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CMS News

EHRs and the ICD-10 Transition: Planning for 2015

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The delay in the implementation of ICD-10-CM/PCS until Oct. 1, 2015, has given EHR users and vendors additional time to prepare their systems for the transition. It is doubtful that the majority of EHR systems and their users would have been able to make the transition seamlessly in 2014, and the delay has allowed time for a more orderly migration to ICD-10. I will discuss some of the challenges associated with updating your EHR for compliance with ICD-10 and the importance of working with your vendor.
EHR applications are often built around the business logic of medicine. A core feature of many of these products is their ability to capture ICD, CPT, and HCPCS codes that can be used for claims submission and provide supporting documentation. However, the methods they use to store billing codes within the several hundred EHR systems that are in use today vary widely. More advanced systems have a central terminology model that uses a reference terminology such as SNOMED CT to store clinical concepts at more precise level than supported by ICD-9 and even ICD-10. An example of this would be a condition called Benign Rolandic Epilepsy. There is no corresponding specific code for this disorder in ICD-9 or ICD-10, but it is represented by SNOMED CT code 44145005. This offers advantage for clinical medicine, quality assessment, and clinical research, but it does not meet the billing requirement. However, once information is captured and stored as SNOMED CT codes, it can be mapped to ICD-9 /ICD-10 codes required for claims submission and reimbursement. Since the core reference terminology does not need to change when a billing terminology update occurs, the EHR can allow user to seamlessly transition to ICD-10, ICD-11, or any other required terminology with minimal impact to the EHR user. In other words, terminology supporting clinical aspects of care are now managed by a code set designed for that purpose; but it still allows for the correct ICD codes to be submitted for claims purposes.
This is the preferred method for migrating to ICD-10 that has been, or is being, adopted by many EHR vendors. However, some systems may allow users to imbed ICD-9 and other billing codes within templates and other forms of locally created content. When this situation is present, imbedded ICD-9 codes will need to be updated to ICD-10 codes. This will require an understanding of ICD-10 billing requirements, as the supporting documentation in the template may need to be modified or expanded to address ICD-10 coding requirements. For example, a number of clinical conditions that were covered by one ICD-9 code now require multiple ICD-10-CM codes based on specific circumstances such as whether or not the patient is there for the initial, second, or third or subsequent visit.
In summary, checking with your EHR vendor on how the transition is being managed would be a good investment of time. If a true central terminology model is in place, and no local modifications are needed to your clinical content, you may be in relatively good shape. If your EHR vendor requires that you update the codes and supporting documentation in your locally developed or modified clinical content, you have a few extra months to complete the task and to learn about the nuances of ICD-10.

By: Michael Stearns

– Source: http://www.physicianspractice.com/medical-billing-collections/ehrs-and-icd-10-transition-planning-2015#sthash.c7fVCsvK.dpuf

General Billing Tips

Sample Payment Policy for Medical Practices

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Accepting insurance at your practice and signing a contract does not mean that you’ve opened your arms up to assume that financial risk. It is important that patients understand this concept.
One way to ensure patients understand your requirements is to ask patients to sign a payment policy.
Here’s a sample policy to consider adapting for your practice:
As a courtesy, (your practice name), verifies your benefits with your insurance company. A quote of benefits is not a guarantee of benefits or payment. Your claim will process according to your plan, if your claim processes differently from the benefits we were quoted, the insurance company will side with the plan and will not honor the benefit quote we received.
It is the policy of (your practice name) that payment is due at the time of service unless other financial arrangements are made in advance. We require all patients to pay their deductible, copay and/or coinsurance payment at the beginning of each visit. The office manager at your location will explain this information to you prior to your first visit. At the conclusion of your visits with us you may be billed for any outstanding balances. If there is a credit, you will be provided a refund promptly.
If you are covered by health insurance with (your practice’s specialty) benefits, we will be happy to bill your insurance. Please provide your insurance information to the front office staff and we will verify your coverage as a courtesy. Accepting your insurance does not place all financial responsibilities onto this practice, and you will be held accountable for any unpaid balances by your plan.
Although we are contracted with most insurance carriers, our services may not be covered by your particular insurance plan. Being referred to our clinic by another physician does not necessarily guarantee that your insurance will cover our services. Please remember that you are 100 percent responsible for all charges incurred: your physician’s referral and our verification of your insurance benefits are not a guarantee of payment.
We highly recommend you also contact your insurance carrier and check into your coverage for (practice specialty). Do not assume that you will not owe anything if you have more than one insurance policy.

By: P.J. Cloud-Moulds

– Source: http://www.physicianspractice.com/medical-billing-collections/sample-payment-policy-medical-practices#sthash.fudpO1sb.dpuf

CMS News

HCC Coding: 10 Tips for Top Scores

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The changes currently taking place with respect to data collection, coding, and billing are some of the most significant transformations in the history of the Medicare Advantage (MA) industry. That makes it more critical than ever for physicians — and physician groups — to put enhanced focus on not only the accurate and timely capture of data but on tracking a patient’s care and condition over time. Those physicians able to do this in a clear and consistent manner will be taking a major step toward ensuring that their practices remain profitable and relevant in the post-Affordable Care Act world.
The stakes are particularly high for physicians caring for patients enrolled in Medicare managed care plans. The guidance issued in April 2014 by CMS calls for reductions ranging from 1.9 percent to 3.65 percent in rates paid to privately run Medicare plans. These reductions have a trickling effect, which is why physicians across the country are already bracing for yet another round of reduced revenue. Physician groups, along with the MA plans with which they work, stand to collectively lose significant dollars in revenue if they don’t quickly learn how to adapt to the new environment.
One of the best ways to combat these reductions is to focus on Hierarchical Condition Category (HCC) coding. Since 2004, Medicare has used the HCC model to calculate payments to providers and health plans, but the sad truth is that most MA plans and their aligned physicians continue to miss significant opportunities to serve their members and maximize their revenue potential because of poor performance in this area.
The good news is that it need not be that way. Here are ten tips to HCC coding that are designed to provide greater efficiencies and enhanced quality and revenues for physicians serving the MA market:
1. As a medical group or independent practice association, you are most likely sending data electronically to your contracted health plans. If you are using an electronic data interchange (EDI) vendor, have a discussion with them to make certain you receive reports on rejected items. Also ask them to verify the maximum number of diagnosis codes they capture and transmit to your health plans. You may be able to locate diagnosis codes, otherwise lost, that will positively affect your revenue.
2. Find out if new patients already have assigned HCCs from their prior health plan. If so, be sure that you maintain those (if appropriate) moving forward. Doing so will assist with both continuity of care and comprehensive data collection.
3. Chart reviews offer great opportunities for in-service education or even the creation of educational materials. If your chart review uncovers common documentation errors, use this as an opportunity to develop training guides or even one-on-one training with physicians and office staff. In short, don’t think of chart reviews as an end, but rather a beginning.
4. New tools on the market make it easier than ever to track diagnosis data for terminated patients. Revenue can be re-captured for members that may have initially appeared on your monthly eligibility reports, but no longer appear because the member’s eligibility has ended. This is one of the most common areas for lost revenue and one that is worth renewed focus.
5. CMS expects member’s conditions to be documented and assessed each year. For that reason it is important to monitor each member’s HCCs for consistency in reporting. Pay particular attention to patients whose HCCs may be dropping as this could be an indication of gaps in care or in failing to accurately document services that were provided. Remember, CMS reimburses because resources were expended, as evidenced by documentation in the medical record, not because a member has a chronic condition.
6. Each October, new diagnosis codes are added and old ones deleted. Make sure you are using the most up-to-date codebooks to ensure that you are using the most current diagnosis codes. The cost of a codebook is minimal compared to the financial benefit.
7. Know how many diagnosis codes your claims system is capable of storing. Data is often lost merely because your system does not have a place to hold it. To ensure you are receiving accurate reimbursement, you must be able to capture and send all diagnosis codes from your claims and encounters.
8. While utilizing the ANSI-837 claims format may make you HIPAA compliant, the process may not be capturing all relevant clinical information. In some cases, providers and EDI vendors have mapped their legacy transaction set to the new format. This results in capturing the original nine codes — one primary (plus eight secondary) diagnoses — and continues to omit diagnosis 10 and beyond. Don’t let this happen to you.
9. Often payable claims take priority over encounters due to the federal regulations on timely payment of claims. If you are close to a CMS sweep, make sure there is no backlog of encounter data unprocessed, which could have detrimental effects on your revenue.
10. Your appeals department receives full medical records. Have a coder review them to see if there are any additional diagnostic codes to be found that will have a positive impact on your HCC scores.
In an era of accelerating medical costs and reduced payments from CMS, concentrating on HCC coding and documentation is one of the best ways to eliminate gaps in care and ensure money isn’t being left on the table. This is what everyone wants and with the right focus and tools, it can be done.

By: Pam Klugman

– Source: http://www.physicianspractice.com/medical-billing-collections/hcc-coding-10-tips-top-scores#sthash.BCEHpL06.dpuf

General Billing Tips

Billing New Physicians Incident-to Current Physicians

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Accepting insurance at your practice and signing a contract does not mean that you’ve opened your arms up to assume that financial risk. It is important that patients understand this concept.
One way to ensure patients understand your requirements is to ask patients to sign a payment policy.
Here’s a sample policy to consider adapting for your practice:
As a courtesy, (your practice name), verifies your benefits with your insurance company. A quote of benefits is not a guarantee of benefits or payment. Your claim will process according to your plan, if your claim processes differently from the benefits we were quoted, the insurance company will side with the plan and will not honor the benefit quote we received.
It is the policy of (your practice name) that payment is due at the time of service unless other financial arrangements are made in advance. We require all patients to pay their deductible, copay and/or coinsurance payment at the beginning of each visit. The office manager at your location will explain this information to you prior to your first visit. At the conclusion of your visits with us you may be billed for any outstanding balances. If there is a credit, you will be provided a refund promptly.
If you are covered by health insurance with (your practice’s specialty) benefits, we will be happy to bill your insurance. Please provide your insurance information to the front office staff and we will verify your coverage as a courtesy. Accepting your insurance does not place all financial responsibilities onto this practice, and you will be held accountable for any unpaid balances by your plan.
Although we are contracted with most insurance carriers, our services may not be covered by your particular insurance plan. Being referred to our clinic by another physician does not necessarily guarantee that your insurance will cover our services. Please remember that you are 100 percent responsible for all charges incurred: your physician’s referral and our verification of your insurance benefits are not a guarantee of payment.
We highly recommend you also contact your insurance carrier and check into your coverage for (practice specialty). Do not assume that you will not owe anything if you have more than one insurance policy.

By: Ericka L. Adler

– Source: http://www.physicianspractice.com/medical-billing-collections/sample-payment-policy-medical-practices#sthash.fudpO1sb.dpuf

RCM / AR

Revenue Boosting Ideas for Every Medical Practice

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Most practices are struggling financially due to declining reimbursement and increasing overhead, and many have made changes to increase practice revenue. But according to Rosemarie Nelson, principal with the Medical Group Management Association Health Care Consulting Group, there’s still more that many practices can do to boost revenue.
To help identify some of the best tactics, Physicians Practice asked Nelson to share some of her tips. Here’s what she told us.

Physicians Practice: Based on your work with practices, what are some common areas that you think practices overlook when it comes to boosting revenue?

Rosemarie Nelson: Underutilizing their existing technology (practice management system, EHR, clearinghouse, patient portal, and so on), and their staff. I always find some feature/function in the practice management system or EHR that could eliminate or reduce a manual effort.
For example, in one practice, nurses kept a paper file on tests that they wanted to be sure to track for incoming results. Instead of printing those test orders and filing them and then fingering through them regularly to look for results, they could have used the EHR to filter on only outstanding tests so that they could follow up as needed. That simple functionality would have saved each nurse an hour a day in that practice.

Physicians Practice: Of the areas you mentioned, what do you think could potentially result in the biggest financial improvement for a practice in the short term? How about the long term?

Rosemarie Nelson: Short-term gains can be earned by optimizing technology. Long-term gains will be earned over time in human resource savings. It is easy to see from this one example on filtering open orders for test result management how the hour saved per day per nurse is a short-term gain.
The practice can more effectively use that hour saved per day per nurse in the short term, but over the long term, the practice can restructure staff with resulting cost savings and therefore an increase in profitability.
Examine everything routinely. When a new upgrade or release of your software is available, learn how to take advantage of the changes. Maintaining the status quo in a dynamic environment is not a recipe for success.
Physicians Practice: If a practice wanted to start on a revenue-boosting project today, what would be the easiest area to start with?
Rosemarie Nelson: Well, nothing comes easily! Optimizing technology takes a very concerted effort because it is hard to get people to change behaviors and adapt to methods to get their work done.
The easiest first step is to reach out to your vendor and ask it to provide you with an evaluation of your own operations — what are you not doing with the technology tool that you could benefit from adopting.
Act as your own consultant. Evaluate your operations by doing a walk-through from the patients’ perspective. Where can you be more patient-friendly? Challenge your staff to identify time-wasting activities. Look at redundant steps in each process from check-in, to rooming patients, to discharge and check-out. Do not accept “because we’ve always done it this way” as an acceptable reason to continue.
Think as if you could create it all from scratch and design the process for patient service and efficiency. Maybe you’ll need to invest in more equipment, but do the analysis to determine how a one-time investment can offset the cost of a daily process that is performed 35 times per day.
To learn more from Nelson, sign up for Practice Rx, Physicians Practice’s new conference for physicians and administrators. At the conference, Nelson will share more of her revenue-boosting tips.

By: Aubrey Westgate

– Source: http://www.physicianspractice.com/blog/revenue-boosting-ideas-every-medical-practice?cid=related_teaser#sthash.b0tSHGtm.dpuf

RCM / AR

A New Financial Model for Primary-Care Providers

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Primary care’s goal, regardless of how insurers pay for it, is not just to improve, but to reliably and consistently deliver the best possible patient-relevant outcomes at optimal cost and to continually improve by cutting waste and investing resources to improve health status.

If, as a primary-care provider, your plan is to continue to rely on fees for service, you are not just short-changing yourself; you will continue to be grossly undercompensated compared to your relative value, and impact, on the overall healthcare delivery system.

No matter what it is called — pay-for-performance, value-based reimbursement, or revenue for results — the only reason not to embrace these new programs is, to put it bluntly, that you are incompetent.

New physician organizations, armed with enabling technologies, put primary-care physicians in charge of the whole dollar of care instead of their respective small fraction, which is about 4.4 percent of the average commercial healthcare spending, or, about $15 per member per month (PMPM) on average. That is out of the average $346 PMPM total Medical Loss Ratio, (MLR) or, the total spending per patient per month in a non-Medicare/Medicaid environment. Adding typical in-office basic laboratory testing and related diagnostics such as EKG among other services, the total average increases to about $18 PMPM.

This means that the typical primary-care physician directly controls (and receives) just 5.2 percent of total healthcare spending. A 20 percent decrease in controllable spending only results in a 1 percent impact to the total spend while rendering primary-care physicians financially unstable, if not financially untenable.

Fee-for-service reductions have exactly the same impact and have been proven to actually increase the overall cost of care.

This is because primary-care physicians affect much more. Improving health status of their patient panel, better managing third-party diagnostics, closing gaps in care and other clinical and quality measures contributes a much higher value relative to total spending, particularly by reducing utilization in the highest cost drivers: imaging, procedures, and hospitalization. Just a 10 percent impact on spending for a panel of 1,500 patients at $34.60 PMPM reduces spending by $51,900 per month, or, $622,800 per year.

Value-based reimbursement in a shared savings environment gives primary-care physicians a share of these savings.

It can’t be done alone except in a fairly constructed Patient-Centered Medical Home (PCMH) program, and then, only rarely. The problem is, without the tools, technology, and techniques in an integrated care environment, most PCMH practices don’t see much gain.

Properly equipped practices (in real terms, not just some care coordination) can generate real results: from 10 percent to 30 percent savings. Dozens of new independent practice associations that provide these capabilities are popping up with many more in the planning stages.

Enabling capabilities include population health platforms, risk, cost, and disease stratification, quality and service metric analytics including the ability to report and close gaps in care, and a clinically integrated network consisting of disease stratified team care organized around primary-care physicians who are ultimately responsible for coordination, documentation, and cost at the minimum.

The most effective are physician owned, controlled, and managed because hospital and hospital system controlled organizations include problematic conflicts of interest.

Choose wisely, and the value in value-based reimbursement is yours. After a 20 percent overall spending reduction in your practice, splitting the difference with the health plan and setting aside, for example, 45 percent of the remainder for technology, expenses, support, training, and overhead and splitting the remainder 80/20 with specialists (otherwise receiving 44 percent of the payer/provider split and 22 percent of the overall savings), the primary-care provider share is about $15.25 per patient per month.

With just 500 attributed patients in the program, that adds up to another $91,500 in reimbursement per year — after fees for service and another $5 or so per patient per month to cover added care coordination costs from the insurer, or, a nearly 85 percent raise.

It takes a lot of work and some uncomfortable cultural and operational changes to achieve these results. But, times are changing and the payoff can be well worth the trouble.

By: James Doulgeris

– Source: http://www.physicianspractice.com/physician-compensation/new-financial-model-primary-care-providers#sthash.4wu9o3ro.dpuf

General Billing Tips

Using Modifier 24: Understand the Rules of the Game

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Appending modifiers on a claim form is like playing Monopoly. Use the right modifier in the right situation, and it is like “passing go,” and collecting $200. The claim sails through the claims processing system on the first pass, and the insurance company deposits money in the practice’s account. However, use modifiers incorrectly, and you will receive payment denials or worse. Not unlike picking a “Go to Jail card,” incorrect modifier use puts your practice at risk for a payer request for a refund.
Modifier 24 is appended to an evaluation and management service (never to a procedure) to indicate that an unrelated E&M service was provided by the same physician during a postoperative period. Other, “same-specialty physicians” are included in the definition of “same physician.” That is, if a surgeon is covering post-op patients for her partner, the covering surgeon is considered the same physician and does not bill for it. Remember, modifier 24 is used for an unrelated E&M service.
The following are three examples where you could use modifier 24:
• A surgeon performs a hernia repair on May 20. The procedure has a 90-day global period, so all related post-op care is included in the payment for the hernia. But, on July 1, the patient returns to have a breast lump evaluated. Report the E&M service with modifier 24 attached and use the new diagnosis — breast lump — as the reason for the visit.
•An orthopedist treats a hip fracture on Dec. 15, and the patient returns with shoulder pain on Jan. 10. The Jan. 10 visit is separately reportable with modifier 24.
• A surgeon who is managing immunosuppressant therapy during a post-op period for a transplant may use also modifier 24 for the E&M services and be paid separately for these.
The Medicare and CPT definition of the post-op global package are slightly different. Medicare states that unless a return trip to the operating room is required, all medical and surgical post-op complications are included in the global payment and may not be separately billed. Also treatment of wound infections or other complications may not be reported to Medicare.
However, the CPT definition of the surgical package is “typical” post-op care. This is found in the introductory material to the surgical section in the CPT book. This raises a question: If a payer follows CPT rules and not Medicare rules, can a surgeon report atypical post-op care for complications? Yes. How? Some practices use modifier 24 in this instance for E&M services for medical complications. Use the complication diagnosis code first on the claim form. However, it is critical that you check with your payer to be sure this follows its rules, because the definition of modifier 24, as developed by the AMA, is for unrelated care.
Other physicians who see the patient during the global period do not need to use modifier 24. If a patient in a surgical post-op period sees an internist, the internist does need to append a modifier to the E&M service. Only the operating physician, and his or her same-specialty partners or covering surgeons, need to use modifier 24.
Review the official definition of each modifier in the CPT book annually. It provides the definitive answers to your questions, so that applying a modifier goes from a game of chance to a sure thing.

By: Betsy Nicoletti

– Source: http://www.physicianspractice.com/medical-billing-collections/using-modifier-24-understand-rules-game#sthash.PVMrXYiq.dpuf

General Billing Tips

New Meaningful Use Rule: Good News for Many Physicians

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Physicians and their practices have a little more breathing room when it comes to meeting the requirements of the EHR incentive program.
CMS recently released a new rule allowing flexibility in certified EHR technology for meeting meaningful use in 2014. The rule also finalizes the extension of Stage 2 through 2016 for certain providers, and it announces that Stage 3 will now begin in 2017.
Here’s more on the key elements of the final rule that physicians and their practices should be aware of:

1. Greater flexibility. Eligible providers will now be able to use 2011 edition certified EHR technology (CEHRT), or a combination of 2011 and 2014 edition certified EHR technology for an EHR reporting period in 2014. In 2015, all eligible professionals will be required to use the 2014 edition CEHRT.

One reason CMS may have added more flexibility to its requirements? By the end of July, only about 1,900 eligible providers had attested to Stage 2.

“We listened to stakeholder feedback and provided CEHRT flexibility for 2014 to help ensure providers can continue to participate in the EHR Incentive Programs forward,” Marilyn Tavenner, CMS administrator, said in a statement regarding the final rule. “We were excited to see that there is overwhelming support for this change.
In an article following the release of the final rule, practice consultant Elizabeth Woodcock wrote that, with many vendors failing to deliver fully functional 2014 certified EHR technology, “this August 29 final rule was the last hope for successful reporting in 2014.”
Later, she told Physicians Practice via e-mail, “I do believe that the flexibility will allow [eligible providers] to participate, given the medley of options.”
Practice consultant Owen Dahl agreed with Woodcock. He told Physicians Practice via e-mail that the added flexibility “takes some burden off” eligible providers and makes attestation more of a “reasonable” possibility.

2. Long reporting period. While more flexibility for providers may be a step in the right direction, the College of Healthcare Information Management Executives (CHIME), said more could be done to ensure that higher numbers of providers could satisfy the meaningful use criteria.

Prior to the release of the final rule, the organization, and many others, had pushed CMS to allow providers to choose any quarterly EHR reporting period to qualify for meaningful use in 2015, rather than requiring 365-days of reporting.
“CHIME is deeply disappointed in the decision made by CMS and ONC to require 365-days of EHR reporting in 2015,” CHIME President and CEO Russ Branzell said in a statement. “This single provision has severely muted the positive impacts of this final rule. Further, it has all but ensured that industry struggles will continue well beyond 2014.”
Dahl agreed that the 365-day reporting period could take a toll on many physicians. It “creates a problem or major area of concern as well,” he said.

3. Useful resources. A solid understanding of how the new rule applies to your practice’s meaningful use journey is critical. Here are a few helpful resources:

By: Aubrey Westgate

– Source: http://www.physicianspractice.com/health-it/new-meaningful-use-rule-good-news-many-physicians#sthash.NGxwcbPo.dpuf

Medicare News

Medicare Moves to Replace Modifier 59

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Effective for dates of service beginning Jan. 1, 2015, CMS will require four new modifiers for Medicare claims, to be appended in lieu of 59 distinct procedural service under defined circumstances.

CMS describes the new modifiers, announced in CMS Transmittal 1422, Change Request 8863,as “subsets of distinct procedural services (-59 modifier),” to include:
• XE – Separate Encounter. Used to describe services that are separate because they take place during separate encounters.
• XS – Separate Structure. Used to describe services that are separate because they are performed on different anatomic organs, structures or sites.;
• XP – Separate Practitioner. Used to describe services that are distinct because they are performed by different practitioners.
• XU – Unusual Non-overlapping Service. Used to describe services that are distinct because they do not overlap the usual components of the main service.
Modifier 59 may be used to override National Correct Coding Initiative (NCCI) edits, or otherwise to gain separate reimbursement by indicating that a code represents a service that is separate and distinct from another service with which it is usually bundled. For example, excision of skin lesions include simple repair at the same location; however, if a repair occurs at a separate location from the lesion excision, you may report it separately by appending modifier 59 to the CPT code describing the repair.
Endemic, ongoing misuse and abuse of modifier 59 is well documented. A 2005 report by the Office of Inspector General (OIG), “Use of Modifier 59 to Bypass Medicare’s National Correct Coding Initiative Edits,” found that 40 percent of modifier 59 claims failed to meet CMS program requirements, resulting in an estimated $59 million in incorrect payments in 2003. More recently, 2013 CERT Report data projected a one-year error of $770 Million in incorrect modifier 59 payments. As a result, modifier 59 is a frequent target of payer audits, and it has appeared on the OIG’s annual work plan, every year for a decade.
“The primary issue associated with the -59 modifier,” according to CMS, “is that it is defined for use in a wide variety of circumstances.” In other words, the broad, “catch-all” applicability of the modifier — it is often called the “modifier of last resort”— invites misuse and abuse. The intent of the four, newly-introduced modifiers, collectively referred to as -X{EPSU} modifiers, is to require providers to specify the circumstances that call for separate reimbursement of the reported services, which generally would not be reported together. For instance, returning to the example above of the lesion excision and separate repair at a different location, you would append modifier XS to the repair code to indicate “separate structure.”
Per CR8863, “CMS will not stop recognizing the -59 modifier but notes that CPT instructions state that the -59 modifier should not be used when a more descriptive modifier is available. CMS … may selectively require a more specific – X{EPSU} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI PTP code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other -X{EPSU} modifiers.”
More information about the new modifiers is sure to come, but CMS is already encouraging their use. CR8863 states, “Contractors are not prohibited from requiring the use of selective modifiers in lieu of the general -59 modifier when necessitated by local program integrity and compliance needs.” Not only should you prepare to use the -X{EPSU} by Jan. 1, you might also expect even greater scrutiny of future modifier 59 claims

By: G. John Verhovshek, MA, CPC

– Source: http://www.physicianspractice.com/medical-billing-collections/medicare-moves-replace-modifier-59#sthash.NFa6csrv.dpuf

Uncategorized

It’s a home health crackdown, but your phone’s going to ring

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Don’t be surprised if you suddenly start to get persistent calls from home health agencies concerning patients you’ve referred for home health care.

Medicare has directed its supplemental medical review contractors (SMRCs) to crack down on the face-to-face visit rules required to certify home health care by auditing five records from every home health agency in the country to ensure they have the proper documentation of the face-to-face visit.

Because the face-to-face visit has to be done by the physician practice, expect the agencies to be calling to make sure they have the right documentation.

The face-to-face visit requirement to certify and recertify patients for home health care came about under the Affordable Care Act (ACA) as a means to reduce what CMS considered to be the overutilization of home health services believed to potentially be not medically necessary.

At the point of implementation, the provision that each patient referred for home health service have a face-to-face encounter for medical necessity challenged home health agencies and physician providers alike.

The agencies were concerned that their revenue was in jeopardy due to the added documentation requirement. Physician advocates were angry that they were being asked to complete yet another paperwork burden for no additional pay.

While a lot of those hiccups seemed to have gone away, an HHS Office of Inspector General (OIG) audit released in April showed that, of the 644 face-to-face encounter documents reviewed by OIG auditors, 32 percent did not meet Medicare requirements, which extrapolated to $2 billion in annual overpayments.

The face-to-face documentation essentially requires the physician to certify that a face-to-face visit related to the patient’s need for home health services took place, that the patient is homebound and that the patient needs medically necessary skilled home care. This must be communicated by the physician in a narrative specific to that patient’s need.

The physician may use a template for this, providing it is neither furnished nor completed by the home health agency. This visit must occur within 90 days prior to the start of home health care or within 30 days of it beginning.

Of the home health cases found to be lacking, 10 percentage points lacked face-to-face documentation and approximately 25 percent were missing one of the above required elements. The narrative statements by the physicians were found to be inconsistent.

Expect home health agencies to push on patient specificity, because that is the key to supporting their encounters. For example, a statement that it is taxing to leave home was found by OIG to lack specific patient detail about the need for home health. Instead, it just lifts a line from the CMS definition of homebound.

Examples cited that do not support home health skilled service include too weak to drive, family needs help, unable to furnish own wound care and diabetes. Examples that don’t support homebound status include unable to leave home, dementia, functional decline, weak and unable to drive.

OIG also challenged many of the uses of check boxes on certification forms, saying that CMS intended these only for limited situations when generated by the physician or the physician’s electronic health record system.

Four recommendations were made by OIG to CMS to reduce errors. First was that CMS use a standardized form for the face-to-face documentation. CMS agreed to consider it, though noted it would eliminate some provider flexibility to port information from the current medical record. Second was to require physicians to include their NPI, which CMS said would not add value.

The third, to provide more education, was agreed to by CMS. The fourth, more oversight, is why you might be getting more calls from home health agencies very soon.

Author: Scott Kraft

– Source: http://codapedia.com/article_712_It%E2%80%99s-a-home-health-crackdown-but-your-phone%E2%80%99s-going-to-ring.cfm#sthash.7FECerL6.dpuf