Advance Care Planning

CMS started paying for voluntary Advance Care Planning (ACP) from January 1, 2016.

ACP helps Medicare patients decide the plan of care that they would like to get when they are unable to take such decisions themselves.

Voluntary ACP is a face-to-face service between a physician (or other qualified health care  professional) and a patient discussing advance directives with or without completing relevant legal forms. An advance directive is a document in which a patient appoints an agent and/or records the  wishes of a patient pertaining to their medical treatment at a future time if they cannot decide for themselves at that time.

There are no limits on the number of times you can report ACP for a given patient in a given time period. When billing the service multiple times for a given patient, document the change in the patient's health status and/or wishes regarding their end-of-life care.

There are no place-of-service limitations on ACP services. You can appropriately furnish ACP services in facility and non-facility settings. ACP services are not limited to a 
particular physician specialty.

CMS requires no specific diagnosis to bill the ACP codes.

CPT 99497                
Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first  30 minutes, face-to-face with the patient, family member(s), and/or surrogate

CPT 99498      
Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

Retrieved from https://www.medicare.gov/coverage/advance-care-planning.html

For more information refer the following link :  https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AdvanceCarePlanning.pdf

Are you Eligible for MIPS in 2018 ?

You are eligible and are required to submit data for MIPS 2018, if you are a,

• Physician (including doctors of medicine, doctors of osteopathy, osteopathic practitioners, doctors of dental surgery, doctors of dental medicine, doctors of podiatric medicine, doctors of optometry, and chiropractors)
• Physician Assistant
• Nurse Practitioner
• Clinical Nurse Specialist
• Certified Registered Nurse Anesthetist

OR

if you see more than 200 Medicare patients annually

OR

if you bill Medicare more than $90,000 in Allowed charges annually.


You are exempt from MIPS 2018, if you,

• do not meet any of the criteria above
• enroll in Medicare for the first time in 2018
• participate in an advanced APM wherein you receive 25% of the Medicare payments or see 20% of the Medicare patients from an advanced APM

You can also know your MIPS 2018 eligibility by clicking this link  https://qpp.cms.gov/participation-lookup  and entering your 10-digit National Provider Identifier (NPI) number to view your MIPS participation status.

Abdomen X-ray coding in 2018

Abdomen X-ray codes have changed, the old Abdomen X-ray codes 74000, 74020 are being deleted and are being replaced by 74018, 74019 and 74021.

As the new Abdomen X-ray codes are coded based on the number of views, from a documentation compliance standpoint it is imperative for the practice to ensure that the number of views are appropriately documented.

The new Abdomen X-ray codes are,

• 74018 Radiologic examination, abdomen; single view
• 74019 Radiologic examination, abdomen; two views
• 74021 Radiologic examination, abdomen; three or more views

Chest X-ray coding in 2018

Chest X-ray coding has become simpler in 2018, the chest x-ray codes are some of the most frequently used imaging codes in healthcare.

Previously Chest X-ray codes used nine different codes, now these nine codes have been replaced with four codes that are simply determined by the number of views.

As  the new Chest X-ray codes are coded based on the number of views, from a documentation compliance standpoint it is imperative for the practice to ensure that the different types / number of views are appropriately documented.

The new Chest X-ray codes are,

• 71045 Radiologic examination, chest; single view
• 71046 Radiologic examination, chest; 2 views
• 71047 Radiologic examination, chest; 3 views
• 71048 Radiologic examination, chest; 4 or more views

Merit-Based Incentive Payment System (MIPS)

MACRA replaced three Medicare reporting programs with MIPS (Medicare Meaningful Use, the Physician Quality Reporting System, and the Value-Based Payment Modifier).

Under the combination of the previous programs, you would have faced a negative payment adjustment as high as 9% total in 2019, but the MACRA ended those programs, reduced the potential negative payment adjustments in the early years, and streamlined the overall requirements. While these three programs will end in 2018, if you have participated in these programs in the past, then you will have an advantage in MIPS because many of the requirements should be familiar.

To check if you need to submit data to MIPS, enter your 10-digit National Provider Identifier (NPI) number in the link below,

https://qpp.cms.gov/participation-lookup

MACRA defined four performance categories for MIPS, linked by their connection to quality and value of patient care.

Quality : Replaces the Physician Quality Reporting System (PQRS)

Most participants: Report up to 6 quality measures, including an outcome measure, for a minimum of 90 days.

Groups using the web interface: Report 15 quality measures for a full year. To submit data as a group through the CMS Web Interface, you must register your group between April 1, 2017 and June 30, 2017.

Groups in APMs qualifying for special scoring under MIPS, such as Shared Savings Track 1 APM or the Oncology Care Model one-sided risk APM: Report quality measures through your APM. You do not need to do anything additional for MIPS quality.

Advancing Care Information : Replaces the Medicare EHR Incentive Program, also known as Meaningful Use

Fulfill the required measures for a minimum of 90 days:

    Security Risk Analysis

    e-Prescribing

    Provide Patient Access

    Send Summary of Care

    Request/Accept Summary of Care

Choose to submit up to 9 measures for a minimum of 90 days for additional credit.

For bonus credit, you can:

    Report Public Health and Clinical Data Registry Reporting measures

    Use certified EHR technology to complete certain improvement activities in the improvement activities performance category

OR

You may not need to submit advancing care information if these measures do not apply to you.

Improvement Activities : New category

Most participants: Attest that you completed up to 4 improvement activities for a minimum of 90 days.

Groups with fewer than 15 participants or if you are in a rural or health professional shortage area: Attest that you completed up to 2 activities for a minimum of 90 days.

Participants in certified patient-centered medical homes, comparable specialty practices, or an APM designated as a Medical Home Model: You will automatically earn full credit.

Participants in certain APMs under the APM scoring standard, such as Shared Savings Program Track 1 or OCM: You will automatically receive points based on the requirements of participating in the APM. For all current APMs under the APM scoring standard, this assigned score will be full credit. For all future APMs under the APM scoring standard, the assigned score will be at least half credit.

Cost : Replaces Value-Based Modifier

No data submission required. Calculated from adjudicated claims.

Retrieved from https://qpp.cms.gov/

Quality Payment Program - MACRA

The Quality Payment Program that is part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) improves Medicare by helping Providers focus on care quality and the one thing that matters most — making patients healthier. The Quality Payment Program is focused on moving the payment system to reward high-value, patient-centered care.

The Quality Payment Program has two tracks you can choose from:

1). Advanced Alternative Payment Models (APMs)

2). The Merit-based Incentive Payment System (MIPS).

Participate in the Advanced APM track:

If you receive 25% of Medicare covered professional services or see 20% of your Medicare patients through an Advanced APM in 2017, then you earn a 5% Medicare incentive payment in 2019.

You are eligible to participate in the MIPS track of the Quality Payment Program if you bill more than $30,000 to Medicare, and provide care to more than 100 Medicare patients per year, and you are a :  Physician, Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Certified Registered Nurse Anesthetist. If 2017 is your first year participating in Medicare, then you are not required to participate in the Quality Payment Program in 2017.

Participate in the MIPS track:

If you choose the MIPS track of the Quality Payment Program,  you have four options.

1.Don't Participate
Not participating in the Quality Payment Program: If you don't send in any 2017 data, then you receive a negative 4% payment adjustment.

2.Submit Something
Test: If you submit a minimum amount of 2017 data to Medicare (for example, one quality measure or one improvement activity), you can avoid a downward payment adjustment.

3.Submit a Partial Year
Partial: If you submit 90 days of 2017 data to Medicare, you may earn a neutral or small positive payment adjustment.

4.Submit a Full Year
Full: If you submit a full year of 2017 data to Medicare, you may earn a moderate positive payment adjustment.

The size of your payment adjustment will depend both on how much data you submit and your  quality results.

Retrieved from https://qpp.cms.gov/

ICD 10 - Improving Clinical Documentation

ICD-10 is finally here and what most of us do not realize is that, it is just not enough that we are able to code in ICD-10 and get the claims billed out, we need to ensure that the documentation is specific and supportive of the ICD-10 diagnoses billed.

We need to make sure that our clinical services are documented in greater detail, so that the documentation supports a more specific ICD-10 code. Physicians / staff  involved in creating the documentation need to become more accustomed to the specific, detailed clinical documentation needed to assign ICD-10 codes.

For example, laterality is expanded in ICD-10-CM. Therefore, clinical documentation for diagnoses should include information about which side of the body is affected (i.e., right, left, or bilateral).

Some of the Clinical parameters that we need to document as per the diagnosis/condition, in order to be able to code in ICD-10-CM are,

        Clinical Documentation Parameters:

• Onset - when did it start
• Manifestation - Paralysis, Loss of Consciousness
• Comorbidities
• Etiology/Causation - Infectious agent, Physical agent, Internal failure, Congenital
• External Causes - Motor vehicle, Injury, Assault, Accidental, Work related, Intentional Self harm
• Complication
• Detailed Anatomical Location - Proximal, Distal, Medial, Lateral, Central, Peripheral, Superior, Inferior, Anterior, Posterior
• Functional Impairment
• Biological & Chemical Agents
• Phase/Stage
• Lateralization /Localization - Rt side, Lt side, Bilateral or Unilateral
• Severity - Mild, Moderate or Severe
• Time Parameters - Intermittent, Recurring, Postoperative, Postdelivery
• Encounter type - Initial, Subsequent
• Healing Level - Routine healing, Delayed healing, Non-Union, Malunion e.t.c

Below are some examples of the specific information that would have to captured and documented to accurately code the following common diagnoses in ICD-10:

        Diabetes Mellitus:

• Type of diabetes
• Body system affected
• Complication or manifestation
• Long-term insulin use

        Fractures:

• Site
• Laterality     
• Type - open, closed
• Encounter type - Initial, Subsequent   
• Healing Level - Routine healing, Delayed healing, Non-Union, Malunion e.t.c

        Injuries:

• Place of occurrence
• External cause - Cause of injury, how the injury happened
• Activity code - what the patient was doing at the time of the injury ?
• External cause status - Injury related to military, work or others

It will be important to make your documentation as detailed as possible, since ICD-10-CM gives more specific choices for coding diagnoses. This information is likely already being shared by the patient during the encounter, it is a matter of capturing all the pertinent information so that we can choose the most appropriate ICD-10 Dx. Proper documentation helps to reduce denials and increase compliance.

New Patient or Established Patient ?

Who is a New Patient ? When do we bill a New Patient ? When does a Patient become an Established Patient ? These are some of the questions that confuse some practices when billing New/Established patients.

There are instances when a patient is seen by a Physician in the Hospital and in the Office and many Practices are not clear as to how to bill the patient visit. 

Determining whether a Patient visit is to be billed as a New Patient visit or an Established Patient visit has significant implications from a Clinical, Financial, Billing and Coding standpoint.

"A New Patient visit is an evaluation and management service provided to a patient who has not received any face-to-face service from any physician of the same specialty who belongs to the same group practice for at least three years".

Conversely an "Established Patient visit is an evaluation and management service provided to a patient who has already received any face-to-face service from any physician of the same specialty who belongs to the same group practice in the last three years".

An established patient is one who has received professional services from the physician/qualified health care professional or another physician/ qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years - See more at: http://www.aap.org/en-us/professional-resources/practice-support/Coding-at-the-AAP/Pages/New-Vs-Established-Patient.aspx#sthash.O0LGrQSh.dpuf

New Patient visits

1. Patient John Doe comes to see Dr A in his practice after a period of 4 years.

2. Patient John Doe was seen by another physician belonging to a different specialty in the same multispecialty practice, but Patient John comes to see Dr A for the first time.

Established Patient visits

1. Patient John Doe comes to see Dr A in his practice for the first time, Dr A has never seen Patient John before but Dr B another physician in Dr A's practice has seen patient John last year.

2. Patient John Doe was seen by Dr A in the hospital a month ago, he comes to see Dr A in his practice for the first time. Since Dr A has seen patient John within the last 3 years, the office visit becomes an Established visit.

E&M and other Procedures

In a Patient encounter we might perform procedures apart from the regular E&M procedure, in such instances payors would deny the E&M procedure but would pay the additional procedure alone.

Let us take an example of an encounter where a Trigger Point Injection (CPT 20553) is given and an E&M procedure (99213)  is also performed.

The procedure 20553 has an Evaluation component built into its reimbursement, this is the reason why payors may deny the payment for the E&M procedure. So the Payors are right in denying the E&M procedure if the E&M procedure is not distinct and not separately identifiable from the other procedure performed.
 
But We are definitely allowed to bill a Procedure (20553)  and a distinct E&M service (99213) on the same visit, as long as the E&M service is separate and distinct from the procedure, and the same is documented in the progress notes. A distinct E&M service refers to an evaluation where the service is significant and separately identifiable from the other procedure.

An example would be :  

20553        Trigger point Inj                                 
99213 - 25  E&M service for  HTN, DM, CAD   
 
Here the E&M service is separate and distinct from the Procedure 20553, the E&M service needs to be submitted with modifier 25 to indicate that it is separate from the other procedure performed. If the E&M service is submitted without the 25 modifier, it would be denied.

E&M Coding & Documentation Guidelines

It is essential that we code and document every patient encounter accurately so as to maximize revenues and avoid potential audits and recoupments later. It is imperative that we document all procedures that are performed. Any procedure that is not documented would be considered as not performed by the payors.

While coding the E&M codes, we need to be careful in choosing the right level of code. We should choose the right E&M code level based on the Complexity of MDM (Medical decision making that is involved in the evaluation of the patient), once we arrive at the level of code based on the level of medical decision making : MDM, we need to ensure that we have sufficiently  documented the progress note  to support the required level of History and Physical Exam.

For e.g if you see a Patient for f/u in hospital for whom the MDM is moderate then as per MDM which points to level 2, we should code only level 2 CPT 99232 and we need to document a EPF (Expanded problem focused) History and an EPF Exam, this would ensure that we comply with regard to Coding and Documentation
guidelines

Instead for the same patient if we have not adequately documented the progress note, let us assume that we have documented only a PF History and PF Exam and have billed CPT 99232, then we may get paid for CPT 99232, but in case of an audit later, CMS / other payors could recoup the payment for inadequate documentation

Another scenario for the same patient would be wherein,  we have documented more than what is needed, let us assume that we have documented  a Detailed History and a Detailed Exam and have billed  CPT 99233 instead of CPT 99232 as per MDM, then again CMS / other payors may recoup the payment for lack of medical necessity / upcoding.

Hope the above examples give you some idea as to Coding the levels and the documentation required. Please refer the below link for CMS manuals  on Coding and Documentation.   http://www.cms.gov/Outreach-and-Education/Outreach-and-Education.html

Prolonged Services codes CPT 99354 - 99357

Prolonged Services billing is allowed by Medicare in the Office, other Outpatient and Inpatient settings, the Prolonged Service codes are used as add-on codes to E&M codes to indicate the extra time that the Physician has spent face-to-face with the patient.

The Prolonged Service codes are billed based on the length of time spent with the patient beyond the usual time required for the E&M code billed, the time spent with the patient need not be continuous but it must be time spent in one calendar day and must be time spent face-to-face with the patient.

For Office/Outpatient settings :

CPT 99354 can be billed when the provider spends direct face-to-face time of more than one hour beyond the usual service/typical time for the E&M code. Additional 30 minutes of face-to-face time with patient can be reported by CPT Code 99355.

For Inpatient settings :

CPT 99356 can be billed when the provider spends direct face-to-face time of more than one hour beyond the usual service/typical time for the E&M code.
Additional 30 minutes of face-to-face time with patient can be reported by CPT Code 99357.

Prolonged service cannot be billed when the prolonged service duration is less than 30 minutes as then it would be considered as included in the E&M code billed.

Prolonged services of less than 15 minutes beyond first hour or less than 15 minutes beyond the final 30 minutes cannot be billed.

Total time of Prolonged services	Outpatient	Inpatient
(do not include visit code time)	Prolonged Services Code	Prolonged Services Code
Less than 30 minutes	Not reported	Not reported
30 – 74 minutes	99354	99356
75 – 104 minutes	99354 and 99355	99356 and 99357

As regards the documentation, the documentation needs to be explicit, documentation is required to be in the medical record about the duration and content of  the medically necessary evaluation and management service and prolonged  services that you bill. 

You must sufficiently document in the medical record that you  personally furnished the direct face-to-face time with the patient specified in the CPT code definitions.   The progress note has to have the start and end times of the visit, along with the date of service.

Signing of Medical Records

Medical Records need to be signed once the services are rendered, the medical record is authenticated when a Provider signs the document.

Payers expect records to be signed within 24 Hrs after services are rendered. In the case of EHR, the records need to be signed electronically.

Medical records that are not signed and records that are signed after a unreasonable delay may not be accepted and could lead to financial and legal implications.

Importance of Documentation

Medical Documentation is very important from a Clinical, Financial and Legal standpoint. 

From a Clinical perspective medical documentation establishes the following,

• the Patient receiving the Service
• the Physician providing the Service
• the Plan of Care provided by the Physician
• the Diagnosis justifying Medical necessity
• the Procedures performed, the Labs ordered
• the Quantity of Service such as consumables
• other details such as Place of service / Date of service e.t.c

From a Financial perspective medical documentation establishes the following,

• proper adjudication of claims
• timely payment of claims

From a Legal perspective medical documentation establishes,

• the justification for the procedures performed
• Legal protection for the Patients and Physicians

The Physician / Provider has to document all the procedures performed and sign the document, procedures that are not documented would be considered as not performed and would not be eligible for payment.

Modifiers 52 & 53

The usage of Modifiers 52 & 53 is very clear and straightforward but still many claims have these modifiers applied incorrectly opening up the possibility of a recoupment later on.

52 Modifier - Reduced Services.

In many instances a procedure or service is reduced at the discretion of  a physician.

We need to apply the 52 modifier to that CPT code, when the physician is performing a reduced procedure rather than the entire procedure, as denoted by the CPT code and when that reduced procedure does not have a specific CPT code for billing. The 52 modifier should not be applied to a CPT code, when the procedure that was planned had to be discontinued / terminated for any reason whatsoever. In these instances we need to use modifier 53 to indicate that the procedure was discontinued.

If the reduced procedure is surgical, the claim needs to submitted with an Operative report and a separate report detailing how the reduced procedure differs from the normal procedure.

For procedures that are non-surgical, a report detailing how the reduced procedure differs from the normal procedure needs to be sent alongwith the claim.

Example :

The provider is planning on performing pure tone audiometry, air only, for a patient on only one ear. There is no CPT code for this test when performed on one ear, while we have CPT code 92552 pure tone audiometry (threshold), air only, for both ears ( bilateral procedure ). 

In this instance since the provider plans to perform the test for one ear only, this becomes a reduced procedure. Hence we need to append modifier 52 to CPT code 92552.

53 Modifier - Discontinued Procedure.

In many instances a surgical or diagnostic procedure may need to be terminated / discontinued due to various reasons.

A procedure that was initiated may need to be terminated / discontinued due to various reasons, in such cases we need to apply Modifier 53 to the CPT code. A procedure may be discontinued / terminated due to various reasons, such as the patient not being able to tolerate the procedure. The 53 modifier basically indicates that the procedure was initiated but not completed.

If the discontinued procedure is surgical then a Operative report needs to be sent alongwith the claim. 

For procedures that are non-surgical, a report detailing how the discontinued procedure differs from the normal procedure needs to be sent alongwith the claim.

The 53 modifier cannot be used, if a Procedure is discontinued by the Physician before administering anesthesia or surgical preparation in the operating room.

Example :

Colonoscopy was initiated on a patient. Polyps were removed by hot biopsy from the descending colon. The provider then attempted to move the colonoscope past the splenic flexure but due to a tortuous colon / blockage the colonoscope could not advance past the splenic flexure. The procedure was hence discontinued.

In this instance the physician had initiated a Colonoscopy by Hot biopsy CPT 45384, but the procedure was discontinued as the colonoscope could not move past the splenic flexure. Hence we need to append mofifier 53 to CPT code 45384.

Hemodialysis & E & M visits

In general when Hemodialysis is billed alongwith an E&M procedure, the Hemodialysis procedure alone is paid while the E&M procedure is denied.

This is because the Hemodialysis procedure has an E&M component built into it and hence the additional E&M procedure is denied. The Evaluation and Management services related to dialysis treatment for ESRD are included in the Dialysis codes and so are not separately reimbursable.

However an E&M can be billed if it is for a separate and distinct service.

For example if a Physician treats a separate and unrelated condition, than the E&M code can be billed with modifier 25, the important point to note is that the documentation should substantiate that the E&M is for a separate and identifiable service apart from the Dialysis procedure on the same day.

Services that are generally included into the Dialysis code are the Physician's evaluation, treatment plan, phone calls, counselling, physician laboratory visits and overall management of the patient.

Key Indicators

Knowing whether your practice is doing well financially is important for the successful running of any practice. Many practices flounder and go bankrupt because they were not monitored properly, leading to their financial ruin.

There are some key indicators which would guide us to make major course corrections where necessary, to bring the practice back on track. Monitoring these key indicators on a regular basis, will ensure that your practice remains financially healthy and continues to run smoothly.

Visits :
The number of Patient visits per month is a straightforward indicator, that is directly proportional to the monthly revenue.

New Patients :
Practices need to ensure that the percentage of New Patients to the total monthly visits is on the increase or steady, on a monthly basis, this would ensure that Old Patients dropping out are compensated by the New Patients, otherwise we would see a drop in the monthly revenue of the practice. When we see the percentage of New Patients decreasing on a monthly basis, this should serve as a warning for us to make course corrections in our practice.

Payor Mix :
An analysis of the Payorwise monthly collections will help us to identify which Payors contribute the most to the revenue of the practice and which payors will significantly impact the practice when their reimbursements change.

Days in AR :
Practices need to know how many days it takes, for them to collect one days charges. The days in AR reflect how quickly and efficiently the practice is able to work the AR and get paid. Higher the Days in AR could be due to a whole host of problems such as Charge / Demographic entry errors, Coding errors,  delayed claim submission, not working the clearing house reports, improper handling of denials and poor AR management. Practices should aim to keep the days in AR under 40.

AR aging :
The AR bucketwise aging is an indicator of how the AR is distributed across different buckets. We can have upto 70% AR (70% of Average monthly charges) in the 0-30 day bucket, upto 15% AR in 30-60 day bucket, upto 10% AR in the 60-90 day bucket, upto 5% AR in the 90-120 day bucket and upto 25% AR in the 120+ days bucket. High AR in the 0-30 day bucket could be due to Charge entry errors, Demographic entry errors, Coding errors or delays in claim submission, high AR in the later buckets could point to improper denial / AR management.

Gross Collection Rate :
The ratio of Actual Collections to Total Charges for a month would be a good indicator of how well we are collecting against the total charges billed. But this ratio needs to be reviewed based on your contractual adjustments. So if you are overbilling your allowed amount by 180 % then a Gross Collection Ratio of 45-50 % is fine.

Net Collection Rate :
The ratio of Actual Collections to Net Charges (Total Charges Less Adjustments) for a month would be a more accurate indicator, than the Gross Collection Rate, of how well the practice is collecting its receivables, since this ratio measures Actual Collections against Actual Collectables, practices should aim for a ratio of 95% or higher.

Preventive Services

Medicare has been reimbursing certain Preventive Services such as Annual Wellness Visits, Cardiovascular Disease Screenings, Diabetes Screening Tests, Screening Pelvic Exam, Glaucoma Screening, Smoking and Tobacco Cessation Counseling e.t.c for some time now.

Recently Medicare has started covering for Screening and Behavioral Counseling to reduce Alcohol misuse and Face-to-Face Behavioral Counseling for Obesity.

Alcohol misuse :

Effective for claims with dates of service October 14, 2011, and later, CMS shall cover annual alcohol screening, and for those that screen positive, up to four, brief, face-to-face behavioral counseling interventions per year for Medicare beneficiaries, including pregnant women.

Obesity Therapy :

Effective for claims with dates of service on or after November 29, 2011, CMS will allow coverage for Face-to-Face Behavioral Counseling for Obesity, 15 minutes, G0447, along with 1 of the ICD-9 codes for BMI 30.0-BMI 70 (V85.30- V85.39 and V85.41- V85.45), only when submitted with one of the following place of service (POS) codes: 11 – Physician’s Office, 22 – Outpatient Hospital, 49 – Independent Clinic or 71 - State or Local Public Health Clinic.

For more information on Medicare preventive services, visit http://www.cms.gov/PrevntionGenInfo on the CMS website.
For more information on Medicare Learning Network® (MLN) preventive services educational products, visit  http://www.cms.gov/MLNProducts/35_PreventiveServices.asp on the CMS website.

Source CMS

Referral vs Authorization

A Referral is not the same as an Authorization. 

In general a referral is required when a PCP refers a patient to a specialist in-network provider for consultation, while an Authorization also known as Prior Authorization, is approval from the Insurance plan for the performance of certain specific medical procedures and services, based on medical necessity.

A typical scenario would be a PCP referring a patient to a in-network Nephrologist. A referral would be required without which the Insurance plan will not pay. If the Nephrologist performs only an evaluation, the referral alone would suffice, but if the Nephrologist chooses to administer a Procrit injection, than this procedure ( which is on the Prior authorization list of the Insurance plan ) would require a Prior authorization for the Insurance plan to make payment.

Referral :

• A referral is required when a PCP refers a patient to a specialist
• HMO Plans in general require a referral while PPO plans do not require a referral
• A referral is valid for a certain period and for a certain number of visits
• A referral is not required for Emergency services
• A referral is not required for Routine / Preventive services
• Without a referral the insurance plan will not pay

Prior Authorization :

• A Prior authorization is required when a provider plans on performing a procedure which is on the Prior authorization list of the Insurance plan
• A Prior authorization needs to be obtained from the Insurance plan before the performance of the medical procedure
• A Prior authorization is provided by the Insurance plan when they are satisfied as to the medical necessity of the procedure
• A Prior authorization is not required for Emergency services
• Without a Prior authorization the Insurance plan will not pay for procedures that are on its Prior authorization list 

Annual Wellness Visit

From January 1, 2011 Medicare has initiated the Annual Wellness Visits. Medicare uses the codes  G0438 and G0439 for these wellness visits.

G0438 Initial visit 

Annual wellness visit, consisting of  a personalized prevention plan of service (PPPS), first visit.

G0439 Subsequent visit

Annual Wellness visit, consisting of  a personalized prevention plan of service (PPPS), subsequent visit.

Annual Wellness Visits can be for both new or established patients. The initial AWV, G0438, is used for patients enrolled with Medicare for more than a year.

A patient becomes eligible for their subsequent AWV, G0439, a year after the initial visit. During the first year a patient has enrolled with Medicare the patient is eligible for the Welcome to Medicare visit or IPPE, Initial Preventive Physical Exam. This visit is billed using HCPCS code G0402. The Annual wellness code of G0438 should not be used in this scenario  and will be denied since the patient is eligible for the Welcome to Medicare visit G0402 during the first year.

Initial Annual wellness visit consists of,

– Medical and family history

– List of current  providers

– Height, weight, BMI, BP and other parameters

– Detection of cognitive impairment

– Review risk factors

– Review of functional ability

– Establish a written screening schedule for next 5-10 years

– Establish list of risk factors

– Provide advice and referrals to health education and preventive counseling services

– Other elements as determined by the Secretary of Health and Human Services

The above list is just a summary. Check out http://www.cms.gov/MLNMattersArticles/downloads/MM7079.pdf for additional information and links to other Medicare resources on services that must be provided at the AWV and subsequent AWV.

5010

The U.S. Department of Health and Human Services has issued a final rule to transition to the next generation of HIPAA electronic transaction standards (5010) by January 1, 2012.


January 1, 2012: Any healthcare entity that submiting electronic claims must comply with HIPAA 5010 by January 1, 2012. After January 1, version 4010A will no longer be valid.
Payors will reject any electronic claims that are not HIPAA 5010 compliant. This will impact claim payments. The new HIPAA 5010 standards has improved functionality and fully support NPI and the new International Classification of Diseases, Tenth Revision (ICD-10) code sets. 

Why 5010 ?

The current format, is unable to meet some important new developments in health care such as supporting the ICD-10 code set and pay for performance. Other changes in the 5010 version will streamline reimbursements. Most of the changes are technical and geared toward improved standardization and uniformity. Many of these can be handled by your vendor and clearinghouse. However, it is important that you understand your own responsibilities in order to become 5010 compliant.

Billing Provider Address

With 5010, the Billing Provider Address you use on claims must be a physical address?  Once 5010 is implemented, you can no longer use PO Box and lock box addresses as a billing provider address.  This rule applies to both professional and institutional claim formats. However, you can still use a PO Box or lock box address as your location for payments and correspondence from payers as long as you report this location as a pay-to address. The pay-to- provider address is only needed if it is different than that of the billing provider. Work with your software vendor to ensure the correct addresses are captured and inserted in the necessary locations on your claim submission.

Nine Digit Zip Codes

In 5010, providers must submit a full 9-digit ZIP code when reporting billing provider and service facility locations? An easy way to determine the 4-digit extension to your standard ZIP code is to look it up on the U.S. Postal Service’s ZIP Code Lookup Tool. Work with your software vendors to ensure they can capture the full nine digits for the billing provider and service facility addresses.

Anesthesia Claims

In 5010, you must report anesthesia services in minutes rather than units if the procedure code does not define a specific time period? However, if the procedure code has minutes in its description, then you can continue to report those charges in units. 
When you need to manually calculate the time period, you can only use minutes for the time measurement. For example, if the total time of anesthesia services is one hour and thirty minutes, services should be submitted as 90 minutes.
Anesthesia providers should verify that their systems can manage this change.

Subscriber vs. Patient Clarification

With 5010, the insurance plan subscriber/patient hierarchy has been clarified. Two possible situations can occur:

1. If the patient has a unique member identifier assigned by the payer, then the patient is considered to be the plan subscriber and is sent as the subscriber. There is no need to also enter their information in the patient section on the claim.
2. If the patient is a dependant of the plan subscriber and does not have their own unique member identifier, then both the subscriber and patient information will be required on the claim.

Providers must check the patient’s insurance card and/or check patient eligibility to ensure the information is appropriately documented for accurate submission in 5010.

Drug Reporting

In 5010, professional claims for injectable medications must include additional drug information and qualifiers, such as National Drug Code (NDC), quantity, composite unit of measure and prescription number.
Currently providers must submit a HCPCS code as the service-line procedure along with the total charge and units of service. In 5010, you will now be required to also submit the NDC Drug Quantity and Composite unit of measure.  Providers who submit service-line drug charges must work with their software vendor to ensure that the drug quantity and unit of measure can be submitted. Claims that do not include this information may be rejected.
Providers should work with their software vendors to determine if the product supports these and other drug entry changes.

Compound Drug Claims

The 4010 standards made it difficult to select a single HCPCS code for a compound injectable medication because each ingredient pointed to a different HCPCS code. In 5010, all ingredients that make up a compound prescription must be identified on the claim, and a unique HCPCS must be assigned to each ingredient. The provider will be required to enter separate lines of service for each HCPCS.  As with single ingredient drugs, the provider must also include their service line charge for each ingredient, the service line associated units, the NDC number, the NDC Drug Quantity, and the Composite unit of measure.   
Providers should work with their software vendors to determine if the product supports these and other drug entry changes.

Durable Medical Equipment

The Durable Medical Equipment (DME) Service segment (2400 SV5) is used when it is required to report both the rental and purchase price information for durable medical equipment at the service line level. In 4010, only the procedure code, unit of measurement and quantity were required for this entry. In 5010, the DME Rental Price, DME Purchase Price and Rental Unit Price Indicator will also be required. If all three of these fields do not contain a valid value, the claim will be rejected.
Some claims may also require the DME Condition Indicator segment (2400 CRC) for a Durable Medical Equipment Regional Carrier Certificate of Medical Necessity (DMERC CMN), a DMERC Information Form (DIF), or an Oxygen Therapy Certification.  In 4010, you could repeat the segment more than once, but 5010 limits you to one DMERC condition indicator segment per service line. The number of condition indicator codes for this segment has also been reduced from five possible codes in 4010 to only two codes in 5010. If invalid indicator codes are used, the claim will be rejected.

Ambulance Claims

In 5010, ambulance suppliers who submit medical transportation claims will be required to report the pick-up and drop-off locations for ambulance transport. Previously, there were no dedicated fields for this information, but now it can be reported at the claim level (5010 loops: 2310E and 2310F) and service line level (5010 loops: 2420G and 2420H). 5010 also added another new segment (2400 QTY) that will be required to report the number of patients transported in the same vehicle for ambulance or non-emergency transportation services.
Additionally, CMS currently does not require ambulance suppliers to submit a diagnosis code on claims for payment. However, in 5010, a diagnosis code must be present on all professional electronic claims, including ambulance claims.
Your billing systems will need to be able to capture and report this information on your electronic claims to avoid rejection.

Line Item Control Number

While some practices have been entering a unique line item control number for each line of service for each patient, it will now be required to be unique in 5010. The line item control number segment is not required but if it is sent it will need to be unique to each line of service. In addition, payers are required to return the line item control number in the electronic remittance advice (ERA) transaction when the provider includes it in the original electronic claim or when they have split the claim or line item. This change is helpful because receiving the unique line item control number within the ERA gives you the capability to automatically post by service line.
If providers send a line item control number they should work with their software vendors to verify that their systems can create a unique line item control for each line of service.

Health Care Diagnosis Codes for Professional Claims

One of the main purposes of 5010 is to support the upcoming change to ICD-10 diagnosis and procedure codes – a change providers must make by October 1, 2013. To help prepare for ICD-10, 5010 now requires a Diagnosis Code on all claims, and the maximum number of Diagnosis Codes was increased from eight in 4010 to 12 in 5010. Although you can report 12 diagnosis codes at the claim level, you can only point or link four codes to a specific service at the service line level.
You need to work with your software vendor to ensure you have the ability to report the number of required diagnosis codes.

Primary Identification Code Qualifiers

Previously, you were allowed to report an Employer’s Identification Number (Tax ID) or Social Security Number (SSN) as a primary identifier for the billing provider. In 5010, you are only allowed to report a National Provider Identifier (NPI) as a primary identifier (ANSI loop 2010AA NM108/NM109). If the billing provider does not qualify for an NPI number, such as an Atypical provider, then only the Tax ID or SSN would be allowed in the REF segment of the billing provider loop.
In addition, 5010 standards have eliminated the use of payer-specific provider numbers in favor of NPI and Tax ID numbers.