 |
 |
 |
 |
             |
CMS Lifts 10-day Freeze on Claim Payments with DOS of March 1st.
March 3rd, 2010
Subject: The “Temporary Extension Act of 2010″ Extends the Zero Percent Medicare Physician Fee Schedule Update and the Therapy Cap Exception Process
March 2, 2010, President Obama signed into law the “Temporary Extension Act of 2010.” Among other things, this law extends through March 31, 2010, the zero percent update to the Medicare Physician Fee Schedule that was in effect for claims with dates of service January 1, 2010, through February 28, 2010. Consequently, effective immediately, claims with dates of service March 1 and later which were being held by Medicare contractors will be released for processing and payment. Please keep in mind that the statutory payment floors still apply and, therefore, clean electronic claims cannot be paid before 14 calendar days after the date they are received by Medicare contractors (29 calendar days for clean paper claims). In addition, the new law extends through March 31, 2010, the exception process for therapy claims reaching the annual cap, retroactive to January 1, 2010. Affected providers may submit claims for exceptions to the annual therapy caps, with dates of service January 1 through March 31, 2010, using the KX modifier, following the pre-January 1, 2010, requirements for therapy cap exceptions. Please watch your listserv and contractors website for more information about the new legislation.
Posted in MEDICARE UPDATES |
Tell your Senators to repeal the flawed Medicare physician payment formula (SGR)
March 2nd, 2010
Last week the Senate failed to repeal the Medicare physician payment formula that caused today’s drastic 21 percent payment cut to physicians. Call your senators at (800) 833-6354 today and tell them it is time to act on permanent repeal of the flawed Medicare physician payment formula (SGR) once and for all.
For too many years, Congress has applied short-term fixes to this long-term problem, which is like putting a band-aid on a gaping wound. Physicians can no longer play this perpetual game of chicken with Congress. The Medicare payment program is unreliable and unsustainable. Physicians can no longer shield their patients from congressional mismanagement of the program.
You are dedicated to your patients, but you cannot run a business when the government doesn’t cover the cost of care. The growing negative margin and cuts have made it untenable for you to continue to care for Medicare patients.
Time and time again, physicians have told the AMA and Congress that this 21 percent cut—and the threat of more to come—will force them to make difficult practice changes. First and foremost, physicians will be forced to limit the number of Medicare patients they can treat—or cease seeing them altogether. In this tough economy, the cuts will have a ripple effect as physicians will also be forced to take other actions to keep their practices viable, such as reducing staff and delaying investments in health IT.
Many of you already know that about one in four Medicare patients looking for a new primary care physician are having trouble finding one. This latest cut and the Senate’s continued failure to adopt a permanent solution will turn this growing problem into a disaster.
America’s military men and women should not have to worry about their loved ones getting in to see a doctor, but that is the position in which Congress has put them. Because TRICARE ties its payment rates to Medicare, active duty military members and their families are at risk of reduced access to care.
The longer Congress delays on permanent action, the greater the cost and the magnitude of the cuts. In 2005 the cost of permanent reform was $49 billion. Today the cost is $210 billion. Again, the longer the delay, the higher the price tag will become. Tell Congress to stop short-term fixes that are nothing more than a budgetary gimmick, and fix the formula for America’s seniors, military families, disabled and baby
boomers.
Congress created this payment formula—the Senate has a responsibility to fix it. No more lip service. It’s time for action on a permanent solution to this problem created by Congress. Senators need to hear directly from you—America’s physicians—on this issue. Call the AMA’s toll-free grassroots hotline at (800) 833-6354 and urge your senators to permanently repeal the SGR. Do it for the future of your practice and the patients in your care.
Choose Medicare participation status by March 17
Physicians have until March 17 to change their Medicare participation status for this year. View an updated document from the AMA <http://t.democracydirect.com/?ti_dn__=2b03d014-3058-4267-84c0-0719389a9 3a2&__u_idz=c07f0d57-12c1-431b 9830-4e648a720f30&__turl=http%3a%2f%2fwww .ama-assn.org%2fama1%2fpub%2fupload%2fmm%2f399%2fmed-par-options.pdf> that explains the current situation with respect to Medicare payment updates for 2010 and the various participation options available to physicians.
Posted in NATIONAL HEALTHCARE NEWS |
21% Medicare Physician Payment Cut Effective on March 1. MSSNY Responds
March 1st, 2010
Thursday Feb. 25 - the House passed HR 4691, legislation that extends a number of expiring programs for 30 days, including current Medicare physician payment rates, which would once again postpone the 21% cut that was scheduled to take effect this year. The Senate attempted unsuccessfully on several occasions last night and this morning to pass the same bill by unanimous consent, but objections were raised by Senator Jim Bunning (R-KY), on the basis that $10 billion cost of the program extensions was not offset. The Senate has now adjourned for the weekend, so the 21% Medicare physician payment cut will be effective on Monday, March 1.
We have been informed by the Centers for Medicare and Medicaid Services (CMS) that they are notifying their contractors to hold Medicare physician claims for 10 business days, effective Monday. The agency will also be sending out a similar message on its various list serves this afternoon to physicians, and contractors will be instructed to disseminate this information as well.
Members of the Federation are urged to express their outrage to Congress about its terrible mismanagement of the Medicare and TRICARE programs, which are so important to the health and well-being of Americans who have served our nation so long and so well. Tell them:
- Congress had more than a year to repeal the Medicare payment formula and ensure the security and stability of the program. Instead, it has abandoned patients who rely on Medicare and TRICARE for their health care.
- Parliamentary procedures offer no excuse for the harm they are causing these programs.
- Stop playing games with patients and the physicians; repeal the sustainable growth rate (SGR) formula once and for all.
Use the AMAs Grassroots Hotline: 1-800-833-6354.
In reaction, MSSNY President David Hannan, MD issued the following statement:
It is an outrage that Congress has put New Yorkers’ access to health care in jeopardy by failing to take action to prevent an unsustainably severe 21% Medicare physician reimbursement cut. Regardless of which party or which individual Senators are to blame for the failure to enact legislation to prevent the cut from going into effect, the bottom line is that this draconian reduction will go into effect on Monday. At a time when physicians face so many other hurdles in their effort to keep a viable practice, including extraordinarily high medical liability insurance costs, insurance companies and the other significant costs in running a small business in New York State, many physician practices will simply be unable to sustain this cut, and this will seriously jeopardize access to needed care for many, many patients.
We appreciate the support given by Senators Schumer and Gillibrand, and Representatives Rangel, Engel and the many other members of New York Congressional delegation who have supported a permanent fix of the grossly flawed formula for determining Medicare reimbursement. It is this failed formula that triggers such staggering cuts, and it must be changed. Our elected leaders must now re-double their efforts to assure the enactment of this legislation which will prevent this and future cuts, and allow physicians to continue to treat Medicare patients. It is not only physicians who support eliminating this ridiculous methodology which regularly threatens access to care. Many other associations of beneficiaries who depend upon this care, including AARP and the Military Officers Association of America, are also demanding reform.
We call upon Congress to roll up its sleeves and take action immediately upon returning to Washington on Monday to assure that seniors access to care is not interrupted and that physicians are fairly paid for treating Medicare patients.
MSSNY has been advised by Senator Schumer’s office that the Senate will be taking up legislation on Monday (HR 4213) that will prevent the 21% cut until October. It is not clear at this time what the ultimate outcome of this vote will be, nor its prospects in the House.
Physicians are urged to call 1-800-833-6354 and urge that action be taken immediately to prevent this cut.
Posted in MEDICARE UPDATES |
Healthcare Provider Taxonomy Codes April 2010 Update
February 24th, 2010
The Health Insurance Portability and Accountability Act (HIPAA) requires that covered entities comply with the requirements in the electronic transaction format implementation guides adopted as national standards. The X12 837 Professional and Institutional Implementation Guides require the use of valid codes contained in the Healthcare Provider Taxonomy Codes (HPTC) set when there is a need to report provider type or physician, practitioner, or supplier specialty for a claim.
The HPTC set is maintained by the National Uniform Claim Committee (NUCC) for standardized classification of health care providers. The NUCC updates the code set twice a year with changes effective April 1 and October 1.
Valid HPTCs are those codes approved by the NUCC for current use. Terminated codes are not approved for use after a specific date and newly approved codes are not approved for use prior to the effective date of the code set update in which each new code first appears. Although the NUCC generally posts their updates on the Washington Publishing Company (WPC) Web site three months prior to the effective date, changes are not effective until April 1 or October 1 as indicated in each update. Specialty and/or provider type codes issued by any entity other than the NUCC are not valid and Medicare would be guilty of noncompliance with HIPAA if Medicare contractors accepted claims that contain invalid HPTCs.
The taxonomy code is not required for processing Medicare claims. However, if a taxonomy code is submitted, it must be valid according to the HPTC code set. The HPTC code set is named in the 837 professional and institutional implementation guides, thus EDI must validate the inbound taxonomy codes against this HPTC maintained code source.
The April 2010 HPTC changes are available on the WPC Web site at http://www.wpc-edi.com/codes/taxonomy, then select New Codes for a listing of new HPTCs or Modifications for a listing of modified HPTCs.
Posted in MEDICARE UPDATES |
CLAIMS NOT AUTOMATICALLY CROSSING OVER TO SUPPLIMENTAL PAYERS
February 22nd, 2010
The Centers for Medicare & Medicaid Services (CMS) has identified a problem where claims were not automatically crossing over to supplemental payers even though the provider remittance advice indicated otherwise. This problem began January 5, 2010. Part A institutional claims and Part B professional claims, with the exception of supplier claims processed by Durable Medical Equipment Medicare Administrative Contractors (DME MACs), were impacted by this problem. Claims processed by DME MACs were not impacted.
Part B Professional Claims
Action is required on behalf of Part B professional providers where a remittance advice with an issue date between January 5, 2010, and February 12, 2010, has two or more service lines for a beneficiary where both of the following apply:
- One service line is 100 percent reimbursable (i.e., the approved amount and amount to be paid are equal,) AND
- One service line where part of or the entire Medicare approved amount is applied to the Part B deductible and/or carries co-insurance amounts.
CMS is not able to forward these beneficiary claims to supplemental payers even though the remittance advice may indicate otherwise. Providers will need to identify these claims by reviewing their remittance advice with an issue date between January 5, 2010, and February 12, 2010, that contain the criteria noted above. Once identified, providers will need to take action to balance bill the beneficiary’s supplemental payer. As of February 12, 2010, this system problem was fixed and all claims are crossing over to supplemental payers as indicated on the provider remittance advice.
The CMS has already notified supplemental payers of these issues. We regret any inconvenience you may experience related to this Medicare claim supplemental payer crossover problem.
Valerie A. Haugen, Director
Division of Provider Information Planning & Development
Provider Communications Group, CMS
(410) 786-6690
valerie.haugen@cms.hhs.gov
Posted in MEDICARE UPDATES, Uncategorized |
PECOS and Consultation
February 22nd, 2010
Unlike Medicare, other health plans will continue to recognize consultation codes. Although Medicare now considers the consult codes invalid for Medicare billing purposes, consultation services might still be necessary. There may be times when a physician needs the advice or opinion of another physician in order to continue the treatment of the patient. Whether or not the physician needs to put his/her advice/opinion in written form is the physician’s call when Medicare is involved since Medicare will need to be billed using the E&M visit codes, only.
However, just because Medicare will not recognize the codes for billing purposes does not mean that consultation services are no longer needed.
In addition, you must remember that Medicare is NOT is only health plan around. If a physician is performing a consultation for a health plan other than Medicare or for WC or NFA, a written report is required if the physician is billing with the consult codes.
PECOS is the provider enrollment system for the Centers for Medicare and Medicaid Services (CMS). PECOS stands for Provider Enrollment Chain Organization System. CMS created PECOS so the government could know who is enrolled in the Medicare Program. The PECOS system is a central computer system for CMS and was not made to be compatible with the provider enrollment systems of the existing Medicare contractors’ enrollment systems. Again, PECOS is the government’s provider enrollment system.
The name and NPI of the referring physician, on the Medicare claim submission, is not only needed for consultations. The name and NPI of the referring or ordering physician is required for laboratory services, medical diagnostic testing, including x-rays and for durable medical equipment (DME). The PECOS website can be found here: https://pecos.cms.hhs.gov/pecos/login.do
If claims are submitted for lab or medical diagnostic testing, the Medicare carrier (NGS in NYS) will review PECOS and their claim system (MCS) to verify that the referring or ordering physician is in their (NGS’) system. The NGS website can be found here: www.NGSMedicare.com <http://www.ngsmedicare.com/>
If a physician has ordered DME for his/her patient, the DME contractor (NHIC for NYS DME) can only search PECOS (since it does not have access to the Medicare Part B claim files of NGS). If the ordering physician is not in PECOS, NHIC will be required to deny the DME claim for benefits. The NHIC website can be found here: http://www.medicarenhic.com/dme
CMS has made a file available that contains the National Provider Identifier (NPI) and the name (last name, first name) of all physicians and non-physician practitioners who are of a type/specialty that is eligible to order and refer in the Medicare program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS that contain an NPI). This file is downloadable from the Medicare provider/supplier enrollment web site: www.cms.hhs.gov/MedicareProviderSupEnroll : click on “Ordering/Referring File” on the left-hand side. Next, scroll down to the DOWNLOAD section and click on the report link. Note, the report is over 13 thousand pages long. So, it is NOT meant to be printed.
This .pdf file contains approximately 800,000 records. A new file will be made available periodically that will replace the posted file; at any given time, only one file (the most recent) will be available. The file can be viewed online. In addition, it can be downloaded by users with technical expertise and further sorted or manipulated. It can also be used to search for a particular physician or non-physician practitioner by NPI or by name. Please note the following: (1) Records are in alphabetical order based on the surname of the physician or non-physician practitioner. (2) Name suffixes (e.g., Jr.), if they exist, are not displayed. (3) There are no “duplicates” in the file. Many physicians or non-physician practitioners share the same first and last name; their corresponding NPIs are the assurance of uniqueness. (4) Deceased physicians and non-physician practitioners are not included in the file. (5) If a user is unsure of a physician or non-physician practitioner’s NPI, he or she can look it up in the NPI Registry (https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do).
Also note, the NPI file is not the same as the PECOS file.
Regina McNally, VP
Division of Socio-Medical Economics
Medical Society of the State of New York
Posted in MEDICARE UPDATES |
Scope on Claims Editing
February 11th, 2010
It is a requirement that claims submitted to the Medicare Part B carrier, the Medicare administrative contractor (A/B MAC) or the durable medical equipment (DME) MAC that are the result of an order or referral must include the National Provider Identifier (NPI) and the name of the ordering or referring provider. Physician and nonphysician practitioners who are eligible to order/refer must be enrolled in the Medicare Provider Enrollment, Chain and Ownership System (PECOS).
Medicare is expanding the current scope of editing for claims processed that require an ordering or referring provider. There are two phases to this implementation.
Phase 1 extends through April 4, 2010.
Claims Submitted to the DME MAC During Phase 1
During this phase, claims processing edits are in place to verify the ordering/referring provider is in PECOS and is eligible to order or refer under Medicare guidelines. If the provider is not in PECOS or is in PECOS but is not of the type/specialty to order or refer, the claim will continue to process. The DMEPOS supplier will receive a warning message for claims submitted electronically. The supplier will not receive a warning message for paper claims.
Claims Submitted to the Medicare Part B Carrier or A/B MAC During Phase 1
During this phase claims processing edits are in place to verify the ordering/referring provider is in PECOS and is eligible to order or refer under Medicare guidelines. If the provider is not in PECOS the contractor will search the claims processing system for the ordering/referring provider. If the provider is not in PECOS or the claims processing system, the claim will continue to process. The provider submitting the claim will receive a warning message on the remittance advice.
Phase 2 begins April 5, 2010 and continues thereafter.
Claims Submitted to the DME MAC During Phase 2
If you order/refer items for a beneficiary that will be billed to the DME MAC by a supplier of durable medical equipment, prosthetics, orthotics or supplies and you are not eligible to order/refer under Medicare guidelines OR you are not in PECOS as of April 5, 2010 the beneficiary’s claims submitted to Medicare by the supplier will not be paid. The DME MAC processing system does not contain the ordering/referring physicians’ eligibility records and cannot verify the information if it is not in PECOS.
Claims Submitted to the Medicare Part B Carrier or A/B MAC During Phase 2
If the NPI and the name of the ordering/referring provider are on the claim the contractor will verify the provider is in PECOS and eligible to order or refer. If the provider is not in PECOS the contractor will search the claims processing system for the ordering/referring provider. A referring or ordering physician that is not enrolled with the Medicare contractor that is processing the claim will not be in the contractor’s claims processing system. Those claims that include the NPI and name of ordering/referring providers that cannot be found in PECOS OR found in the claims processing system will be rejected and not paid.
To ensure your reimbursement is not affected and your patients’ DME claims are paid, follow these steps:
- Log on to www.cms.hhs.gov/MedicareProviderSupEnroll. In the box on the left, under Medicare Provider Supplier Enrollment, select the Ordering Referring Report. Search for your National Provider Identifier (NPI) in the Medicare Ordering Referring File found in the Downloads section. If your NPI and name are on the list you are in the Provider Enrollment Chain of Ownership System (PECOS). You do not need to enroll in PECOS. If your NPI is not on the list or you want to confirm and review your enrollment in PECOS, go to step 2.
- Providers that are already in PECOS do not need to revalidate, enroll or submit an 855 application to the contractor at this time unless you receive a request from the contractor. If you are not in PECOS or want to review your enrollment information you may do so by visiting the PECOS Web site at https://pecos.cms.hhs.gov/pecos/login.do. You will need to create a User ID and Password if you have not accessed PECOS previously. For helpful guidance on PECOS please use this link http://www.cms.hhs.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS.asp#TopOfPage.
Two recommended documents to get you started with enrollment in PECOS are:
- Internet Based PECOS – Getting Started Guide for Physicians and Nonphysician Practitioners
- Internet Based PECOS – Enrollment Example
Tips for revalidating or enrolling:
- If revalidating a Group Member, the CMS 855I and the CMS 855R must be submitted.
- If revalidating an Individual, the CMS 855I application must be submitted.
- If revalidating a Group or Organization, the CMS 855B application must be submitted.
Services that require an ordering/referring provider can be found in the CMS Medicare Claims Processing Manual, Publication 100-04, Chapter 26, Section 10.4 at http://www.cms.hhs.gov/Manuals/IOM/list.asp.
The Medicare Learning Network Matters articles released on this implementation are:
- MM6417: Revised Final – Expansion of the Current Scope of Editing for Ordering/Referring Providers for Claims Processed by Medicare Carriers and Part B Medicare Administrative Contractors (MACs)
- MM6421: Final – Expansion of the Current Scope of Editing for Ordering/Referring Providers for Durable Medical Equipment, Prosthetics, Orthotics, and Supplier (DMEPOS) Suppliers Claims Process by Durable Medical Equipment Medicare Administrative Contractors (DMEMACs)
Thank you,
National Government Services, Inc.
Corporate Communications
Posted in MEDICARE UPDATES |
LEGISLATION WOULD REQUIRE GREATER EXPERTISE FOR HEALTH PLAN DENIALS
February 9th, 2010
Posted in NEWS FROM THE NYS LEGISLATURE |
Attention Part B Providers Billing for Ozurdex™ with Unlisted Code J3490
February 8th, 2010
Ozurdex was approved for the treatment of macular edema following branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO) on June 17, 2009. Claims with dates of service prior to 6/17/2009 will be denied as noncovered.
Claims with dates of service after 6/17/2009 are payable if the drug was administered to treat macular edema (reported with ICD-9 code 362.83 (retinal edema)). Claims submitted for other indications will be denied as not medically necessary as there are no other FDA-accepted uses for the drug.
For example: Claims containing ICD-9 codes 362.35 (central retinal vein occlusion) or 362.36 {venous tributary (branch) occlusion of retina} as the only diagnosis codes will be denied as Ozurdex is indicated for the treatment of the macular edema caused by the occlusion; not the treatment of the occlusion.
Claims that were incorrectly coded and contain a covered diagnosis of retinal edema (362.83) in the medical records, or suspected of being incorrectly denied despite the presence of the 362.83 code on the submitted claim, must be appealed, as no automated system adjustments will be done for them. Please access the Appeals section of www.NGSMedicare.com for instruction on filing a timely appeal.
Thank you,
National Government Services, Inc.
Corporate Communications
Posted in MEDICARE UPDATES |
2010 Health Alert #2: Increase in Viral Gastrointestinal Illness
February 8th, 2010
- In the week, there has been an increase in reports of vomiting and diarrhea indicating the presence of viral gastroenteritis in the county.
- Similar patterns have recently been noted in EDs in New York City
- Report any outbreaks by calling:
- 516-227-9694 During business hours OR
- 516-742-6154 After hours, holidays and weekends
Posted in HEALTH DEPARTMENT UPDATES |
Archives
Categories
-
Meta
