/coordination of care;

Duration of the visit; and

Sufficient documentation to support counseling/coordination of care

 

 

E/M Weekly Tip:   General Principles

 

There are general principles of medical record documentation that are applicable to all types of medical and surgical services in all settings. While E/M services vary in several ways, such as the nature and amount of physician work required, the following general principles help ensure that medical record documentation for all E/M services is appropriate:

 

The medical record should be complete and legible

The documentation of each patient encounter should include:

Reason for the encounter and relevant history, physical  examination findings and prior diagnostic test results

Assessment, clinical impression or diagnosis

Medical plan of care

Date and legible identity of the observer

If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred

Past and present diagnoses should be accessible to the treating and/or consulting physician

Appropriate health risk factors should be identified

The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented

The diagnosis and treatment codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record

 

 

Implementation of Phase 2 PECOS Delayed

 

This information was reported earlier but is still in effect. The implementation was scheduled to take place on May 1, 2013, but has been delayed indefinitely.  

 

Due to technical issues, implementation of the Phase 2 ordering and referring denial edits is being delayed. These edits would have checked the following claims for an approved or validly opted-out physician or non-physician who is an eligible specialty type with a valid individual National Provider Identifier (NPI). If either of these were missing or incorrect, claims would deny.

 

 •Medicare Part B claims from laboratories, imaging centers and Durable Medical Equipment, Orthotics, and Supplies (DMEPOS) that have an ordering or referring physician/non-physician provider

 

•Part A Home Health Agency (HHA) claims that require an attending physician provider

 

CMS will advise  of the new implementation date in the near future. In the interim, informational edits will continue to be sent for those claims that would have been denied had the edits been in place.

 

The WVSMA's provider "look up" tool is now on the our website, www.wvsma.org.  

 

 

 

Palmetto GBA will host the J11 Part B June Quarterly Updates, Changes and Reminders webinar on June 13, 2013 at 10 a.m. EST. 

 

This 90-minute webinar is designed to provide pertinent updates, changes and reminders to assist the provider community in staying compliant with Medicare rules and regulations and will include:

 

 

Registration is required to attend.   You may register at the website, www.palmettogba.com.  

 

Upon completion of the webinar, a question and answer session will afford providers an opportunity to submit questions related to the topics discussed.


Redertimination Requests Need to be Sent to the Appeals Department

 

 

Palmetto GBA has noticed a trend in providers sending in redetermination requests to the medical review department after their additional development request (ADR) results in a denied claim. Providers should note that the medical review department does not process redeterminations and cannot forward the documentation on to the appeals department without the redetermination request form. 

 

If a provider receives an ADR, submits documentation and then has their claim denied by the medical review department, the next step would be to submit a redetermination request. Providers can do this by accessing the appropriate redetermination request form from the Palmetto GBA website under the 'Forms' section and submitting the form, along with the documentation, to the address listed on the form. This assures that the documentation is received and processed in the allowed amount of time. Misrouted documentation that does not include the redetermination request form cannot be processed and could result in a provider missing timeliness guidelines for filing a Medicare redetermination request. 

 

Note: A provider has 120 days from the date the claim is denied on the Medicare remittance advice to request a redetermination.

 

 

General Appeals Information 

 

The Medicare Prescription Drug, Improvement, and Modernization Act requires an annual reevaluation of the dollar amount in controversy required for an Administrative Law Judge (ALJ) hearing or Federal District Court review. The amount that must remain in controversy for ALJ hearing requests filed on or before December 31, 2012, is $130. 

 

This amount increases to $140 for ALJ hearing requests filed on or after January 1, 2013. The amount that must remain in controversy for Federal District Court review requests filed on or before December 31, 2012 is $1,350. This amount increases to $1,400 for appeals to Federal District Court filed on or after January 1, 2013. 

 

 

COMMON WORKING FILE (CWF) INFORMATIONAL UNSOLICITED RESPONSE (IUR) OR REJECT FOR A NEW PATIENT VISIT BILLED BY THE SAME PHYSICIAN OR PHYSICIAN GROUP WITHIN THE PAST THREE YEARS

 

 

The Recovery Auditors, under contract with the Centers for Medicare & Medicaid Services (CMS), are responsible for identifying and correcting improper payments in the Medicare Fee-For-Service payment process. The Recovery Auditors have identified claims with 'New Patient' Evaluation and Management (E/M) services to have improper payments, because the new patient services have been billed two or more times within a three-year period by the same physician or physician group. 

 

The 'Medicare Claims Processing Manual,' Chapter 12, Section 30.6.7 provides that 'Medicare interpret the phrase 'new patient' to mean a patient who has not received any professional services (i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years). For example, if a professional component of a previous procedure is billed in a three-year time period (e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit).

 

As a result of overpayments for new patient E/M services that should have been paid as established patient E/M services, CMS will implement changes to the CWF to prompt CMS contractors to validate that there are not two new patient CPTs being paid within a three year period of time.

 

The new patient CPT codes that will be checked in these edits include 99201 through 99205, 99218 through 99223, 99304 through 99306, 99324 through 99328, 99341 through 99345, 99381 through 99387, 99460 through 99461, 99468, 99471, 99475, 99477, G0245, G0402 and G0344. The edits will also check to ensure that a claim with one of these new patient CPT codes is not paid subsequent to payment of a claim with an established patient CPT code.

 

If Medicare discovers that a new patient code has been paid more than one time in a three-year period to the same physician, then Medicare Contractors will consider this an overpayment and will take steps to recoup the payment. If the situation is detected prior to payment of a second claim, the second claim will be rejected.

 

The implementation date for this will be October 7, 2013.   

 

 

West Virginia Bureau for Medical Services has announced that the materials for the Medicaid Enhanced Primary Care Payment are now available on their website, www.dhhr.wv.gov/bms  under News and Announcements. 

 

The available materials include:

 

 

The enhanced payments will be made for select E/M (Evaluation and Management) and vaccine administration codes for dates of service between January 1, 2013 and December 31, 2014.  Qualifying providers will receive the retroactive enhanced payments dating back to January 1, 2013, as long as the completed Self-Attestation Form is sent to BMS by December 31, 2013. 

 

A self-attestation form must be completed for 2013 and for 2014.  The CY2013 form is available now to be completed.  The CY2014 Self-Attestation form will be released later this year.

 

Complete directions are included in the material on the website.  If you have additional questions, please contact Molina's Provider Enrollment Department within the West Virginia call center at:

 

(888) 483-0793 (phone)

(304) 340-2763 (fax)

wvproviderenrollment@molinahealthcare.com (email) 

 

 

 

Governor Earl Ray Tomblin recently announced his decision to exercise the state option under the federal Affordable Care Act to expand Medicaid to 138% of the federal poverty level.  West Virginia was one of the few remaining states to announce a Medicaid expansion decision.  

 

Governor Tomblin emphasized in his remarks that he was most focused on three issues: fiscal responsibility, Medicaid enrollee responsibility and administrative efficiency.  He acknowledged concern over the federal government’s ability to sustain its financial commitment in the future and stated clearly that the state reserves the right to reevaluate eligibility criteria if necessary.  He also stressed that the expansion would include co-pays to promote better health care decision making and utilization on the part of the enrollee.  He said there would be a new push for expanded participation in managed care within the Medicaid program.  

 

In reaching his decision, Governor Tomblin relied heavily on a state commissioned actuarial analysis from CCRC Actuaries.  The ‘Medicaid Expansion Report’ was given to the Governor on April 16 detailing the anticipated expansion costs.  Key findings of the report include:

 

 

What are the National CLAS Standards?

 

The National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care, from the U.S. Department of Health and Human Services, Office of Minority Health, provide individuals and organizations with a blueprint for successfully implementing and maintaining culturally and linguistically appropriate services.

 

The National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care disparities. Adoption of these Standards will help advance the cause of better health and health care in the United States.

 

Accompanying the National CLAS Standards is a technical assistance document entitled, The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care: A Blueprint for Sustaining CLAS Policy and Practice (The Blueprint), which aims to provide comprehensive, but not exhaustive, information on each Standard.

 

You can access the National CLAS Standards and accompanying documents at https://www.thinkculturalhealth.hhs.gov

 

 

Aetna has announced that the plan’s acquisition of Coventry Health Care, Inc. is now complete.  Aetna and Coventry share a commitment to creating mutually beneficial relationships with 

providers. 

 

Providers need not take any action now. Aetna has pledged to

keep you updated as this new relationship progresses and let you 

know about any future changes.

 

For more information, you may visit Aetna’s website, www.aetna.com.   

 

 

(information provided by the AMA)

 

Effective July 1, 2013, Cigna will no longer offer second-level appeals. There will no longer be two levels of appeal; instead there will be a single level.  The time frame to complete an appeal will be extended from 30 – 60 days.  The time to file an appeal is 180 days.

 

The AMA recently contacted Cigna requesting clarification and Cigna graciously answered the questions and provided the following information regarding this change.

 

 

Why is Cigna changing the appeals process?

 

Only 14 percent of appeal determinations were changed or overturned upon review at the second level. Therefore, in an effort to improve efficiency and reduce administrative costs, Cigna is moving to a single-level review process. This will allow Cigna to have a consistent approach for health care professionals and customers across their network. Cigna will have consistent appeal processes across all business segments. Cigna will be able to retain a high level of review while still maintaining costs.  

 

Additionally, Cigna is making this change now because it is consistent with the direction of the health care industry.
 

Patient Protection and Affordable Care Act (PPACA) requirements have changed requiring an offer of external review on all medical appeals.  
 

Regulators are moving to a single-level internal appeal process and continue to move in this direction.  
 

This process is consistent with Employee Retirement Income Security Act (ERISA) guidelines. 

 

How is this change being communicated to health care professionals?

 

Besides the notice in the Cigna Network News April 2013 edition the Cigna Reference Guides for health care professionals were updated to note a single level of appeals. Also a follow-up article will be printed in the July edition of Cigna Network News.

 

Additionally, Cigna will send an email update to affected health care professionals in the affected markets. 

 

Is this only for medical necessity appeals?

  

All appeals will follow a thorough single appeal review process and will be completed within 60 days. (Please see question eight for exceptions.)

 

What can health care professionals do to reduce the effect of this change?

 

Prior to initiating medical appeals, health care professionals should contact Cigna for precertification and should follow the physician-to-physician process that is available to them. 

 

To allow Cigna the opportunity to provide a full and thorough review, health care professionals should submit complete information with their appeal and  should submit appeals in a timely manner. 

 

To assure that complete information is submitted and that Cigna is able to quickly identify the reason for the appeal, health care professionals should use the appeal form on the www.CignaforHCP.com website. 

 

What options do health care professionals have if they disagree with Cigna’s appeals decision?

 

If the single-level appeal is denied, and the health care professional is not satisfied with the decision, the health care professional can request alternative dispute resolutions (e.g., arbitration), as outlined in the dispute resolution sections of their Agreement with Cigna. Requests for alternate dispute resolutions must be submitted within one year from the date of the appeal decision, and are subject to applicable state law and the health care professional’s Agreement. 

 

Will the initial appeal be performed by a physician of like specialty?

 

Yes. This remains unchanged. All member appeals are reviewed by a physician in the same or similar specialty.

 

Will the physician need to be contacted, if so when or where in the process? 

 

Cigna encourages health care professionals to contact Cigna to discuss any initial adverse determine prior to begMon General Hospital in the Conference Center 

 

 

The WVSMA recently met with officials from UnitedHealthcare, including Ed Kosa, MD, Medical Director for West Virginia, and heard the latest updates and goals from the plan.   Some of the changes are listed below.

 

Effective July 1, 2013, UnitedHealthcare is changing its existing Outpatient Radiology Notfication Protocol and Cardiology Notification Protocol to include a prior authorization requirement whent a UnitedHealthcare commercial member’s benefit document requires health services to be medically necessary in order to be covered.  For members with this type benefit, once UnitedHealthcare is notified of a planned service that is subject to UnitedHealthcare’s Outpatient Radiology Notification Protocol or Cardiology Notification Protocol, UnitedHealthcare will conduct a clinical coverage review to determine whether the service is medically necessary, and then inform the physician.  

 

Please note that you must notify UnitedHealthcare of any planned service that is subject to UnitedHealthcare’s Outpatient Radiology Notification Protocol and Cardiology Notification Protocol and complete the prior authorization even if the medical practice is 

located in a state in which these programs have not currently been implemented. 

 

Effective July 1, 2013, ordering healthcare providers must notify UnitedHealthcare prior to scheduling certain CT, MRI, MRA, PET scan, Nuclear Medicine, and Nuclear Cardiology procedures for UnitedHealthcare commercial members in accordance with the terms of the Outpatient Radiology Notification Protocol.  To see a complete list of CPT codes for which notification is required, please refer to UnitedHealthcareOnline.com   

 

If you have questions about any UnitedHealthcare requirement, please contact your UnitedHealthcare Network Management representative, or call (800) 637-5792. You may also contact the plan via email (radiology@customerrelation.com).   

 

 

The WVSMA’s Annual Healthcare Summit will be held on August 23-25, 2013, at the Greenbrier Resort.  Registration information for both the Summit and for Greenbrier lodging is available on the WVSMA’s website, www.wvsma.org.   

 

If you have any questions, please contact Karie Sharp, WVSMA Conference Coordinator, at (304) 925-0342, ext 12 or via email (karie@wvsma.org).   

 

 West Virginia will have strong representation at the upcoming Practice Management Institute (PMI) Conference.   Seven office managers/administrators are registered to attend.   If you are interested in attending, there is still time to register.  Contact Barbara Good (barbara@wvsma.org) or view the information on PMI’s website, www.pmimd.com.   

 

The Morgantown Chapter of the Office Managers Association will meet on 

Wednesday, June 5th, 11:30 AM for lunch at the Mon General Hospital Conference Center.  

 

Bernie Deem of Deem HR will be the speaker.  Her topic will be  "Building High Impact Relationships: Sucessful Self Management".  The meeting will be extended to 1:30 or 2:00 PM in order to provide Bernie with sufficient time for her presentation.   If you’ve not heard this high energy speaker, you should plan to attend.   If you’ve heard her, you’ll definitely want to hear her again!  

 

Please RSVP to Melody Meleady at (304) 293-2535 or via email (mamruns@hotmail.com) so the OMA can have an accurate count for lunch and 

handouts.

 

2013 Certified Medical Coder Class Scheduled!

 

The WVSMA has scheduled the 2013 Certified Medical Coder Class for September, 2013.  The class will begin on Friday, September 13th, and meet each Friday through October 18th, at the WVSMA office in Charleston.    

 

We are excited to offer this class and know it will fill up quickly.   More information will be coming soon.  Mark your calendars now!

 

ICD-10 Class Offered!

 

The WVSMA has scheduled an ICD-10 class for Thursday, September 26, 2013.   You won’t want to miss this opportunity to learn all that is new with the upcoming ICD-10 codes!    Watch for more information in the Wesgram Online and also on the WVSMA website, www.wvsma.org.