December 2011
EXTENSION- The compliance deadline for the implementation of Version 5010 is still January 1, 2012; however, CMS will not initiate enforcement action until March 31, 2012.
More Auditors?? Yes, more auditors! Starting in November, healthcare organizations will be subject to audits by the Office of Civil Rights (OCR), evaluating their compliance with the HIPAA privacy and security rules and breach notification standards. Who will be targeted? "Every covered entity and business associate is eligible for an audit," states the Health & Human Services website. Here is a sample of the audit letter providers may receive. Understanding HIPAA Privacy HIPAA FAQ search OCR enforces the Privacy and Security Rules in several ways
PO Box billing provider addresses no longer permitted with HIPAA 5010 Practices will no longer be permitted to use a PO Box or lock box address as the “billing provider� address to receive payments. See this checklist CMS offers to prepare for HIPAA 5010 The HIPAA 5010 project is a prerequisite for the ICD10 project What 5010 DOES: 1. Increases the field size for ICD codes from 5 bytes to 7 bytes 2. Adds a one-digit version indicator to the ICD code to indicate version 9 vs.10 3. Increases the number of diagnosis codes allowed on the claim What 5010 DOES NOT do: 1. Does not add processing needed to use ICD10 codes 2. Does not add a cross walk of ICD9 to ICD10 codes 3. Does not require the use of ICD10 codes 1
Medicare 2012 Participation Open Enrollment Period – November 14 - December 31 During this period, providers can change their current participation status beginning the next calendar year on January 1. This is the only time Medicare providers are given the opportunity to change their participation status.
Finding relevant information online can be very timeconsuming and confusing. This website aims to make it easier for patients to find a selection of reliable and credible information on how to manage type 2 diabetes.
All enrolled providers are required to revalidate their enrollment information under new enrollment screening criteria and this rule applies to those providers and suppliers that were enrolled prior to March 25, 2011.
Newly enrolled providers and suppliers that submitted their enrollment applications to CMS on or after March 25, 2011, are not impacted.
Between now and March 23, 2015, MACs will send out notices on a regular basis to begin the revalidation process for each provider and supplier.
Providers and suppliers must wait to submit their revalidation only after being asked by their MAC to do so.
In the "Downloads" section on this link there is a listing of all providers and suppliers who were mailed a revalidation letter so far.
Medicare’s Recovery Auditors will no longer issue demand letters to you as of January 3, 2012. They will submit claim adjustments to your Medicare contractor, who will perform the adjustments based on the Recovery Auditor’s review, and issue an automated demand letter to you.
What is Blood Sugar Basics? A website resource for information and helpful tips on how to control blood sugar levels to help manage diabetes successfully.
Reminders- CERT and Medicare contractors require a legible identifier for services ordered/provided. The method used shall be hand written or electronic signature. Stamp signatures are not acceptable. Refer to CMS Internet-Only Manual Publication 10008, Medicare Program Integrity Manual, Chapter 3, Subsection 3.4.1.1.D It is critical that the signed physician order for all diagnostic tests be included with all record requests. Without the signed order, the services could be determined to be medically unnecessary and the claim will be denied. Please remember to verify that a legible signature is present on all medical records before documentation is filed and/or claims have been submitted. CERT Fact Sheet from Trailblazer, a Medicare Administrative Contractor Throughout this site, you’ll find ways for helping improve the dialogue between patients and healthcare professionals.
Importance of Documentation from Trailblazer, a Medicare Administrative Contractor
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The CY 2012 Physician Fee Schedule repeals a requirement that physicians sign paper requisition forms for clinical diagnostic laboratory tests. is the one-stop-shop for all patient health awareness initiatives created and promoted by the American College of Endocrinology (ACE) in conjunction with the American Association of Clinical Endocrinologists (AACE).
What Is An Order? An "order" is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a patient. An order may be delivered via the following forms of communication: •
A written, signed document from the treating physician/practitioner, which is hand-delivered, mailed or faxed to the testing facility. Examples would be: o An order with physician signature and diagnoses that necessitate the services rendered. o Physician progress notes of a visit in which the procedure was ordered showing physician's signature and medical necessity.
Medicare Benefit Policy Manual 100.02 Chapter 15 sec. 80.6.1 states the following: •
An "order" is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. ... An order may be delivered via the following forms of communication:
•
A written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility. NOTE: No signature is required on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services. A telephone call by the treating physician/practitioner or his/her office to the testing facility; and an electronic mail by the treating physician/practitioner or his/her office to the testing facility. If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary's medical record. While a physician order is not required to be signed, the physician must clearly document, in the medical record, his or her intent that the test be performed.
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An electronic mail by the treating physician/practitioner or his/her office to the testing facility Screen print of the electronic request by the physician o With electronic system requests, include diagnoses and either a copy of your protocol to order the tests or procedures (can be sent once per provider) OR evidence of physician entry into the request system with unique logon ID and password such as audit trail that proves the doctor entered the request for services electronically
The Magazine has multiple sections about diabetes including type 1, type 2, treatment and prevention of diabetes. Learn It Live It Share It
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The CMS Quarterly Provider Update (QPU) is a comprehensive resource that provides a list of non-regulatory changes to Medicare, including new and revised manual instructions and any other instructions that may impact Medicare providers or suppliers. QPU October – December 2011 QPU January – March 2012 This service notifies subscribers via e-mail immediately of any regulations 3
CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding.
How to Read the Medicare Remittance Advice Part B Overpayment Letters Participating Providers vs. Non Participating Providers Educational material is from Trailblazer, a Medicare Administrative Contractor.
The coding policies are based on: ® coding conventions defined in the AMA's CPT manual national and local policies and edits coding guidelines developed by national societies analysis of standard medical and surgical practices a review of current coding practices **Check commercial carrier’s administrative guidelines to determine if they follow the NCCI from CMS. How to Use the NCCI Tool NCCI Policy Manual for Medicare Services – Effective 1/1/2012 (This information is under the downloads section) Medicare Claims Processing Manual Correct Use of Modifier 59 NCCI FAQs NCCI Edits for Physicians
2012 Medicare Deductible, Coinsurance, and Premium Rates
CMS developed Medically Unlikely claims error rate for Part B claims.
Edits (MUEs) to reduce the paid
®
An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. All HCPCS/CPT® codes do not have an MUE. Although CMS publishes most MUE values on its website, other MUE values are confidential and are for CMS and CMS contractors' use only. MUEs MUE Publication Announcement Letter Practitioner Service MUE Table (This information is listed under the downloads section) MUE FAQs
Medicare Expands Prevention Services To reduce cardiovascular disease contributing to the Million Hearts Initiative and to reduce obesity
Common Endocrinology CPT® Codes with an MUE CPT® Code
Maximum Units to Report
76942 (ultrasound guided biopsy)
1
76536 (diagnostic ultrasound)
1
88172 (review of aspiration, 1st evaluation, EACH site)
3
88177 (review of aspiration, each additional episode, SAME site)
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*Check commercial carriers’ administrative guidelines to determine if they follow the MUEs from CMS. 4
Physicians, providers or suppliers are expected to be aware of both national coverage determinations (NCD) and local determinations (LCD). NCDs are developed by CMS to describe the circumstances for Medicare coverage nationwide for a specific medical service procedure or device. An LCD is a decision by a local Medicare contractor whether to cover a particular service on a contractor-wide basis.
SNEAK PEAK! THYROID AWARENESS MONTH coming in January! Be on the lookout in January for the new Thyroid Awareness icon, a blue paisley ribbon! AACE will be mailing goodies and resources to members’ medical offices to share with your doctors and patients, including: • Blue paisley lapel pins • EmPower Magazine with the blue paisley ribbon • Thyroid Neck Check™ cards in blue paisley theme Resources are also available at www.ThyroidAwareness.co m, as well as access to blue paisley ties and scarves, car magnets, extra lapel pins, and more.
Each NCD/LCD contains the following:
Indications and limitations of coverage and/or medical necessity ICD-9-CM codes that support medical necessity Documentation requirements (don’t assume you know what they are) Utilization/frequency guidelines Attached coding articles
NCD/LCD Facts:
LCDs may vary among Medicare Administrative Contractors (MACs) One MAC may allow a service for a particular diagnosis, but another MAC may not Commercial carriers may or may not follow the NCD/LCD guidelines RACs and MACs are using these in their audits Subject to be changed, revised, or deleted
Common Endocrinology Services, Supplies and Procedures with NCD as of December 2011 Blood Glucose Testing Bone Density Studies DSMT Glycated Hemoglobin Home Blood Glucose Monitors Infusion Pumps (CSII) Insulin Syringe Lipid Testing Medical Nutritional Therapy PSA and Prostrate Screening Services Thyroid Testing Treatment of Obesity Check you LOCAL Coverage Determinations through your individual Medicare Administrative Contractors.
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C oding T R AC
We want to hear from you! Tell us what you think of Endonomics! Please take a few minutes to take this survey. Your feedback is very important to us as we strive to assist you with a profitable and compliant business office. o Is Endonomics valuable and useful for your office? o What other topics would you like to see offered in Endonomics? o Other comments…
AACE's Socioeconomic and Member Advocacy Department's goal is to reach out into the endocrinology business world and become the onestop- shop, not only for endocrinology clinicians, but their support staff as well. Currently, Endonomics is a free newsletter for both members and non members. Interested parties should send an email to Endonomics@aace.com with their name, phone and fax numbers, location and preferred e-mail address to be added to our Practice Support Network database.
T ips on reimburs ement and c oding • Modifiers RT(right) and LT(left) should be used when reporting FNAs 1002x- RT 1002x-LT • Modifier 76 indicates a REPEAT procedure Example: FNA performed on the right side. Specimen reviewed for adequacy and determined to be inadequate. A REPEAT procedure was performed on the same nodule. Modifier 76 would be appropriate. 1002X-RT 1002X-RT-76 • Modifier 59 would be used to report a SEPARATE nodule. Example: FNA performed on a nodule on the right and on the left side of the neck. 1002x –RT 1002X-LT-59 • It is not appropriate to bill an E/M with scheduled FNAs unless there is a significant and separately identifiable service performed. (the E/M documentation would stand alone and all key elements would be met for a medically necessary evaluation and management service). Typical pre and ® post operative work is included in the 1002X CPT code according to CMS. According to the Medicare Claims Processing Manual Chapter 12 Section30.6.6.B, “Carriers pay for an E/M service provided on the day of a procedure with a global fee period if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work of the procedure. Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Modifier -25 is added to the E/M code on the claim.
Examples: Established patient X saw Dr. Endocrinology. Dr. Endocrinology determined the need for an FNA on a right nodule and scheduled the patient to return on Wednesday. Patient X came in Wednesday for the scheduled FNA with no other complaints or concerns. Proper coding for the FNA would be: 1002x- RT Established patient X saw Dr. Endocrinology on Monday. After evaluating the patient, Dr. Endocrinology decided to perform an FNA on a right nodule the same day. Proper coding for the E/M and FNA would be: 9921x-25 1002x-RT **We encourage you to review commercial carriers’ administrative guidelines for their determination of appropriate modifier use. Scenarios above are based on Medicare guidelines.
All medical coding must be supported with documentation and medical necessity. **While this document represents our best efforts to provide accurate information and useful advice, we cannot guarantee that third-party payers will recognize and accept the coding and documentation ® ® recommendations. As CPT , ICD-9-CM and HCPCS codes change annually, you should reference the current CPT , ICD-9-CM and HCPCS manuals and follow the "Documentation Guidelines for Evaluation and Management Services" for the most detailed and up-to-date information. This information is taken from publicly available sources. The American Association of Clinical Endocrinologists cannot guarantee reimbursement for services as an outcome of the information and/or data used and disclaims any responsibility for denial of reimbursement. This information is intended for informational purposes only and should not be deemed as legal advice, which should be obtained from competent local counsel. © Current Procedural Terminology (CPT ) is copyright and trademark of the 2010 American Medical Association (AMA). All Rights Reserved. No © fee schedules, basic units, relative values, or related listings are included in CPT . The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
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