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.

R A C

The RAC program has been established to identify and recover improper Medicare payments to providers that are under fee-for-service Medicare plans, including medical practices, hospitals and nursing homes.

Practices that bill Medicare may be subject to an audit to review inaccurate reimbursements and may be required to refund the money back to Medicare. There are four RACs, each pertaining to a region of the country. 

Types of government audits :

Medicaid Integrity Contractors (MICs) conduct audits of Medicaid claims instead of Medicare. Unlike RACs and Zone Program Integrity Contractors (ZPICs), whose appeal processes are determined by federal regulations, MIC appeals processes vary by state.

ZPIC audits look for cases of fraud by analyzing claims data.

Medicare Administrative Contractor (MAC) audits determine whether particular billed services are medically necessary and should be covered under Medicare.

Looking to eliminate Medicare overpayments to providers, the Centers for Medicare and Medicaid Services from 2005 until early 2008 conducted pilot tests of a new program to audit provider billings, called the Medicare Recovery Audit Contractor program.

Medicare started rolling out the RAC program nationwide during 2009. But 2010 was when its effects were widely felt by hospitals, with some health systems undergoing multiple RAC audits while others were notified they'll soon be up to bat. CMS intends to eventually audit all U.S. hospitals, and is now expanding the RAC program to physicians, laboratories, pharmacies and other providers.

There was no shortage of health care payer audit programs before RACs came around. Medicare already conducts audits under the Medicare Administrative Contractors program, state Medicaid agencies have audit programs, and so do commercial insurers and quality improvement organizations. And a proposed federal rule published in November 2010 has put the wheels in motion for establishment of Medicaid RAC programs.

Lately, commercial carriers are starting to copy RACs and that has really increased audits across the country.

RAC Audits :

There are two types of RAC audits-automated and complex. An automated review, also called a claims review, is a computerized analysis of a provider's Medicare claims based on algorithms that look for specific discrepancies in the claims. These include medical procedure that don't match the patient's age or gender, inpatient claims without a discharge disposition, or two or more units for a colonoscopy when only one unit can be billed a year.

Medicare has contracted with four companies to serve as the Recovery Audit Contractors in four regions that span the nation. These contractors can and do subcontract with other companies to conduct audits.

RACs can conduct an automated review anytime without notifying providers. Following an automated review that finds discrepancies, a RAC will send a "demand letter" to a provider organization identifying the overpayments found and stipulating reimbursement. RACs also are finding underpayments in favor of providers, but those account for about a fifth of the findings.

Under a complex audit, RACs can demand up to 300 medical charts from a hospital every 45 days, based on Medicare claims volume, for comprehensive review. These charts include any paper and electronic documentation that support a flagged encounter.

How RACs work :

The biggest difference with the RAC program compared with other payer audits is how contractors are reimbursed. Contractors for other audit programs get paid a fixed amount for doing their work. But RAC contractors get paid via contingency fees. They make money finding overpayments and underpayments, and the more they find the more money they make. So, RACs tend to be more aggressive than other audit programs.

The payment set-up for RACs has been perceived as bounty-hunting by many industry stakeholders.

Physician practices also fall under the RAC program. The number of records that can be demanded every 45 days for a complex review is based on the practice size and tops out at 50 for the largest practices. RAC auditors spent much of 2010 focused on automated reviews of hospital claims, which give quick results and cash in the door, with complex hospital reviews and physician audits starting to build toward year-end.

Following the receipt of a demand letter, a provider can appeal the findings and present documentation to support its position.

After a provider submits the requested medical records for a complex audit-with the RAC contractor, the contractor then has 60 days to review the records and inform the provider of findings.

Providers increasingly are using software specifically designed for the RAC program and embedded with the RAC rules to manage request fulfillment within 45 days, and generating supporting documentation to use during the appeals process.

ACOs In Practice

The accountable care organization ( ACO ) is a new model that has been proposed for health care reform.

The primary objectives of the ACO are to reduce costs, increase efficiency and improve the quality of patient care. The payer is basically aiming to reduce costs and at the same time improve quality of care. Since payers would give the ACO's a lump sum to cover all care, the ACO's would retain any savings that result from more efficient patient care. This is supposed to be the motive for physicians and hospitals to ensure that the patient is healthy and out of the hospitals and not do more procedures.

The ACO members will  share in the savings that results from their cooperation and coordination. Thus, ACOs can–theoretically–act as a reform tool by incentivizing more efficient and effective care. This would help to combat the current perverse incentives of overutilization and overbuilding of health care facilities and technology.

ACOs In Practice :

The ACO would have to be a legal organization that can receive shared savings, and would have to incorporate primary care physicians who solely practice under the ACO. Furthermore, there would have to be at least 5,000 beneficiaries in the ACO for it to be viable. The ACO would provide CMS with a list of their providers willing to participate in the ACO. The beneficiaries would be determined by, among other things, the patterns of patient referrals in the region. However, beneficiaries would not be “locked in” to a given provider. The ACO would receive savings if their risk-adjusted, per beneficiary spending levels were below their benchmark.

 

An Example :

An hypothetical independent practice association (IPA) teams up with a community hospital to create an ACO. Medicare determines a benchmark, that is, what it will cost to treat the average beneficiary in that geographic area per year–let’s say $10,000. The physicians submit their traditional claims to Medicare under the RBRVS system while the hospital submits its typical DRG-base claim. Thus, the traditional fee-for-service system remains in place. At the end of the year, Medicare determines if the ACO has provided care for less than $10,000. If they have, the ACO is entitled to share in the cost savings, and the savings are divided among the providers and hospital. Though simple in theory, ACOs become more difficult when attempting to construct payment models that will distribute the savings of the ACO to the individual providers.

ACO

The primary objectives of Accountable Care Organizations (ACO) are to reduce costs, increase efficiency, increase accountability and improve the quality of patient care.

The payer is basically aiming to reduce costs and at the same time improve quality of care. Since payers would give the ACO's a lump sum to cover all care, the ACO's would retain any savings that result from more efficient patient care. This is supposed to be the motive for physicians and hospitals to ensure that the patient is healthy and out of the hospitals and not do more procedures.

The patient is supposed to get better care and this model aims to provide a patient centric care plan. The physicians may need to do a lot of  screening procedures and wellness checkups ensuring that the patient is taking the right labs and medicines and staying healthy. So the clinical perspective would be that of being proactive and ensuring that the patient requires the right care ensuring that he is in good health, and that he makes as few visits to the Hospital as possible. This is to mean that the physician will proactively care for the patient, instead of the regular model of treating patients after a health event.

Challenges :

• ACO's would find it a challenge to construct a payment model that would distribute the savings of the ACO to its individual providers.
• The patient may feel  that he is being forced to see a small group of physicians in the ACO that he is participating.
• The patient may not perceive the quality of care that the ACO model proposes.
• Would patients continue to stay within their ACO ?
• Would patients see value in the ACO and support the ACO ?

ACO's have a lot of challenges ahead but it looks very viable and feasible considering the advantages is has over existing HMOs, but then again there are some physicians who feel that the ACO's are a little ahead of time, and now may not be the good time.

The ACO debate is endless but its success or failure will depend on how the patients perceive it. If the patients see value for themselves in the ACO than the patients would support the ACO and it will succeed, if the patients do not see any value from the ACO than it would be very difficult for the ACO to succeed.