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Archive for January, 2010
« Older Entries |ATTENTION: PAPER CLAIMS SUBMITTERS:
Friday, January 29th, 2010
Currently, paper claims that are received where the health insurance claim number (HICN) and the beneficiary name do not match, are returned to the provider with a development letter advising the provider to correct the problem and submit as a new claim.
The Centers for Medicare and Medicaid Services (CMS) is now directing contractors to follow the current electronic rejection process with all claims, electronic and paper.
These paper claims will now be rejected and returned to the provider with a rejection letter specifying the reason the claims were returned. The effective date of this change is tentatively scheduled for February 26, 2010.
As always, thank you for your assistance.
Jim
James D. Bavoso
Provider Outreach & Education
National Government Services
50 Broadway, Suite 103
Hawthorne, NY 10532
Posted in MEDICARE UPDATES | No Comments »
Temporary Change in Medical Reporting Requirements
Friday, January 29th, 2010
Authorized Provider Shortage in Rochester Area;
Temporary Change in Medical Reporting Requirements
Date: January 26, 2010
Physicians, with limited exceptions, podiatrists, chiropractors and psychologists must be authorized by the Chair in order to treat workers’ compensation claimants. Physical and occupational therapists may treat claimants either under the direct supervision of or upon referral by a physician. Nurses and other health providers may only treat workers’ compensation claimants under the direct supervision of an authorized physician.
It is important that injured workers have access to authorized providers in order to receive necessary care and treatment. Further, it is also important that injured workers receive such care and treatment as quickly as possible in order to ensure the best and speediest recovery. The faster an injured worker is treated and recovers, the faster such worker can return to work. In order to receive treatment quickly there must be authorized providers available to treat injured workers.
In the past two years a number of physicians have voluntarily surrendered their authorizations to treat workers’ compensation claimants. A large number of these physicians are located in the Rochester area of the state resulting in a temporary shortage of authorized providers to treat injured workers. Specifically, the temporary shortage of authorized physicians exists in the counties of Monroe, Livingston, Steuben, Allegheny, Wyoming and Ontario.
When these providers surrendered their authorizations, injured workers treated by them were forced to find a new provider. In addition, newly-injured workers had to find other providers to treat them. This has resulted in an increased demand for the services of the providers who have retained their authorization to treat injured workers. This demand has placed a burden on authorized providers to timely complete and submit the prescribed medical report forms. Delays in the submission of medical reports cause delays in the receipt of benefits by injured workers.
I find that there is a temporary shortage of authorized providers in the counties of Monroe, Livingston, Steuben, Allegheny, Wyoming and Ontario. These counties shall collectively be deemed the Provider Temporary Shortage Area.
In order to address this situation, in the Provider Temporary Shortage Area I am including in the list of prescribed medical report forms the CMS-1500 (or HCFA-1500) form with detailed narrative reports or office notes. Authorized physicians, podiatrists, chiropractors and psychologists in the Provider Shortage Area may submit a CMS-1500 with a detailed narrative report or office notes in lieu of one of the prescribed C-4 forms. If a CMS-1500 is submitted without the detailed narrative report or office notes, it is not a prescribed form. A narrative report or office notes are considered detailed when they contain the necessary information in sufficient detail so the insurance carrier can properly process the submission.
Further, the statement in Subject Number 046-301R dated March 23, 2009, that the Board will not enforce payment for examinations, services and/or treatments provided after April 1, 2009, if they are not reported using the correct new C-4 report is rescinded Statewide. In all areas of the State, the Board will enforce payment in accordance with the Workers’ Compensation Law and regulation regardless of the version of the C-4 form used to report examinations, services and/or treatments rendered by providers. For providers located within the Provider Temporary Shortage Area, the Board will also enforce payment in accordance with the Workers’ Compensation Law and regulations if a CMS-1500 (or HCFA-1500) with detailed narrative report or office notes is used to report examinations, services and/or treatment for the duration of the shortage.
Insurance carriers may not refuse to pay bills for failure to file one of the prescribed C-4 forms; however, they may raise an objection to the bill if the service is not sufficiently detailed in the office notes or narrative reports.
The Provider Temporary Shortage Area designation and addition to the prescribed list of medical report forms takes effect immediately. Once it is determined that the shortage no longer exists the list of prescribed medical report forms will be revised to require use of the C-4 forms.
Any questions regarding these matters should be referred to the Office of General Counsel at 518-486-9564.
Robert E. Beloten
Chair
Posted in WORKERS' COMPENSATION UPDATES | No Comments »
Nassau County Department of Health Alert #1 – 2010: Measles
Wednesday, January 27th, 2010
Nassau County Department of Health Alert #1 – 2010: Measles
Please Distribute to All Primary Care Staff, Infectious Disease, Emergency
Medicine, Internal Medicine, Pediatrics, Family Medicine, Laboratory
Medicine and Infection Control Personnel
• A laboratory confirmed case of measles has been identified in Nassau County.
• All clinically suspect cases of measles must be reported immediately (prior to laboratory confirmation) to Nassau County Department of Health (NCDOH) at 516.227.9496 during business hours or 516.742.6154 evenings, weekends and holidays.
• Patients with febrile rash illness should notify staff before arriving so that they may be placed in isolation immediately.
January 27, 2010
Dear Colleagues,
Nassau County Department of Health today announced that a case of measles has been confirmed in the county. The individual recently traveled to a country with widespread measles. Residents may have been exposed to the case if they visited the following locations on the dates and times listed below:
Island Garden Basketball Facility, 45 Cherry Valley Avenue
West Hempstead, NY 11552
January 21 (Thursday) from 9:30am to 2:30pm
975 Franklin Avenue, Garden City, NY 11530
January 23 (Saturday) from 8:25am to 12:15pm
January 25 (Monday) from 8:45am to 12:45pm
January 26 (Tuesday) from 8:45am to 2:15pm
Clinical Presentation:
Measles is an acute viral illness characterized by a prodrome of fever (101–105F), cough, coryza, and/or conjunctivitis, followed by rash. The measles rash is erythematous maculopapular and lasts ≥3 days. It usually starts on the face and proceeds down the body to involve the extremities last, including the palms and soles. The maculopapular rash is usually discrete but may become confluent on the upper body. The rash resolves in the same order that it appeared. Koplik’s spots (punctate blue-white spots on the bright red background of the buccalmucosa) may be present but are often not seen and are not required for the diagnosis of measles.
Complications:
Complications include diarrhea, otitis media, pneumonia and encephalitis.
Diagnosis:
The diagnosis is confirmed by the serologic testing (ELISA or EIA) of a blood sample for measles specific IgM antibody. Because IgM may be negative in the first 72 hours after rash onset, negative IgM results in these patients should be repeated after 72 hours. The IgM response is detectable for approximately one month after rash onset; the IgG response persists for years. The NCDOH Public Health Laboratory is capable of obtaining rapid IgM results, within 12-24 hours. By notifying NCDOH, as required, we can facilitate obtaining rapid results and institution of control measures, if indicated.
Transmission:
Measles is spread via airborne transmission and direct contact with infectious droplets. Cases of fever and rash illness should immediately be placed in airborne isolation. If an airborne infection isolation room is not available, then the exam room used to isolate a suspect measles case should not be used for three hours after the case leaves the room. Providers should make all attempts to minimize exposure, such as having the suspect case don a surgical mask prior to entering the facility and/or scheduling the visit at the end of the day. All staff present during the time of the visit should be immunized or have serologic evidence of immunity.
Post-exposure Prophylaxis:
Measles vaccination should be administered to susceptible contacts of a measles patient within 72 hours of exposure and may offer some protection. Immune globulin is indicated for susceptible household or other close contacts of patients with measles, particularly contacts
younger than 1 year of age, pregnant women and immunocompromised persons, for whom risk of complications is highest. Immune globulin should be given within 6 days of exposure, to prevent or modify measles. Note that immune globulin should not be given to household contacts who have received 1 dose of vaccine at 12 months of age or older unless they are immunocompromised; these contacts should receive a second dose of MMR.
The recommended dose for immune globulin is 0.25mL/kg of body weight intramuscularly; immunocompromised children should be given 0.50 mL/kg. Use of immune globulin will necessitate delay in administration of live-virus vaccines (measles-mumps-rubella and varicella) for 5–6 months. The successful initiation of measles post-exposure prophylaxis (PEP) requires rapid intervention.
Reporting:
One of the major delays in institution of measles PEP is delayed reporting. Clinically suspect cases of measles must be reported immediately to NCDOH. Reports should be made at time of initial clinical suspicion. If you are considering the diagnosis of measles and are ordering diagnostic testing for measles then you should report the case at that time. This will allow NCDOH to arrange for rapid measles IgM testing. Fever/rash illness may also be caused by other infections that are also contagious and require isolation; two examples are rubella and varicella zoster virus infection. A high index of suspicion must be maintained to avoid transmission to other patients.
MMR Vaccination:
NCDOH strongly recommends that children receive their first dose of MMR vaccine at 12 months of age. Delaying MMR vaccination prolongs the period that children are susceptible to measles infection and increases their risk of becoming infected. The majority of recent measles cases in the U.S. were eligible for measles vaccination, but had not been vaccinated and therefore, their infection could have been prevented. These children can in turn infect those who are not eligible for vaccination such as children < 12 months and the immunocompromised. Two doses of MMR are required to be considered fully vaccinated.
In summary:
1) Report all suspect measles cases immediately (DO NOT WAIT FOR LABORATORY CONFIRMATION) to the Bureau of Communicable Disease Control at 516.227.9496 during business hours or 516.742.6154 evenings, weekends and holidays.
2) Patients with febrile rash illness should notify staff before arriving so that they may be placed in isolation immediately.
3) Offer measles vaccine or immune globulin to susceptible exposed contacts.
4) Assure that all those eligible for MMR vaccine receive appropriate and timely vaccination.
Please contact Bureau of Communicable Disease Control at 516.227.9496 during business hours or 516.742.6154 evenings, weekends and holidays. As always, your cooperation is greatly appreciated.
EDWARD P. MANGANO
COUNTY EXECUTIVE
MARIA TORROELLA CARNEY, M.D. F.A.C.P.
COMMISSIONER
Posted in HEALTH DEPARTMENT UPDATES | No Comments »
Preventing the Misuse of Modifiers PA, PB, and PC on Incoming Claims
Wednesday, January 27th, 2010
Requirements to Prevent the Misuse of Modifiers PA, PB, and PC on Incoming Claims
MLN Matters® Number: MM6718
Related Change Request (CR) #: 6718
Related CR Release Date: December 4, 2009
Effective Date: January 15, 2009
Related CR Transmittal #: R1867CP
Implementation Date: No later than January 4, 2010
Provider Types Affected: Physicians, nonphysician practitioners, and hospitals submitting claims to Medicare contractors (fiscal intermediaries (FIs), carriers, and Medicare administrative contractors (MACs)) for services provided to Medicare beneficiaries are affected:
Provider Action Needed: This article, based on CR 6718, advises you that the PA, PB and PC modifiers are often being submitted incorrectly on claims. This can cause incorrect denials.
The Centers for Medicare & Medicaid Services (CMS) issued CR 6718 to direct contractors on handling incorrect claims in order to alleviate the issue. These detailed instructions are explained in the background section of this article. Your billing staffs need to be aware of the proper uses of the modifiers PA, PB, and PC. The instructions are in MM6405, available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6405.pdf on the CMS Web site.
Background:
This article is based on CR 6718, which clarifies billing instructions and claims processing for information provided in a previous article MM6405. CR 6718 does not change the policy for the coverage or non‐coverage of the adverse events described in MM6405.
CR 6405, “Wrong Surgical or Other Invasive Procedure Performed on a Patient; Surgical or Other Invasive Procedure Performed on the Wrong Body Part; Surgical or Other Invasive Procedure Performed on the Wrong Patient,” a revised version of which was issued on September 25, 2009, implemented billing procedures for these adverse events.
CMS has learned that the modifiers described in the CR 6405 are, in many cases, being submitted incorrectly by the providers. In particular, some providers are using the PC modifier to represent the professional component of a service. This is incorrect. The PC modifier is defined as “Wrong Surgery on a Patient.” The incorrect use of this modifier results in claims being incorrectly denied. Medicare contractors will follow the requirements in CR 6718 to help prevent claims from being processed with modifiers incorrectly submitted on them.
Medicare contractors will:
- Suspend, review, and develop all claim lines that are submitted with the PA, PB, or PC modifiers; and
- Contact the provider to determine whether the claims are related to one of the adverse events as described by the modifiers PA, PB, or PC.
If the contractor determines that the modifiers PA, PB, or PC have been incorrectly submitted, they will:
- Reject (return to provider) Part A outpatient claims;
- Return Part B claims as unprocessable with;
a) Claim Adjustment reason Code 4 (The procedure code is inconsistent with the modifier used or a required modifier is missing.); and
b) Remittance advice Remark Code MA130 – Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.
Additional Information:
If you have questions, please contact your Medicare contractor at their toll‐free number which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.
CPT
Posted in MEDICARE UPDATES | No Comments »
UNITEDHEALTHCARE 2010 Fee Schedule Updates
Monday, January 25th, 2010
Update of Physician Fee Schedules to Reflect Temporary Medicare Conversion Factor
President Obama signed the Department of Defense appropriations bill into law on December 21, 2009, delaying a 21.2% reduction in physician fees for 60 days. On December 23, 2009, the Centers for Medicare & Medicaid Services (CMS) released the January 2010 Physician Fee Schedule file that contains the 2010 relative value units and temporary conversion factor of $36.0846. This conversion factor will be effective for Medicare services rendered on or after January 1, 2010 through February 28, 2010.
Upon receiving the CMS publication, UnitedHealthcare immediately engaged in our 2010 annual fee schedule update process in order to comply with relevant contractual and regulatory requirements for in-network physicians and to comply with regulatory requirements for out-of-network physicians who render services to members of UnitedHealthcare and our affiliates, as well as members of SecureHorizons®, Evercare® and AmeriChoice®.
If you participate in our network and your fee schedule is not tied to Current Year or 2010 Medicare rates, you are not affected by this change. It is important to note that the majority of in-network physicians who serve our commercial and AmeriChoice members are not affected by this change. Please refer to your contract to refresh your understanding of your fee schedule.
Most of the physicians, who participate in our network serving SecureHorizons and Evercare members, as well as a small number of physicians who serve commercial and AmeriChoice members, are affected by this temporary change. During this system update, claims will be paid at the 2009 Conversion Factor but will not reflect 2010 relative value units and geographic practice cost indicies.
We are expediting updates of relevant fee schedules and anticipate completion by February 27, 2010.
To avoid potential cash flow disruption to physician practices, we will not be holding claims for processing during this time. Physicians and other health care professionals may choose to hold claims and submit them after our update process is complete. Please note that if you choose to hold your claims and submit them at a later date, timely filing limits will not be waived. If you have any questions, please speak with your Network Management representative or Physician Advocate.
Thank you for the services you provide to our members.
Posted in HEALTH INSURER UPDATES, MEDICARE UPDATES | No Comments »
Corrected Anesthesia File and Updated 52 Codes
Monday, January 25th, 2010
This specifically affects Queens County physicians. It would also affect physicians in Brooklyn or Nassau counties that might have offices in Queens.
The Centers for Medicare & Medicaid Services issued a corrected anesthesia file and updated 52 codes paid under the Medicare Physician Fee Schedule (MPFS). The updated fee schedule files have been posted to the National Government Services Web site and can be accessed by choosing the Fee Schedules link from the Quick Links listing on your provider portal. The corrected codes are also listed below.
Important Information for Providers in New York Area 04
It has come to our attention that the Excel (.xls) and comma separated value (.csv) MPFS files previously posted on our Web site for New York Area 04 were incorrect. These have now been corrected, and providers should re-download those files to obtain the correct fees for Area 04. We apologize for the inconvenience.
Corrected Codes
| ANES | 01953 | 01996 | 22819 | 32445 | 33305 |
| 33411 | 33413 | 33782 | 33783 | 33860 | 33863 |
| 33864 | 33877 | 33935 | 33945 | 33980 | 39503 |
| 43108 | 43113 | 43118 | 43123 | 43124 | 47135 |
| 47136 | 47142 | 49605 | 61518 | 61519 | 61520 |
| 61521 | 61526 | 61530 | 61538 | 61545 | 61585 |
| 61592 | 61597 | 61607 | 61608 | 61613 | 61616 |
| 61682 | 61684 | 61686 | 61692 | 61697 | 61698 |
| 61700 | 61702 | 63250 | 63251 | 63252 | 63287 |
| 63290 |
Thank you,
National Government Services, Inc.
Corporate Communications
Posted in MEDICARE UPDATES | No Comments »
NYS Dept. of Health INFLUENZA VACCINE UPDATE
Thursday, January 21st, 2010
January 15, 2010
Dear H1N1 Influenza Vaccine Provider,
The purpose of this letter is to:
• Request that you continue to vaccinate patients for H1N1 influenza and retain your current stocks of vaccine in case there is a disease resurgence;
• Remind you about the need for a second dose of H1N1 vaccine for children less than 10 years of age; and
• Remind you to report all vaccine doses administered or wasted.
Continue to vaccinate for H1N1 influenza and retain current vaccine stocks. January through March is the traditional influenza season. While disease activity is now low, there is a real possibility of a third wave of H1N1 influenza disease, similar to what happened in the 1957-1958 pandemic. As a result, the New York State Department of Health (NYSDOH) is encouraging you to:
• Continue to offer and encourage H1N1 influenza vaccination to your patients;
• Retain your current supply of H1N1 influenza vaccine in your office, unless you do not have sufficient space to store it. Contact your county health department if you have vaccine that you are unable to store;
• Call 1-800-KID-SHOT to place a vaccine order. You may check your order status at: http://www.health.state.ny.us/diseases/communicable/influenza/h1n1/health_care_providers/vaccine/ordering_history.htm;
• Instructions on what to do with unused vaccine will be provided in the future.
Reminder on second vaccine doses for children less than 10. Children less than 10 years old are recommended to get a second dose of H1N1 vaccine at least 28 days after the first dose. The state immunization registry, NYSIIS, can be used to check on which children need a second dose and can generate reminder lists and letters. A short on-line tutorial for using the NYSIIS Reminder-Recall function (Module #10) is located at: https://commerce.health.state.ny.us/hpn/bcdc/immunization/instantdemo/tutorials.html
• Either nasal spray (if appropriate) or injectable vaccine may be used for the second dose regardless of the type of vaccine administered for the first dose.
• Pre-filled 0.25 ml syringes for children under age 3 years are no longer available. Please use Sanofi or CSL multi-dose vials for second doses of injectable vaccine.
• NYSDOH has waived the provisions of state law which usually restricts the use of thimerosal-containing influenza vaccines in pregnant women and children under the age of 3 years. There is no scientific evidence of harm caused by the low doses of thimerosal in vaccines. For more information, see: http://www.nyhealth.gov/diseases/communicable/influenza/h1n1/health_care_providers/frequently_asked_questions/vaccine_containing_thimerosal.htm
Reminder to report vaccine doses administered. The federal provider agreement which you signed to receive H1N1 influenza vaccine commits you to report vaccine usage.
• Vaccine administered to persons less than 19 years of age must be reported by state law to the New York State Immunization Information System (NYSIIS). For more information, see: http://www.health.state.ny.us/prevention/immunization/information_system/
• Doses administered to persons age 19 years and older may be reported to NYSIIS with patient consent, or aggregate doses administered must be reported to the NYSDOH telephone or web-based systems. See the following website for additional information: http://www.nyhealth.gov/diseases/communicable/influenza/h1n1/health_care_providers/vaccine/docs/vaccine_reporting_requirements.pdf.
For more information on your order, second dose administration, or reporting, please call 1-800 KID-SHOT.
Thank you for your continued efforts to vaccinate New Yorkers against influenza.
Posted in FLU/IMMUNIZATION UPDATES | No Comments »
2010 MEDICARE PAYMENT SCHEDULE Summary Now Available
Thursday, January 21st, 2010
Every year the 2010 Medicare physician payment schedule contains numerous policy changes that will affect different practices in different ways. Some of the major changes this year include revised practice expense relative values, elimination of Medicare payment for consultation codes, new quality reporting options and simpler reporting requirements for the e-prescribing incentive program. To learn more about these changes, including projected payment impacts for each specialty, go to:
www.ama-assn.org/go/medicarepaymentkit and click on “2010 Medicare Physician Payment Schedule.”
An updated version of the AMA’s “Medicare Participation Options for Physicians” document is also available at this site, including information on a recent extension of the deadline for participation decisions to March 17, 2010.
Posted in MEDICARE UPDATES | No Comments »
Important Notice: Medicare Part B Claim Issue Causing Incorrect Claim Denials
Wednesday, January 20th, 2010
Medicare Part B Claim Issue Causing Incorrect Claim Denials
National Government Services has identified a claim denial and refund
request situation.
Claim adjustments are denying in error, indicating on the provider
remittance that the claim has been paid to another carrier. This is due
to an issue with the Common Working File (CWF) and claims processing
errors against CWF. The CWF file validates beneficiary eligibility,
among other things.
Any new adjustments are suspending so additional incorrect denials
should not occur. In addition, claims that were mass adjusted (e.g.,
claims for ESA services, J0881 and J0885, which were erroneously denied)
have either denied as being paid by another carrier or refunds were
requested in error.
Providers who have received a notice of overpayment regarding this issue
do not need to send refunds and we will not offset your claims to recoup
the funds.
National Government Services is diligently working with the Centers for
Medicare & Medicaid Services and the CWF maintainer to rectify this
situation. We have been advised that this issue is to be corrected by
CWF in the Tuesday, January 19, 2010 cycle. Once corrected, we will
issue an update via our Web site and Listserv and begin to reprocess
claims affected by this issue.
Thank you for your patience as we work to correct this problem.
National Government Services, Inc.
Posted in MEDICARE UPDATES | No Comments »
MANAGED CARE REFORM LEGISLATION ADVANCES IN ASSEMBLY
Wednesday, January 20th, 2010
The Assembly advanced a series of MSSNY-supported bills to provide comprehensive reform to the many hassles experienced by patients and physicians in their dealings with health insurance companies. Very significantly these bills included legislation (A.4301, Canestrari, Gottfried et al.) which was unanimously approved by the Assembly Health Committee and which fundamentally changes the nature of health plan-physician interactions by granting physicians and other health care providers the legal ability to collectively negotiate critically important patient care and reimbursement contract terms with health plans. The bill now advances to the Assembly Ways and Means Committee.
Additionally a number of bills that passed the Assembly last session, but not the Senate, have been advanced for consideration again by the full Assembly, including the following legislation:
- A.723 (Gottfried) – Would require a coverage denial decision made by a health plan to be made by a physician board-certified in the same or similar specialty as the physician who typically provides the recommended treatment.
- A.726 (Gottfried) – Would prohibit health plans from including certain offensive provisions in contracts with health care providers, such as limiting referrals to out of network providers, and “most favored nation” clauses
- A.729 (Gottfried) – Would better assure the ability of a patient to be successful in an external appeal of a health plan denial by facilitating evidence-based appeals founded on medical and scientific literature, the patient’s medical record, and other pertinent information.
- A.764 (Gottfried) – Would mandate the use by health plans of universal credentialing and re-credentialing forms
All physicians are asked to communicate their support for these bills to their elected member of the Assembly. All Assembly members can be reached by calling (518) 455-4100.
Posted in NEWS FROM THE NYS LEGISLATURE | No Comments »
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