This edition of the Wesgram Online contains information on many topics, including the new HIPAA Rule, Medicare Changes, Coding Changes, Upcoming Educational Events/Opportunities and more. 

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(information supplied by HHS)

HHS has finally released the HIPAA “mega-rule” that incorporates several other rules and will change how your practice, agency or hospital safeguards patient information.
 
The rule, released Jan. 17, is effective March 26, but covered entities and business associates won’t have to comply until Sept. 23.
 
The long-awaited HIPAA omnibus rule:

   replaces the breach notification rule’s harm threshold with “a more objective standard.”
   holds business associates liable for certain HIPAA requirements.
   allows patients to receive electronic copies of their health information.
   requires changes to the notice of privacy practices.
   limits the use and disclosure of protected health information for marketing and fundraising.
   prohibits most health plans from using or disclosing genetic information for underwriting purposes, as required by the Genetic Information Nondiscrimination Act.
   adopts increased and tiered civil monetary penalties of up to $1.5 million per violation.

The rule may be viewed at http://www.ofr.gov/OFRUpload/OFRData/2013-01073_PI.pdf.

HHS released an update to HIPAA standards, with emphasis on protecting consumer PHI in an electronic age.  Some of these changes include:

   Patients can now ask for a copy of their electronic medical record in an electronic form.
   Individuals now having the ability to tell their provider to not share information about their treatment with their health plan.
   Prohibiting the sale of patients' health information without permission.
   Limits on how patient health information can be used and disclosed for marketing and fundraising purposes.

There were also increased requirements for business associates, who have until September 30, 2013 to comply with the new mandates. HHS' justification is that…"some of the largest breaches reported to HHS have involved business associates…"  Some of these include:

   Applying all of the Security Rule standards and implementation specifications and certain Privacy Rule provisions directly to business associates;
   Adding “subcontractors” to the definition of “business associate” and requiring business associates to enter into written contracts with subcontractors that are substantially similar to business associate agreements.

Other requirements include:

   Changes to the HIPAA Enforcement Rule to incorporate the increased and tiered civil money penalty structure provided by the HITECH Act, originally published as an interim final rule on Oct. 30, 2009.

   Modifications to the HIPAA Privacy, Security, and Enforcement Rules mandated by the Health Information Technology for Economic and Clinical Health Act, and certain other modifications to improve the rules, which were issued as a proposed rule on July 14, 2010.

The official press release from HHS can be found here:
http://www.hhs.gov/news/press/2013pres/01/20130117b.html

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(information from HHS and the AMA)

The U.S. Department of Health and Human Services (HHS) issued a letter to physicians and other providers to ensure that they are aware of their ability under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule to take action, consistent with their ethical standards or other legal obligations, to disclose necessary information about a patient to law enforcement, family members of the patient, or other persons, when they believe the patient presents a serious danger to himself or
other people. This letter was issued in the wake of the Newtown, Ct., shootings and clearly articulates that HIPAA “does not prevent your ability to disclose necessary information about a patient to law enforcement, family members of the patient, or other persons, when you believe the patient presents a serious danger to himself or other people.”

The HIPAA Privacy Rule protects the privacy of patients’ health information but is balanced to ensure that appropriate uses and disclosures of the information still may be made when necessary to treat a patient, to protect the nation’s public health, and for other critical purposes, such as when a provider seeks to warn or report that persons may be at risk of harm because of a patient. When a health care provider believes in good faith that such a warning is necessary to prevent or lessen a serious and imminent threat to the health or safety of the patient or others, the Privacy Rule allows the provider, consistent with applicable law and standards of ethical conduct, to alert those persons whom the provider believes are reasonably able to prevent or lessen the threat. Further, the provider is presumed to have had a good faith belief when his or her belief is based upon the provider’s actual knowledge (i.e., based on the provider’s own interaction with the patient) or in reliance on a credible representation by a person with apparent knowledge or authority (i.e., based on a credible report from a family member of the patient or other person). These provisions may be found in the Privacy Rule at 45 CFR § 164.512(j).

Under these provisions, a health care provider may disclose patient information, including information from mental health records, if necessary, to law enforcement, family members of the patient, or any other persons who may reasonably be able to prevent or lessen the risk of harm. For example, if a mental health professional has a patient who has made a credible threat to inflict serious and imminent bodily harm on one or more persons, HIPAA permits the mental health professional to alert the police, a parent or other family member, school administrators or campus police, and others who may be able to intervene to avert harm from the threat.

In addition to professional ethical standards, most states have laws and/or court decisions which address, and in many instances require, disclosure of patient information to prevent or lessen the risk of harm. Providers should consult the laws applicable to their profession in the states where they practice, as well as 42 CFR Part 2 under federal law (governing the disclosure of substance abuse treatment records) to understand their duties and authority in situations where they have information indicating a threat to public safety.

The Office for Civil Rights understand that health care providers may at times have information about a patient that indicates a serious and imminent threat to health or safety. At those times, providers play an important role in protecting the safety of their patients and the broader community.

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(Information from CMS and Palmetto GBA)

President Obama Signs the American Taxpayer Relief Act of 2012: New Law Includes Physician Update Fix through December 2013

On Wednesday, January 2, 2013, President Obama signed into law the American Taxpayer Relief Act of 2012. This new law prevents a scheduled payment cut for physicians and other practitioners who treat Medicare patients from taking effect on January 1, 2013. The new law provides for a zero percent update for such services through December 31, 2013. This provision guarantees seniors have continued access to their doctors by fixing the Sustainable Growth Rate (SGR) through the end of 2013. President Obama remains committed to a permanent solution to eliminating the SGR reductions that result from the existing statutory methodology. The Administration will continue to work with Congress to achieve this goal.

The new law extends several provisions of the Middle Class Tax Relief and Job Creation Act of 2012 (Job Creation Act) as well as provisions of the Affordable Care Act. Specifically, the following Medicare fee-for-service policies (with January 1, 2013, or October 1, 2012, effective dates) have been extended. Information is included below describing Medicare billing and claims processing information associated with the new legislation. Please note that these provisions do not reflect all of the Medicare provisions in the new law, and more information about other provisions will be forthcoming.

Section 601 – Medicare Physician Payment Update – As indicated above, the new law provides for a zero percent update for claims with dates of service on or after January 1, 2013, through December 31, 2013. The Centers for Medicare & Medicaid Services (CMS) is currently revising the 2013 Medicare Physician Fee Schedule (MPFS) to reflect the new law’s requirements as well as technical corrections identified since publication of the final rule in November. For your information, the 2013 conversion factor is $34.0230.

In order to allow sufficient time to develop, test, and implement the revised MPFS, Medicare claims administration contractors may hold MPFS claims with January 2013 dates of service for up to 10 business days (i.e., through January 15, 2013). We expect these claims to be released into processing no later than January 16, 2013. The claim hold should have minimal impact on physician/practitioner cash flow because, under current law, clean electronic claims are not paid sooner than 14 calendar days (29 for paper claims) after the date of receipt. Claims with dates of service prior to January 1, 2013, are unaffected. Medicare claims administration contractors will be posting the MPFS payment rates on their websites no later than January 23, 2013.

The 2013 Annual Participation Enrollment Program allowed eligible physicians, practitioners, and suppliers an opportunity to change their participation status by December 31, 2012. Given the new legislation, CMS is extending the 2013 annual participation enrollment period through February 15, 2013. Therefore, participation elections and withdrawals must be post-marked on and before February 15, 2013. The effective date for any participation status changes elected by providers during the extension remains January 1, 2013.

Section 602 - Extension of Medicare Physician Work Geographic Adjustment Floor The 2012 1.0 floor on the physician work geographic practice cost index is extended through December 31, 2013. As with the physician payment update, this extension will be reflected in the revised 2013 MPFS.

Section 603 - Extension Related to Payments for Medicare Outpatient Therapy Services
Section 603 extends the exceptions process for outpatient therapy caps through December 31, 2013. Providers of outpatient therapy services are required to submit the KX modifier on their therapy claims, when an exception to the cap is requested for medically necessary services furnished through December 31, 2013. In addition, the new law extends the application of the cap and threshold to therapy services furnished in a hospital outpatient department (OPD), and counts outpatient therapy services furnished in a Critical Access Hospital towards the cap and threshold.

The therapy caps are determined for a beneficiary on a calendar year basis, so all beneficiaries began a new cap for outpatient therapy services received on January 1, 2013. For physical therapy and speech language pathology services combined, the 2013 limit for a beneficiary on incurred expenses is $1,900. There is a separate cap for occupational therapy services which is $1,900 for 2013. Deductible and coinsurance amounts applied to therapy services count toward the amount accrued before a cap is reached, and also apply for services above the cap where the KX modifier is used.

Section 603 also extends the mandate that Medicare perform manual medical review of therapy services furnished January 1, 2013 through December 31, 2013, for which an exception was requested when the beneficiary has reached a dollar aggregate threshold amount of $3,700 for therapy services, including OPD therapy services, for a year. There are two separate $3,700 aggregate annual thresholds: (1) physical therapy and speech-language pathology services, and (2) occupational therapy services.

Section 604 - Extension of Ambulance Add-On Payments
Section 604 extends the following three Job Creation Act ambulance payment provisions: (1) the 3 percent increase in the ambulance fee schedule amounts for covered ground ambulance transports that originate in rural areas and the 2 percent increase for covered ground ambulance transports that originate in urban areas is extended through December 31, 2013; (2) the provision relating to air ambulance services that continues to treat as rural any area that was designated as rural on December 31, 2006, for purposes of payment under the ambulance fee schedule, is extended through June 30, 2013; and (3) the provision relating to payment for ground ambulance services that increases the base rate for transports originating in an area that is within the lowest 25th percentile of all rural areas arrayed by population density (known as the “super rural” bonus) is extended through December 31, 2013.

CMS is currently revising the 2013 Medicare Ambulance Fee Schedule (MAFS) to reflect the new law’s requirements. In order to allow sufficient time to develop, test, and implement the revised MAFS, Medicare claims administration contractors may hold MAFS claims with January 2013 dates of service for up to 10 business days (i.e., through January 15, 2013). We expect these claims to be released into processing no later than January 16, 2013. The claim hold should have minimal impact on supplier cash flow because, under current law, clean electronic claims are not paid sooner than 14 calendar days (29 for paper claims) after the date of receipt. Claims with dates of service prior to January 1, 2013, are unaffected.

Suppliers of ambulance services affected by these provisions may continue billing as usual.

Section 605- Extension of Medicare Inpatient Hospital Payment Adjustment for Low-Volume Hospitals
The Affordable Care Act allowed qualifying low-volume hospitals to receive add-on payments based on the number of Medicare discharges. To qualify, the hospital must have less than 1,600 Medicare discharges and be 15 miles or greater from the nearest like hospital. This provision extends the payment adjustment through September 30, 2013, retroactive to October 1, 2012. Be on the alert for further information about implementation of this provision.

Section 606 - Extension of the Medicare-Dependent Hospital (MDH) Program
 The MDH program provides enhanced payment to support small rural hospitals for which Medicare patients make up a significant percentage of inpatient days or discharges. This provision extends the MDH program until October 1, 2013, and is retroactive to October 1, 2012. Be on the alert for further information about implementation of this provision.

Be on the alert for more information about the American Taxpayer Relief Act of 2012.

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CMS announces 90-day period of enforcement discretion for compliance with eligibility and claim status operating rules

The Centers for Medicare & Medicaid Services’ (CMS) Office of E-Health Standards and Services (OESS) announced that to reduce the potential of significant disruption to the health care industry, it will not initiate enforcement action until March 31, 2013, with respect to Health Insurance Portability and Accountability Act (HIPAA)-covered entities (including health plans, health care providers, and clearinghouses, as applicable) that are not in compliance with the operating rules adopted for the following transactions as required by the Affordable Care Act: eligibility for a health plan and health care claim status. Notwithstanding OESS’ discretionary application of its enforcement authority, the compliance date for using the operating rules remains January 1, 2013.
 
This enforcement discretion period does not prevent applicable HIPAA-covered entities that are prepared to conduct transactions using the adopted operating rules from doing so. Although enforcement action will not be taken, OESS will accept complaints associated with compliance with the operating rules beginning January 1, 2013. Physicians are encouraged to file a complaint with the AMA at www.ama-assn.org/go/clickandcomplain when an insurer is out of compliance with HIPAA transaction and code set standards. If you wish to file a complaint with CMS, you may do so on the CMS website.

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Physicians who were unable to file for a Medicare ePrescribing hardship exemption by the original deadline have until Jan. 31, 2013 to avoid the 1.5 percent payment penalty in 2013.

Acting upon AMA requests, the Centers for Medicare & Medicaid Services (CMS) has re-opened the Communications Support Web page to allow physicians who missed the June 30, 2012 deadline to file for an exemption.

Physicians may request a waiver of the 2013 penalty under any of the following categories:

•    The physician is unable to ePrescribe as a result of local, state or federal law or regulation.
•    The physician wrote fewer than 100 prescriptions during the period of Jan. 1–June 30, 2012.
•    The physician practices in a rural area that doesn't have sufficient high-speed Internet access.
•    The physician practices in an area that doesn't have enough pharmacies that can do ePrescribing.

CMS also added two hardship categories for those participating in Medicare’s electronic health record meaningful use program. Physicians do not need to apply for an exemption related to these meaningful use hardship categories; CMS will automatically determine whether physicians meet those requirements.

Visit the CMS ePrescribing Web page to learn more. Physicians can contact CMS’s QualityNet Help Desk at (866) 288-8912 or via email with questions or for assistance submitting their hardship exemption requests. Support is available from 8 a.m. to 8 p.m. Eastern time Monday through Friday.

Physicians who use Apple computers may experience technical problems so CMS encourages them to contact the Help Desk for assistance.

Hardship exemption requests for the 2014 payment penalty will be accepted during a separate period this year.

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The Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative (CCI) to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment in Part B claims.

The coding policies developed are based on coding conventions as defined in the American Medical Association's (AMA's) Current Procedural Terminology (CPT) Manual—

   National and local policies and edits;
   Coding guidelines developed by national societies;
   Analysis of standard medical and surgical practice; and by
   Review of current coding practice.

The latest package of CCI edits, Version 19.0, is effective January 1, 2013, and includes all previous versions and updates from January 1, 1996, to the present. It will be organized in the following two tables:

Column 1/ Column 2 Correct Coding Edits, and
Mutually Exclusive Code (MEC) Edits.

Additional information about CCI, including the current CCI and MEC edits, is available at http://www.cms.hhs.gov/NationalCorrectCodInitEd on the CMS website

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Patient Name and Health Insurance Claim Number Mismatch: Rejection

Palmetto GBA is receiving increased calls resulting from Change Request 7260 that went into effect on October 1, 2012. With this change, Medicare contractors will reject a claim with ANSI reason code MA130 and MA61 when the beneficiary name and Health Insurance Claim Number (HICN) do not match information listed in the Common Working File (CWF) record for that beneficiary.

Providers should ensure they report the beneficiary’s name and Medicare HICN exactly as they appear on their Medicare card. Do not place hyphens or blanks in the HICN field. If the Medicare card shows that the beneficiary name has a suffix (e.g. Jr., Sr., II, III, etc.), report the name exactly as shown. If the claims are filed electronically, providers should ensure the Electronic Data Interchange (EDI) loop for the suffix field is populated and that the suffix is not added to the beneficiary’s last name.

Providers will receive the same name and Medicare HICN they submitted on their claim returned on their Remittance Advice. Instead of calling the Provider Contact Center (PCC), who will not be able to supply you with the correct information, we suggest you obtain the correct name and Medicare HICN from the patient, their Medicare card or authorized representative. Once the correct information is received, the provider should re-file the claim with the correct information.

Notice of New Interest Rate for Medicare Overpayments and Underpayments

Medicare Regulation 42 CFR §405.378 provides for the assessment of interest at the higher of the current value of funds rate (1 percent for calendar year 2013) or the private consumer rate as fixed by the Department of the Treasury. The Department of the Treasury has notified the Department of Health and Human Services that the private consumer rate has been changed to 10.625 percent effective January 17, 2013, for Medicare overpayments and underpayments.

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“Incident-to services are defined as those services that are furnished incident-to physician professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s home. ... These services are paid at 100 percent of the physician fee schedule, while services reported by Non-Physician Practitioners (Nurse Practitioners and Physician Assistants) are paid at 85 percent.”

“These services are submitted as Part B services to Palmetto GBA as if you personally provided them and are paid under the physician fee schedule.”

The information above is from Palmetto GBA’s MLN article SE0441. Questions have arisen concerning this subject so the following information should be helpful.

The physician must be in the office when incident-to services are provided. If the physician who ordered the services is not available, the physician’s partner may supervise the service. In this instance, report the service under the supervising physician’s number. In addition, the service must be an integral part of the patient’s treatment course and must have been initiated by a physician at a previous encounter.  The doctor must be involved in the treatment plan and be in the office when the service is provided.

"Incident to" services are also relevant to services supervised by certain non-physician practitioners such as physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives or clinical psychologists. These services are subject to the same requirements as physician-supervised services. Remember that 'incident services' supervised by non-physician practitioners are reimbursed at 85 percent of the physician fee schedule.

To qualify as "incident to," services must be part of the patient's normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment.

The physician does not have to be physically present in the patient's treatment room while these services are provided, but he/she must provide direct supervision, that is,  must be present in the office suite to render assistance, if necessary.
 
The patient record should document the essential requirements for incident to service.

These services must be all of the following:

   An integral part of the patient's treatment course
   Commonly rendered without charge (included in your physician's bills)
   Of a type commonly furnished in a physician's office or clinic (not in an institutional setting)
   An expense to the physician

Examples of qualifying 'incident to' services include providing non-self-administrable drugs and other biologicals, and supplies usually furnished by the physician in the course of performing his/her services (e.g., gauze, ointments, bandages and oxygen).

In your office, qualifying 'incident to' services must be provided by a caregiver qualified to provide the service, who the physician directly supervises, and who represents a direct financial expense to the physician (such as a W-2 or leased employee, or an independent contractor).

If the physician is a solo practitioner, he/she must directly supervise the care, but if the physician is in a group, any physician member of the group may be present in the office to supervise.

If claims are submitted under the NPP’s own provider number, the physician must accept Medicare reimbursement (85 %). In order to bill for incident-to, the NPP must decide if the established patient visit meets the requirements of incident-to billing. If the NPP is treating an existing problem, under an existing treatment plan, and the physician is in the office, it should be billed under the physician. New patients and new problems must be billed under the NPP’s provider number.

If the physician steps into the room and says hello to the patient and “I agree with the NPP’s plan”, this is called “seen and agreed” and should be billed under the NPP’s number. Some specialty practices schedule the NPP and the physician to see a patient on the same day. If the visit is documented by the NPP it should be billed to Medicare under the NPP’s provider number, and not the physician’s number since this circumstance does not meet the requirements of incident-to billing.

This type billing can be confusing.   Good sources of information are the CPT book and Medicare Learning Network Matters article SE0441, “Incident To and Non-physician Practitioner Services”. 

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HCPCS code J1055 (Injection, medroxyprogesterone acetate for contraceptive use, 150 mg) was deleted and replaced with new code J1050 (Injection, medroxyprogesterone acetate, 1 mg).  Now that the coding description is for 1mg, offices now must bill out 150 units on claims.

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(information from the AMA)

The "early release" of the Category I vaccine product codes prior to publication of CPT® 2006 was approved by the CPT Editorial Panel. In recognition of the public health interest in vaccine products, the Panel has agreed that new vaccine product codes should be published prior to FDA approval. These codes are indicated with the (  ) symbol and will be tracked by the AMA to monitor FDA approval status. Once the FDA status changes to approval, the (  ) symbol will be removed. The new vaccine product code(s) will be available through a bi-annual electronic release in January and July in a given CPT cycle to facilitate immunization reporting.

To facilitate immunization reporting, when applicable, the most recent new or revised vaccine product codes, resulting from recent Panel actions, will be published to the American Medical Association CPT Web site on July 1st and January 1st in a given CPT cycle. These dates correspond with CPT Editorial Panel meetings for each CPT cycle (June, October and February).

The full set of vaccine codes will be included in the next published edition for that CPT cycle. For example, if a vaccine product code was approved at the October Panel meeting, the vaccine product code would then be released for "electronic" publication the following January 1, as opposed to waiting until the next CPT publication release approximately 12 months later. All new vaccine product codes would also be included in the next published edition for that CPT cycle.

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Join the WVSMA on Friday, February 15, 2013, for the Annual Business Meeting/Physician Practice Conference. We guarantee that you will leave the conference with additional knowledge and resources to help ensure your practice is the best that it can be!

Twelve major payors, including government payors PEIA, West Virginia Medicaid, and Tricare, will be participating in the morning session of the conference. Medical Directors, management and representatives from the payors will give updates on the latest news with their plans.  Attendees will have the opportunity to speak with them and obtain the most recent updates.  You’ll also be able to seek guidance about specific issues. You won’t want to miss this wonderful opportunity to have individual conversations with so many payors in one location!

The schedule for the day also includes keynote speaker Robert Liles, JD, MBH, MHA, nationally known attorney and former Department of Justice Health Care Fraud Prosecutor.  Liles will speak on “Red Hot Compliance Issues—What Every Practice Needs to Know”.  This important session will be held on Friday afternoon.  Physicians, practice administrators, office managers and staff are encouraged to attend this extremely important session.

In addition to these and other sessions, attendees will have the opportunity to network with other medical professionals.  Not only are CME credits available for physicians; in addition, six (6) CEUs are available for PMI certified attendees.

The conference will begin with registration at 7:30 AM and the breakfast session will start at 8:00 AM. 

To register for the conference, visit the WVSMA’s website, www.wvsma.org for a registration form.  If you have additional questions, please contact Karie Sharp. (304) 925-0342, ext. 12 or via email (karie@wvsma.org).

Don’t miss out!  Register today!

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The WVSMA has scheduled the 2013 Certified Medical Office Manager Class (CMOM) for March, 2013.  Registrations are being taken now for the popular class.

The Certified Medical Office Manager (CMOM) provides advanced knowledge to help improve the productivity and profitability of your practice. Becoming a CMOM gives managers an improved confidence to guard the practice against risks, motivate employees, increase revenue and ultimately improve the patient experience in your office.  

You may register online at www.wvsma.org.  If you have any questions, contact Barbara Good (Barbara@wvsma.org).  This is a great class!

The WVSMA is proud to be the West Virginia exclusive partner of Practice Management Institute (PMI). 

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The WVMGMA will be hosting their first conference of the year on February 22, 2013, in Charleston at the Marriott.  Guest speakers will include Jennifer Martin, Government Affairs Representative from the National MGMA, Keith Burdette from the State Chamber of Commerce, Jeremiah Samples from the Insurance Commissioner’s Office and Evan Jenkins, State Senator and CEO of the West Virginia State Medical Association.

For more information about membership in the WVMGMA, contact President Mark Morgan (mmorgan@uhswv.com) or Barbara Good (Barbara@wvsma.org). 

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The Practice Management Institute’s (PMI) 2013 Conference will be held in New Orleans, La, on  May 29-31.   This is a great conference with terrific educational sessions.  Past attendees have praised the conference for the information and networking provided. 

West Virginia attendees can obtain a substantial discount to attend the conference.   Contact Barbara Good (Barbara@wvsma.org) for more information and plan on joining your peers in New Orleans!
 

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(information provided by the WVHIN)

The WVHIN Invites You to a Webinar Presentation on January 29, 2013 from 11AM – 12PM, titled “Overview of the WVHIN: Your Connection to Secure Patient Data Exchange”
 
Are you tired of wasting time flipping through your patient’s paper records or waiting for paperwork to arrive from another healthcare provider?
 
Are you looking for solutions that will assist you in improving your quality initiatives and meeting requirements under Meaningful Use?
 
If so, please participate in a webinar that provides information on WVHIN’s services. These services include WVDirect and Health Information Exchange (HIE). 
WVHIN’s services assist healthcare providers in saving valuable time and money, facilitating care coordination through enabling real time communication among providers and getting patient data to providers when and where it is needed.

Registration is Free.

Visit http://www.wvhin.org/events to register for the January 29th webinar.  This webinar will repeat throughout the upcoming months as noted on the WVHIN website.  Thus, if you cannot attend on January 29th, please register for a session on another date and time that works best for you.

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Several Changes to Stage 1 Meaningful Use Measures Begin This Year

The Stage 2 rule for the Electronic Health Record (EHR) Incentive Programs included changes to the Stage 1 meaningful use objectives, measures, and exclusions for eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs). Some of these Stage 1 changes took effect on October 1, 2012, for eligible hospitals and CAHs, or January 1, 2013, for EPs. Several are optional, but others are required.

Stage 1 Changes and Timing:
Computerized Physician Order Entry (CPOE)

Change: Addition of an alternative measure based on the total number of medication orders created during the EHR reporting period
Timing: 2013 and onward

Change: Revised the description of who can enter orders into the EHR and have it count as CPOE
Timing: 2013 and onward (regardless of what stage of meaningful use the provider is attesting to)

Electronic Prescribing

Change: Additional exclusion to the objective for electronic prescribing for providers who are not within a 10 mile radius of a pharmacy that accepts electronic prescriptions
Timing: 2013 and onward

Record and Chart Changes in Vital Signs

Change: Age limit increased for recording blood pressure in patients from ages 2 to ages 3;  no age limit for height and weight
Timing: Optional in 2013; required starting in 2014

Change: Exclusion if the EP sees no patients 3 years or older, if all three vital signs are not relevant to their scope of practice, if height and weight are not relevant to their scope of practice, or if blood pressure is not relevant to their scope of practice
Timing: Optional in 2013; required starting in 2014

Public Health Reporting Objectives

Change: Require that providers perform at least one test of their certified EHR technology's capability to send data to public health agencies, except where prohibited
Timing: Required in 2013 and onward (for all Stage 1 public health objectives)

Electronic Exchange of Key Clinical Information

Change: Objective for electronic exchange of key clinical information no longer required for Stage 1 for EPs, eligible hospitals, and CAHs
Timing: No longer required in 2013 and onward

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Injections and Infusions

For services furnished on or after January 1, 2004, Palmetto GBA will not pay for CPT code 99211, with or without CPT modifier 25, if it is billed with a nonchemotherapy drug infusion code or a chemotherapy administration code. This also applies when it is billed with a diagnostic or therapeutic injection code on or after January 1, 2005.

 Diagnosis/Management Options

The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician.

Medical Necessity

Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation must support the level of service reported.

Initial Preventative Physical Examination (IPPE) and Annual Wellness Visit (AWV)

When the physician or qualified non-physician practitioner (NPP), provides a significant, separately identifiable medically necessary E/M service in addition to the Initial Preventative Physical Examination (IPPE) or an Annual Wellness Visit (AWV), CPT codes 99201 – 99215 may be reported depending on the clinical appropriateness of the circumstances.

Some of the components of a medically necessary E/M service (e.g., a portion of history or physical exam portion) may have been part of the IPPE or AWV and should not be included when determining the most appropriate level of E/M service to be submitted for the medically necessary, separately identifiable, E/M service.

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• • Wesgram Online
• • HIPAA HITECH Omnibus Rule Released!
• • Health and Human Services (HHS) Recent HIPAA Guidance
• • Medicare News
• • CMS Announces Delay of Enforcement Discretion
• • Deadline to Request Exemption from ePrescribing Penalty is Jan. 31
• • Correct Coding Initiative Update
• • Palmetto GBA Updates
• • Incident-to Billing Issues
• • Important OBGYN Coding Change
• • CPT Category I Vaccine Codes
• • Register Now for WVSMA's Physician Practice Conference!
• • WVSMA Schedules 2013 CMOM Class!
• • West Virginia Medical Group Managers Association Conference
• • Practice Management Institute's 2013 Conference
• • WVHIN Offers Webinar
• • Changes to Meaningful Use
• • Coding Tips from Palmetto GBA