November 2011
In Less Than 65 Days Your Reimbursement Payments Could Stop FROM ALL PAYERS- NOT JUST MEDICARE Are you prepared for HIPAA Version 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
In 1996, the Health Insurance Portability and Accountability Act or "HIPAA" was endorsed by the U.S. Congress. Therefore, it is the LAW, and compliance is not negotiable. HIPAA standards for Version 5010: o Are national and apply to ALL HIPAA covered entities that perform any electronic transactions (health plans, clearinghouses, and certain health care providers) o Cover all payers, not just with FFS Medicare so prepare to implement these transactions for non-FFS Medicare businesses as well o Concern claims, remittance, eligibility, claim status requests, referral authorizations, responses and other electronic health care administrative transactions o Require changes to software, systems and procedures used to bill Medicare and other payers If you can answer NO to any of the following questions, you’re at risk of not being able to meet the January 1, 2012, deadline and not being able to submit claims: 1. Have you contacted your software vendor (if applicable) to ensure that they are on track to meet the deadline or contacted your MAC to get the free Version 5010 software (PC-Ace Pro32)? 2. Alternatively, have you contacted your clearinghouses or billing services to have them translate your Version 4010 transactions to Version 5010 (if not converting your older software)? 3. Have you identified changes to data reporting requirements? 4. Have you started to test with your trading partners, which began on January 1, 2011? 5. Have you started testing with your MAC, which is required before being able to submit bills with Version 5010? 6. Have you updated MREP software to view and print compliant HIPAA 5010 835 remittance advices? 1
Is your vendor or clearinghouse HIPAA 5010 compliant with your MAC (Medicare Administrative Contractors)? Lists of HIPAA 5010 compliant
FREE
vendors and clearinghouses were found on the following MAC’s websites. This list is informational only. The AACE does not endorse any vendors, billing companies, or clearinghouses. This information is subject to change. First Coast Service Options
Trailblazer WPS NGS
Palmetto-Jurisdiction 1 Palmetto Jurisdiction 11
CMS offers free billing software that is Version 5010 compliant. Please contact your MAC, FI or Carrier to obtain the latest Version of PC-Ace Pro32.
Highmark NHIC Jurisdiction 14 CGS – Idaho Kentucky Ohio If you or your software vendor or clearinghouses are not ready, there are service providers who are.
This is your money!
What is PC-Ace Pro32? PC-Ace Pro32 is a complete, self-contained electronic processing system for health care claims submission and management. Additional information can be found here.
Don’t leave it up to vendors/clearinghouses!
CMS also provides the Medicare Remit Easy Print (MREP) software to view and print compliant HIPAA 5010 - 835 remittance advices. Please visit this link to view the software.
"Preparing for Electronic Data Interchange (EDI) Standards: The Transition to Versions 5010 and D.0"
Additional Resources
"Important Reminders about HIPAA 5010 & D.0 Implementation" Additional educational resources about HIPAA 5010 & D.0 Ensure that your staff is aware and knowledgeable of the changes for Version 5010. A side-by-side comparison of the current and new transaction formats can be found here under the downloads section.
The deadline to file for an exemption to avoid the electronic prescribing penalty is November 8th, 2011. If you are an eligible professional and did not successfully meet the requirements of the eRx incentive program or qualify for a significant hardship exemption, you will be subject to the 2012 eRx payment adjustment of 1% of your total allowable Medicare Part B charges in 2012. Click the e-RX button for additional information from AACE or go to CMS’s website at this link.
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CMS has a list of EHR vendors that have the capability to report quality data for the 2011 Physician Quality Reporting System program year. Some are also capable of reporting the electronic prescribing (eRx) measure.
Navigating the Meaningful Use Standards and Certification Criteria Final Rules can sometimes be a challenge. To help, ONC developed grids that capture the meaningful use objectives, measures, and exclusions, and the correlated certification criteria and standards. •
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The first main column references meaningful use objectives and measures and serves as the anchor around which the rest of the grid is organized. The core set objectives and measures are listed first followed by the menu set objectives and measures. The second column references the certification criteria that correlate with each meaningful use objective and measure. Note: the combined version includes colored text for two purposes: 1) to identify certification criteria that are specific to either ambulatory (blue) or inpatient (red) settings; and 2) to call out wording nuances that are unique to an ambulatory or inpatient specific certification criterion where we have combined the ambulatory and inpatient certification criteria to save space. Where black text is used, the certification criterion is the same for both settings. The third column identifies the standard(s) and implementation specifications referred to by each certification criterion, where applicable.
**Includes only the Eligible Providers objectives and measures and the standards and certification criteria for the ambulatory setting. Please note that these grids are unofficial recitations of only a portion of the regulations. The official version of all federal regulations is published in the Code of Federal Regulations. Click the EHR button for additional information from AACE or go to CMS’ official site
Medicare and Other Federal Updates Medicare Regulation 42 CFR §405.378 provides for the assessment of interest at the higher of the current value of funds rate (one percent for calendar year 2012) or the private consumer rate as fixed by the Department of the Treasury. The Medicare contractors shall implement an
interest rate of 10.875 percent effective October 20, 2011, for Medicare overpayments and underpayments.
Ever wonder what the suffix on the Medicare identification card means?
ABN Mandatory Use Date: January 1, 2012 The new version of the ABN is now available for immediate use. All ABNs with the release date of March 2008 that are used after January 1, 2012 will be considered invalid. All physicians, practitioners, suppliers, and independent laboratories should use an ABN where Medicare payment is expected to be denied. Here is the newest version of the ABN and the instructions on appropriate use.
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Practice Management
The New Medicare Secondary Payer Provisions Web-BasedTraining Course has Been Released and is designed to provide general
& Coding Educational
education on when Medicare may or may not pay first. It includes an overview of the MSP Provisions, common payment situations, Medicare conditional payments, and the role of the Coordination of Benefits Contractor.
Opportunities for 2011 Al l C o ur s e s
Trailblazer, a Medicare Administrative Contractor, offers a free interactive tree to assist your staff in determining Medicare Secondary.
This proposed rule would amend the CLIA regulations to specify that, upon a patient’s request, the laboratory may provide access to completed test reports that, using the laboratory’s authentication process, can be identified as belonging to that patient.
Fundamentals and Advanced Endocrine Coding Course December 2-3, 2011 Phoenix, AZ Phoenix Marriott Mesa
The Fundamentals of Endocrine Coding provides attendees with foundational coding, billing, and documentation knowledge required to stay compliant and obtain maximum reimbursement. Fundamentals Course Agenda and Learning Objectives Presenter: Vanessa Lankford, CPC, CMOM, AACE-CEC Course Duration: 8:00am – 4:30pm
The Advanced Course provides the physician and staff with additional knowledge and skill in understanding the business side of the office. Advanced Course Agenda and Learning Objectives AACE-CEC General Information Presenter: Anita Henderson-Sumpter, MHA, MBA, CPC Course Duration: 8:00am - 4:00pm AACE-CEC Exam: 4:00pm - 6:00pm
At the end of the course, attendees will have the opportunity to take the AACEsponsored Certified Endocrine Coder (AACE-CEC) exam. All courses are subject to change.
For more information, please visit www.aace.com/advocacy/coding/cour ses-and-webinars or contact kmiller@aace.com.
A SUMMARY OF THE 2011 ANNUAL SOCIAL SECURITY AND MEDICARE TRUST FUND REPORTS This message summarizes our 2011 Annual Reports. What Are the Trust Funds? What Were the Trust Fund Results in 2010? What Were the Sources of Income to the Trust Funds in 2010? What is the Long-Range (2011-85) Outlook for Social Security and Medicare Costs?
Office of Inspector General's (OIG) has been at the forefront of the nation's efforts to fight waste, fraud and abuse in Medicare, Medicaid and more than 300 other HHS programs. Their 2012 work plan includes further investigation into: o o o o o o
Part B payments for Home Blood Glucose Testing Supplies Questionable billing for Medicare Diabetic Testing Supplies Physicians: Incident-To Services Physician: Impact of Opting out of Medicare E/M Services: Trends in Coding of Claims E/M Services: Potentially Inappropriate Payments o “Medicare contractors have noted an increased frequency of medical records with identical documentation across services.” o Part B payments for glycated hemoglobin A1C tests
See the complete OIG Work plan for 2012 here
CMS has directed SafeGuard Services, the producers of Comparative Billing Reports (CBRs), to release another report on Ordering Durable th Medical Equipment: Diabetic Supplies on November 9 , 2011. As a reminder, the providers for these reports are drawn from across all specialties. For more information and to review a sample of the Ordering Durable Medical Equipment: Diabetic Supplies CBR, please visit the CBR Services website, located at www.cbrservices.com, or call the SafeGuard Services’ Provider Help Desk, CBR Support Team at 530-896-7080.
Medicare Covers Screening & Counseling for Alcohol Misuse & Screening for Depression 4
Do you want to be an Innovation Advisor? The Center for Medicare and Medicaid Innovation (Innovation Center) will seek to introduce transformative models of care delivery across the nation that will meet the aim of reducing cost and improving quality for Medicare, Medicaid, and CHIP beneficiaries. The Innovation Advisors Program will engage individuals in the health care system to test and refine new models of payment and care delivery. Selected Innovation Advisors will refine, apply, and sustain managerial and technical skills necessary to deepen several key skill sets, including: • • • •
Health care finance; Population health; Systems analysis; and Operations research
Individuals who apply to be Innovation Advisors can be any professional employed by public health or health care facility, institution, or department. Candidates include, but are not limited to: o o o o o
physicians nurses allied health professionals instructors non-clinicians (i.e., health care executives, practice managers)
with experience in the health care field and a desire to participate in a valuable hands-on learning experience. Management or leadership experience will be viewed as an asset. The deadline to submit applications is November 15, 2011. The formal program will launch in January 2012 with an expectation that the first fifty advisors selected will devote 10 hours per week plus time for one-day quarterly meetings.
More Information
Breaches of unsecured protected health information affecting 500 or more individuals are now posted in a new format that allows users to search and sort the posted breaches.
Palmetto GBA, a Medicare Administrative Contractor stated, “Whether the cloned documentation is handwritten, the result of pre-printed template, or use of Electronic Health Records, cloning of documentation will be considered misrepresentation of the medical necessity requirement for coverage of services.” Did you know if a physician or supplier was to charge interest or late fees to beneficiaries for the collection of deductible and/or coinsurance amounts, that it would be a violation of the assignment rules or the limiting charge provisions? See 42 CFR 424.55 for details regarding assignment and 42 CFR 414.48 for details regarding the limiting charge. Reference: CMS Central Office.
What is the Federal Register? Published by the Office of the Federal Register, National Archives and Records Administration (NARA), the Federal Register is the official daily publication for rules, proposed rules, and notices of Federal agencies and organizations, as well as executive orders and other presidential documents.
The Federal Register states on page 59442, “The OIG understands that most physician practices do not employ a professional coder and that the physician is often primarily responsible for all coding and billing. However, it is in the practice’s best interest to ensure that individuals who are directly involved with billing, coding or other aspects of the Federal health care programs receive extensive education specific to that individual’s responsibilities.” Some examples of items that could be covered in coding and billing training include: 1. Coding requirements; 2. Claim development and submission processes; 3. Signing a form for a physician without the physician’s authorization; 4. Proper documentation of services rendered; 5. Proper billing standards, procedures and submission of accurate bills for services or items rendered to Federal health care program beneficiaries and the legal sanctions for submitting deliberately false or reckless billings. 5
CMS hosted a national provider call on "ICD-10 Implementation Strategies for Physicians." CMS subject matter experts discussed ways that physician offices can prepare for the change to ICD-10 for medical diagnosis and inpatient procedure coding
Coding TRAC Tips on reimbursement and coding o The Comprehensive Error Rate Testing (CERT) data has identified a high error rate for advanced imaging services. The errors include: missing/incomplete orders, missing documentation of medical necessity and missing or illegible signature.
o Medical necessity is the overarching criterion for E/M services. A lot of visits can be documented to a “level 4 or 5”, but that doesn’t mean the medical necessity was met for a level 4 or 5. E/M Services: Complying with Documentation Requirements and E/M Services Guide.
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…
o Do you know the difference between 95 and 97 guidelines? Which guidelines does your office follow? CMS’ Medicare Learning Network (MLN) has both sets of guidelines under the downloads section on this page. o
Certain services and situations require the submission of the referring/ordering physician information. In such cases, two pieces of information are necessary. Enter the name and NPI of the referring/ordering physician listed in item 17. (For details, see the CMS-1500 Claim Form instructions). If either is missing, invalid or incomplete, an unprocessable claim denial will occur. Even if a physician may never bill Medicare directly, all physicians who order or refer Medicare beneficiaries or services must report this data.
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One of the main reasons claims are denied by Medicare is because the beneficiary name entered on a claim doesn’t match their Medicare card exactly. Common Causes: 1. First or last name is spelled incorrectly 2. First and last name are transposed 3. JR, SR or other suffixes absent when they should be used and vice versa 4. Medicare number has transposed digits 5. Incorrect letter at the end of the Medicare number 6. Beneficiary nickname is used.
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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