Manage My Practice

What?

But aren’t eligible providers getting that money as an inducement, actually a prize for hoop-jumping, having purchased a certified EMR and now using it meaningfully?

Oh, man, I knew there was a catch to this deal.

Next you’ll be telling me that Medicare’s reimbursement will be shrinking 21.2% November 30, 2010 and an additional 6.1% January 1, 2011.

What?

*Thanks to HIStalk Practice for pointing out this revelation from the AAFP.

If you’re wondering how to get your point across to your staff, your patients, or even your kids – why not make a video?

Here’s a delightful video that Caregiver Ben made about employee BMI screening for Heartland Health. All it takes is a flip video camera ($100 – $200) and a little practice. Think of all the ways you could use video at your practice:

1. New employee orientation & training
2. Training for existing employees learning new processes
3. Introduction of new protocols
4. Documentation of office events
5. Pediatrics – filming baby’s first visit as a gift to the parents
6. Geriatrics – filming the doctor’s instructions for the caregiver
7. Filming instructions for a non-English speaker with the translator
8. Filming instructions for a low-literacy patient
9. Filming new physician visits to help improve eye contact and communication
10. Welcome to our practice video on your website
11. Videos on your website showing patient how to check blood sugar, take their blood pressure, check their home for fall risks – endless!
12. Videos of each provider introducing themselves
13. Videos of most frequently asked questions in your practice
14. Testimonials of satisfied patients on your website
15. If it’s hard to have regular staff meetings or if you typically write an office newsletter once a month or so, make a video staff meeting or newsletter!

More information on Medicare wellness visits in 2011 can be found here.

Information on the 2011 Medicare Part A and Part B deductibles and premiums can be found here.

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The extensive changes coming for Medicare Part B coverage in 2011 should have primary care practices and some specialty practices thinking about their current processes. If you meet with your team now to educate them about the Medicare changes and explore process tweaking, you’ll be ready when January 1 rolls around.

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Here are a few areas to think about:

1. Advance Beneficiary Notices (ABNs) – Many practices struggle with the who and when of ABNs and the new coverage might not make it easier. There are lots of services now covered with new frequency limitations, so practices must be on their toes to recognize when a service is covered and when it isn’t. Sure, you can ignore ABNs and wait for Medicare to tell you a service is not covered, but then it’s too late to collect from the patient – not only too late, but also illegal to collect.
2. The annual wellness visit is going to be a special challenge because the timing is precise. Medicare patients will hear “annual visit”, but won’t realize it will not be paid for if performed within 12 months of a previous wellness visit (Welcome to Medicare exam or annual visit). I’ve not seen any practice management software that handles this really well, but maybe it’s out there. I’d love to see Medicare patients scheduling their annual visits during their birthday month so staff would have a fighting chance of identifying the last annual visit and getting the date right. Of course, using your electronic recall will work too if you schedule the next year’s visit when the patient is checking out. (Do you proactively contact your Medicare patients to invite them to come in for their Welcome to Medicare exam?) Also encourage patients to keep up with the preventive services they are eligible to receive by registering with the My Medicare website (https://mymedicare.gov/). This is their personal Medicare website for tracking their Medicare services. It will send them e-mail reminders when they are eligible for Medicare coverage of preventive services. Great idea!
3. Who will be doing the counseling about the “preventive services covered by Medicare” during the annual exam? Let’s hope Medicare puts out a really great handout!
4. Most EMRs will let you load requirements for services based on diagnosis – for example, diabetes. Make sure you are taking advantage of the EMR’s ability to set up protocols for age, diagnosis and risk factors. If you are not on EMR yet, use your appointment schedule or recall system to set reminder appointments to contact patients for their services.
5. Don’t forget your patients on Medicare who are not yet age 65. Run a report to find these patients and flag them to acknowledge that their Medicare services are at different times.
6. Collections at time of service will change too, of course, as most services listed below will not be applied to the deductible. Exceptions are glaucoma screening, diabetes monitoring and education, medical nutritional, and smoking cessation. Patients understandably will be confused, so make sure your check-out staff are crystal clear.
   

Medicare Benefits Beginning January 1, 2011

• Medicare covers a one-time preventive physical exam within the first twelve months of having Part B. The exam will include a thorough review of health, education and counseling about the preventive services covered by Medicare and referrals for other care if needed. No Part B deductible and effective January 1, 2011 you pay nothing if the doctor accepts assignment.

• Abdominal Aortic Aneurysm Screening – People at risk for abdominal aortic aneurysms may get a referral for a one-time screening ultrasound at their Welcome to Medicare physical exam. Effective January 1, 2011 no deductible and no copayment.

• New Annual Wellness Visit – Effective January 1, 2011 Medicare will cover an Annual Wellness Visit that includes a thorough review of health, education and counseling about the preventive services covered by Medicare and referrals for other care if you need it. It is available every 12 months (after first 12 months of Part B coverage) but not within 12 months of receiving either a Welcome to Medicare physical exam or another Annual Wellness Visit. No Part B deductible Medicare pays 100% of the approved amount.

• Cardiovascular Screening Blood Tests - Medicare covers cardiovascular screening tests that check cholesterol and other blood fat (lipid) levels every 5 years. Includes:
  • Total Cholesterol Test
  • Cholesterol Test for High Density Lipoproteins; and
  • Triglycerides Test
  • No Part B deductible Medicare pays 100% of approved amount.

• Diabetes Screening Tests - Anyone enrolled in Medicare identified as high risk for diabetes will be able to receive screening tests to detect diabetes early. Covers up to two screenings each year. Includes:
  • Fasting plasma glucose test
  • Post-glucose challenge test
  • No Part B deductible Medicare pays 100% of approved amount
• Glaucoma Screening – Must be done or supervised by an eye doctor (optometrist or ophthalmologist). Covered annually for:
  • Those with diabetes
  • Those with a family history of glaucoma
  • African-Americans age 50 and older
  • Hispanic-Americans age 65 and older
  • Other high risk individuals
  • Medicare pays 80% of the approved amount after you meet the yearly Part B deductible.
• Bone Mass Measurement - For those enrolled in Medicare at high risk for losing bone mass. Effective January 1, 2011 no Part B deductible Medicare pays 100% of approved amount.

• Screening Mammography (including new digital technologies) – For women age 40 and older enrolled in Medicare:
  • Covered annually
  • No Part B deductible Medicare pays 100% of approved amount beginning January 1, 2011.
• Screening Pap Test & Pelvic Examination (Includes clinical breast examination) – For all women enrolled in Medicare:
  • Covered once every two years for most
  • Covered annually for women at high risk
  • No Part B deductible Medicare pays 100% of approved amount for Pap test and effective January 1, 2011 pays 100% of approved amount for pelvic and breast exam.
• Colorectal Cancer Screening – For all those enrolled in Medicare age 50 and older:
  • Fecal-Occult blood test covered annually No Part B deductible & Medicare pays 100% of approved amount.
  • Flexible sigmoidoscopy once every four years or 10 years after a previous screening colonoscopy No Part B deductible or copayment starting January 1, 2011.
  • Barium enema can be substituted for sigmoidoscopy or colonoscopy No Part B deductible – Medicare pays 80% of the approved amount. You will pay a higher coinsurance if the test is done in a hospital outpatient department.
  • Colonoscopy for any age enrolled in Medicare
  • Average risk – Once every ten years, but not within four years after a screening flexible sigmoidoscopy
  • High-risk – Once every two years
  • No Part B deductible and effective January 1, 2011 Medicare pays 100%.
• Prostate Cancer Screening Tests -For all men enrolled in Medicare age 50 and older:
  • Covered annually
  • Digital rectal exam Medicare pays 80% of the approved amount after the deductible
  • Prostate Specific Antigen (PSA) test
  • No Part B deductible – Medicare pays 100% of approved amount.
• Diabetes Monitoring and Education – Covers Type I and Type II diabetics enrolled in Medicare who must monitor blood sugar (Not paid for those in a nursing home) Covered services:
  • Glucose-monitoring devices, lancets & strips
  • Education & training to help control diabetes
  • Foot care once every 6 months for those with peripheral neuropathy
  • Medicare pays 80% of the approved amount after you meet the yearly Part B deductible.

• Medical Nutritional Therapy – Covered for those with diabetes or kidney disease. Includes diagnosis of special nutrition needs, therapy and counseling services to help you manage your disease. Medicare pays 80% of the approved amount after you meet the yearly Part B deductible.

• Smoking Cessation Services – Medicare will cover up to 8 counseling sessions per year for individuals who have an illness caused or complicated by tobacco use or you take medication affected by tobacco use. Medicare pays 80% of the approved amount after you meet the yearly Part B deductible.

• Flu Vaccination Annually (Medicare pays once per season. You do not have to wait 365 days since your last one.) No Part B deductible you pay nothing if your doctor accepts assignment. My post on billing for the flu shot is here.

• H1N1 Flu Vaccine Medicare covers the administration of the H1N1 flu shot. You cannot be charged for the vaccine. No Part B deductible or co-insurance.

• Pneumococcal Pneumonia Vaccination- Once per lifetime for all enrolled in Medicare. (A doctor may order additional ones for those with certain health problems.) No Part B deductible Medicare pays 100% of approved amount.

• Hepatitis B Shots – Covered for those who are at medium or high risk. Effective January 1, 2011, there will be no Part B deductible and Medicare pays 100%.

The Office of the Inspector General just unveiled their 2011 Work Plan in a remarkably readable and succinct 159 pages. The Work Plan reveals their review targets for the coming year. The entire plan is here, but I’ve excerpted the parts that I thought would be of most interest to MMP readers. Skip to the bottom to get to my top ten pointers for physician practices for 2011.

• Medicare Secondary Payer/Other Insurance Coverage

We will review Medicare payments for beneficiaries who have other insurance. Pursuant to The Social Security Act, 1862(b), Medicare payments for such beneficiaries are required to be secondary to certain types of insurance coverage. We will assess the effectiveness of procedures in preventing inappropriate Medicare payments for beneficiaries with other insurance coverage. For example, we will evaluate procedures for identifying and resolving credit balance situations, which occur when payments from Medicare and other insurers exceed the providers charges or the allowed amounts.

(OAS; W001135317; various reviews; expected issue date: FY 2011; new start)

• Medicare Brachytherapy Reimbursement

We will review payments for brachytherapy, a form of radiotherapy where a radiation source is placed inside or next to the area requiring treatment, to determine whether the payments are in compliance with Medicare requirements. Pursuant to the Social Security Act, 1833 (t)(16)(C), as amended by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), 142, Medicare pays for radioactive source devices used in treatment of certain forms of cancer.

(OAS; W001035520; W001135520; various reviews; expected issue date: FY 2011; work in progress)

• PlaceofService Errors

We will review physician coding of place of service on Medicare Part B claims for services performed in ambulatory surgical centers (ASC) and hospital outpatient departments. Federal regulations at 42 CFR 414.32 provide for different levels of payments to physicians depending on where the services are performed. Medicare pays a physician a higher amount when a service is performed in a nonfacility setting, such as a physicians office, than it does when the service is performed in a hospital outpatient department or, with certain exceptions, in an ASC. We will determine whether physicians properly coded the places of service on claims for services provided in ASCs and hospital outpatient departments.

(OAS; W000935113; W001035113; various reviews; expected issue date: FY 2011; work in progress)

• Coding of Evaluation and Management Services

We will review evaluation and management (E&M) claims to identify trends in the coding of E&M services. Medicare paid $25 billion for E&M services in 2009, representing 19 percent of all Medicare Part B payments. Pursuant to CMSs Medicare Claims Processing Manual, Pub. No. 10004, ch. 12, 30.6.1, providers are responsible for ensuring that the codes they submit accurately reflect the services they provide. E&M codes represent the type, setting, and complexity of services provided and the patient status, such as new or established. We will review E&M claims to determine whether coding patterns vary by provider characteristics.
(OEI; 041000180; expected issue date: FY 2011; work in progress)

• Payments for Evaluation and Management Services

We will review the extent of potentially inappropriate payments for E&M services and the consistency of E&M medical review determinations. CMSs Medicare Claims Processing Manual, Pub. No. 10004, ch. 12, 30.6.1 instructs providers to select the code for the service based upon the content of the service and says that documentation should support the level of service reported. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. We will also review multiple E&M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments.

(OEI; 041000181; 041000182; expected issue date: FY 2012; work in progress)

• Evaluation and Management Services During Global Surgery Periods

We will review industry practices related to the number of E&M services provided by physicians and reimbursed as part of the global surgery fee. CMSs Medicare Claims Processing Manual, Pub. No. 10004, ch. 12, 40, contains the criteria for the global surgery policy. Under the global surgery fee concept, physicians bill a single fee for all of their services that are usually associated with a surgical procedure and related E&M services provided during the global surgery period. We will determine whether industry practices related to the number of E&M services provided during the global surgery period have changed since the global surgery fee concept was developed in 1992.

(OAS; W000935207; various reviews; expected issue date: FY 2011; work in progress)

• Medicare Payments for Part B Imaging Services

We will review Medicare payments for Part B imaging services. Physicians are paid for services pursuant to the Medicare physician fee schedule, which covers the major categories of costs, including the physician professional cost component, malpractice costs, and practice expense. The Social Security Act, 1848(c)(1)(B), defines practice expense as the portion of the resources used in furnishing the service that reflects the general categories of expenses, such as office rent, wages of personnel, and equipment. For selected imaging services, we will focus on the practice expense components, including the equipment utilization rate. We will determine whether Medicare payments reflect the expenses incurred and whether the utilization rates reflect industry practices.

(OAS; W001135219; various reviews; expected issue date: FY 2011; new start)

• Appropriateness of Medicare Payments for Polysomnography

We will review the appropriateness of Medicare payments for sleep studies. Sleep studies are reimbursable for patients who have symptoms consistent with sleep apnea, narcolepsy, impotence, or parasomnia in accordance with the CMS Medicare Benefit Policy Manual, Pub. No. 102, ch. 15, 70. Medicare payments for polysomnography increased from $62 million in 2001 to $235 million in 2009, and coverage was also recently expanded. We will also examine the factors contributing to the rise in Medicare payments for sleep studies and assess provider compliance with Federal program requirements.

(OEI; 000000000; expected issue date: FY 2012; new start)

• Medicare Payments for Sleep Testing

We will review the appropriateness of Medicare payments for sleep test procedures provided at sleep disorder clinics. The Social Security Act, 1862(a)(1)(A), provides that Medicare will not pay for items or services that are not reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member. CMSs Medicare Benefit Policy Manual, Pub. No. 10002, ch. 15, 70, provides CMSs requirements for coverage of sleep tests under Part B. A preliminary OIG review identified improper payments when certain modifiers are not reported with sleep test procedures. We will examine Medicare payments to physicians and independent diagnostic testing facilities for sleep test procedures to determine whether they were in accordance with Medicare requirements.

(OAS; W001035521; W001135521; various reviews; expected issue date: FY 2011; work in progress)

• Excessive Payments for Diagnostic Tests

We will review Medicare payments for highcost diagnostic tests to determine whether they were medically necessary. The Social Security Act, 1862 (a)(1)(A), provides that Medicare will not pay for items or services that are not reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member. We will determine the extent to which the same diagnostic tests are ordered for a beneficiary by primary care physicians and physician specialists for the same treatment.

(OAS; W001135454; various reviews; expected issue date: FY 2011; new start)

• Medicare Part B Payments for Glycated Hemoglobin A1C Tests

We will review Medicare contractors procedures for screening the frequency of clinical laboratory claims for glycated hemoglobin A1C tests. CMSs Medicare National Coverage Determinations Manual, Pub. 10003, Ch. 1, pt. 3, 190.21, states that it is not considered reasonable and necessary to perform a glycated hemoglobin test more often than every 3 months on a controlled diabetic patient unless documentation supports the medical necessity of testing in excess of national coverage determinations guidelines. Preliminary OIG work at two Medicare contractors showed variations in the contractors procedures for screening the frequency of glycated hemoglobin A1C tests. We will determine the appropriateness of Medicare payments for glycated hemoglobin A1C tests.

(OAS; W001135455; various reviews; expected issue date: FY 2011; new start)

• Independent Diagnostic Testing Facilities Compliance With Medicare Standards

We will review selected IDTFs enrolled in Medicare to determine the extent to which they comply with selected Medicare standards. IDTFs received payments of about $860 million in 2009. Federal regulations at 42 CFR 410.33, require IDTFs to certify on their enrollment applications that they comply with 17 standards. Such standards include requirements that IDTFs comply with all of the Federal and State licensure and regulatory requirements that are applicable to the health and safety of patients, provide complete and accurate information on their enrollment applications, and have on duty technical staff members who hold appropriate credentials to perform tests. We will also identify billing patterns associated with IDTFs that were not compliant with selected Medicare standards.

(OEI; 050900560; expected issue date: FY 2011; work in progress)

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• Medicare Providers Compliance With Assignment Rules

We will review the extent to which providers comply with assignment rules and determine whether and to what extent beneficiaries are inappropriately billed in excess of amounts allowed by Medicare requirements. Pursuant to the Social Security Act, 1842(h)(1), physicians participating in Medicare agree to accept payment on an assignment for all items and services furnished to individuals enrolled in Medicare. CMS defines assignment as a written agreement between beneficiaries, their physicians or other suppliers, and Medicare. The beneficiary agrees to allow the physician or other supplier to request direct payment from Medicare for covered Part B services, equipment, and supplies by assigning the claim to the physician or supplier. The physician or other supplier in return agrees to accept the Medicareallowed amount indicated by the carrier as the full charge for the items or services provided. We will also assess beneficiaries awareness of their rights and responsibilities regarding potential billing violations and Medicare coverage guidelines.

(OEI; 000000000; expected issue date: FY 2012; new start)

• Medicare Payments for Claims Deemed Not Reasonable and Necessary

We will review Medicare payments for Part B claims in 2009 that providers note as not reasonable and necessary on claim submissions. The CMS Claims Processing Manual states that providers may use GA or GZ modifiers on claims they expect Medicare to deny as not reasonable and necessary. A recent OIG study found that Medicare paid for 72 percent of pressurereducing support surface claims with GA or GZ modifiers, amounting to $4 million in potentially inappropriate payments. We will determine the extent to which Medicare paid for Part B claims with these modifiers, as well as the types of providers and the types of services
associated with these claims. We will also assess the policies and practices that Medicare contractors have in place with regard to these claims.

(OEI; 021000160; expected issue date: FY 2011; work in progress)

• Medicare Billings With Modifier GY

We will review the appropriateness of providers use of modifier GY on claims for services that are not covered by Medicare. CMSs Medicare Carriers Manual, Pub. No. 143, pt. 3, 4508.1, states that modifier GY is to be used for coding services that are statutorily excluded or do not meet the definition of a covered service. Beneficiaries are liable, either personally or through other insurance, for all charges associated with the provision of these services. Pursuant to CMSs Medicare Claims Processing Manual, Pub. No. 10004, ch. 1, 60.1.1, providers are not required to give beneficiaries advance notice of charges for services that are excluded from Medicare by statute. As a result, beneficiaries may unknowingly acquire large medical bills for which they are responsible. In FY 2008, Medicare received over 75.1 million claims with a modifier GY totaling approximately $820 million. We will examine patterns and trends for physicians and suppliers use of modifier GY.

(OEI; 000000000; expected issue date: FY 2012; new start)

To Re-Cap, here’s YOUR Work Plan for 2011:

1. If you’re not using the MSP questionnaire in your practice for Medicare patients, start. Here’s a fact sheet (pdf) to get up to speed.
2. If your practice provides brachytherapy, ensure that you are following the MIPPA guidelines for diagnoses.
3. Check your place of service codes and make sure they are absolutely correct on all counts.
4. Don’t wait for Medicare to audit your documentation, audit it yourself or hire a professional to audit for you. Make sure the coding is correct for what was documented. If you are using an EMR, beware of over-dependence on templates! If your practice performs surgery, track that global period like a hawk and make sure you understand when you may or may not bill an E & M code during the global period.
5. Sleep studies – if you do them, make sure the diagnosis and medical necessity support them.
6. Does your practice provide imaging services? Are your utilization rates above the national average for your specialty? Was the service medically necessary? It’s a good time to find out. Oh, and don’t forget to disclose any financial interest your practice has in any imaging center and to provide the patient options for other centers.
7. Hemoglobin A1c – first we weren’t doing enough, now we’re doing too many! Medicare will pay for a hemoglobin A1c every three months for diabetic patients. Make sure to have an electronic or manual system in place for tracking this. Most practices use a diabetic flow sheet in a paper chart – start using one if you aren’t now.
8. Do you have an IDTF? Do you comply with the 17 standards you certified upon enrollment?
   
9. Are you “par” (participating) or “non-par” (non-participating) with Medicare? Are you collecting the appropriate amount from Medicare patients?
10. My favorite – the ABN – Advanced Beneficiary Notice. Are you using the ABN correctly and advising Medicare patients of their rights? Or are you just telling them to “Sign here, please”? Here’s an article about ABNs published on MMP.

Will you be called to task in 2011 for the above 10 items?

There is tremendous pressure on Medicare and other government-sponsored payers to weed out fraud and eliminate waste. It is the responsibility of the professional administrator to protect the practice from risk, as well as guide the office in all things legal and ethical. You may be the only one in your practice who understands the liability that non-compliance can expose the practice to – make sure your practice does it right!

Recently the Mayo Clinic launched its Center for Social Media and announced the names of 13 well-suited social media stars to sit on its volunteer external advisory board. An additional 12 people will be chosen from nominations and applications. This post is my application.

I’ve been writing about social media in healthcare since I read Phil Bauman’s groundbreaking “140 Healthcare Uses for Twitter” almost two years ago. The exciting potential for social media in healthcare settings is also cause for apprehension among administrators and clinical staff. What once was so hidden, so cloistered, so proprietary, so inscrutable is now emerging into the sunlight and is becoming collaborative, transparent, open, consumerist and available. It’s refreshing and scary.

I started my career in healthcare as a temp receptionist in an orthopedic office over 25 years ago. I have been a consultant, a private practice manager of small practices, a Chief Operating Officer of a very large practice. I’ve worked with physicians and care providers of all kinds in settings both rural and urban, for-profit and not-for-profit, and I have done most everything in healthcare except serve on the Mayo Clinic Center for Social Media Advisory Board. (hint)

For the talent portion of my program, I will be interviewing myself live.

Q: Tell us something interesting about yourself.
A: I was Butler County (PA) Junior Miss of 1976 (a brains pageant with some physical fitness thrown in for good measure.)

Q: What is your greatest regret?
A: I wish I had taken touch typing in high school.

Q: Are you a cat person or dog person?
A: A cat person but I get along well with dogs.

Q: Favorite charity?
A: My brother is a missionary in Ukraine and his organization (www.muchhope.org) helps disadvantaged children with food, clothing, healthcare and education.

Q: How do feel about shameless plugs?
A: I find them tacky, but ultimately necessary.

Q: What social media apps do you use?
A: Twitter, Facebook, LinkedIn, YouTube, GoAnimate, Wellsphere, WordPress Blog

Q: What is your favorite social media app for healthcare?
A: Ummm. Pass.

Q: Why you?
A: Why not me? I’m a patient, a mom, a wife, a healthcare manager, a social media groupie, a blogger, a reader, a thinker, a cartoonist, a learner, a writer, an observer of life. Every board needs me.

Q: What is the future of social media in healthcare?
A: Mobile, for sure, and I think QR codes have tremendous promise.

Q: What is your favorite social media app for healthcare?
A: Facebook. The potential is unlimited.

Q: Last question: “healthcare.” One word or two?
A: One.

NOTE: If my beloved readers wish to support my appointment to the MCCSM Advisory Board, please Tweet about me with the hashtag #mccsc, leave a comment on the MCCSM blog here, or send an email of support to socialmediacenter@mayo.edu. Thank you!

Update posted 8-14-2012: For flu shot updates for the 2012-2013 influenza season, click here.

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Update posted 9-22-2011: For flu shot updates for the 2011-2012 influenza season, click here.

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Update Posted 12-20-2010 – Medicare posted code changes for flu vaccines billed to Medicare after January 1, 2011. Click here for the changes.

For dates of service on or after September 1, 2010, the corrected Medicare Part B payment allowance for CPT 90655 is $14.858.

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It’s that time again, and despite delayed deliveries to some hospitals and practices, the word on the street is that there will be enough flu vaccine (171 million doses) this year for all who want a flu shot.

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The Center for Disease Control (CDC) recommends that everyone 6 months and older get a flu shot. Each year’s flu vaccine cocktail is unique and this season’s (2010-2011) flu vaccine will protect against three different flu viruses: an H3N2 virus, an influenza B virus and the H1N1 virus that caused so much illness last season.

The Affordable Care Act and the Influenza Vaccine

Just in time for flu season is the Affordable Care Act’s emphasis on preventive care. The ACA states:

This influenza season, children 6 months through 18 years, certain high-risk adults 19 through 49 years, and adults 50 years and older who are enrolled in new group and individual health plans will be eligible to receive the seasonal flu vaccine without cost-sharing when provided by an in-network provider. Beginning in the plan year that starts after March 2, 2011, all adults 19-49 years of age will be eligible to receive the seasonal flu vaccine with no cost-sharing requirements when provided by an in-network provider.

This is great news for the patient and for healthcare in general. You may consider it good news or bad news, depending on your view of the whole flu shot process. Here’s how it works in many practices:

1. The vaccine is ordered in the spring, with everyone trying hard to guess correctly how many patients will want flu shots in 6 months.
2. The vaccine arrives in the fall and the first hurdle is pricing it, as you will have to decide how much to mark it up to cover the cost of the ordering, handling and stocking and possibly a teeny profit.
3. The administration of the vaccine also has to be priced to cover the cost of supplies (syringe, alcohol swab, sometimes a bandaid, printed Vaccine Administration Sheets) and the cost of labor (assessing the patient to make sure they can get the flu shot, giving the shot, and documenting the lot numbers in case of a recall.)
4. The next decision is disbursement. Do you have a flu shot clinic and have people get in line for the flu shot, or do you take flu shot appointments, do you give flu shots during regular appointments, or some combination thereof? What about drive-through flu clinics? Do people sit in the parking lot for 15 minutes to make sure there are no bad after-effects? How do you let patients know about your flu shot plans without costly postcards or advertisements?
5. Then, there is policy setting for patients whose insurance covers the flu shot and for patients whose insurance does not. Do you collect and refund if necessary, or do you not collect and bill the patient after insurance responds (Jaws theme music here, please.)

Does Medicare pay for flu shots?

Medicare pays 100% of the allowable for influenza vaccine (and pneumococcal vaccines) and the administration of the vaccines without any out-of-pocket costs to the patient. One flu vaccine is allowable per flu season, but Medicare will pay for a second flu shot if a physician determines and documents the medical necessity. A physician’s order is not necessary and a physician’s supervision is not necessary – that’s why patients are able to get a flu shot at the drugstore. A patient can receive a flu shot twice in one calendar year by getting a flu shot late in one season and getting a flu shot early in the next season.

How should a provider that is not enrolled in Medicare bill for the flu vaccine?

CMS typically does not allow non-enrolled providers to treat Medicare beneficiaries, however, CMS is allowing them to give flu shots this year. Beneficiaries can receive a flu vaccine from any licensed physician or provider. However, the billing procedure will vary depending on whether the physician or provider is enrolled in the Medicare Program.

If you are not a Medicare-enrolled physician or provider who gives a flu vaccine to a Medicare beneficiary, you can ask the beneficiary for payment at the time of service. The beneficiary can then request Medicare reimbursement. Medicare reimbursement will be approximately $18 for each flu vaccine.

To request reimbursement, the beneficiary will need to obtain and complete form CMS 1490S. So the beneficiary may receive reimbursement, you will need to provide the beneficiary with a receipt for the flu vaccine that has the following information written or printed on it:
The doctors or providers name and address
Service provided (flu vaccine)
Date flu vaccine received
Amount paid

What codes are used for flu shots?

For flu vaccine and vaccine administration, the following codes are used.

Effective September 1, 2009, (no 2010 changes have been announced) the Medicare Part B payment allowances for influenza vaccines are as follows:

• For HCPCS 90655, the payment will be $15.447: Influenza virus vaccine, split virus, preservative free, for children 6- 35 months of age, for intramuscular use
• For HCPCS code 90656, the payment will be $12.541: Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years and above, for intramuscular use
• For HCPCS code 90657, the payment will be $15.684: Influenza virus vaccine, split virus, for children 6-35 months of age, for intramuscular use;
• For HCPCS code 90658, the payment will be $11.368: Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use
• HCPCS 90660 (FluMist, a nasal influenza vaccine) may be covered if the local Medicare contractor determines its use is medically reasonable and necessary for the beneficiary. When payment is based on 95 percent of the Average Wholesale Price (AWP), the Medicare Part B payment allowance for CPT 90660 is $22.316 (effective September 1, 2009).

G0008 is the Medicare HCPCS for Administration of influenza virus vaccine, including FluMist. Other payers usually require use of 90465, 90466, 90467, 90468, 90471, 90472, 90473 or 90474 for administration of the vaccine.

The associated ICD-9 codes for flu shots are:

V04.81 Influenza
V06.6 Pneumococcus and Influenza (both vaccines at one visit)

Other resources:

• Get your practice and your staff ready for flu season by following the guidelines I write about here.
• Free downloads from the CDC here.
• MedLine Plus Articles, Downloads and Resources here
• Article: Mandating Influenza Vaccine – One Hospital’s Experience (MedScape free account required)
• National Foundation for Infectious Diseases: Influenza
  
• National Influenza Vaccine Summit: Prevent Influenza
• Vaccine Education Center at Children’s Hospital of Philadelphia (CHOP) -Influenza: What You Should Know (pdf) EnglishSpanish
• Medicare Preventive Services Quick Reference Information Chart: Medicare Part B Immunization Billing (Influenza, Pneumococcal, and Hepatitis B) is available here (pdf.)
• For information on roster billing (billing for many patients at one time) see the Medicare Claims Processing Manual for Preventive and Screening Services (Chapter 18) here (pdf) Section 10-3.

NOTE: Beneficiaries have been advised to contact the Inspector General hotline at 1-800-HHS-TIPS (1-800-447-8477) to file a complaint if they believe their physician or provider charged an unfair amount for a flu vaccine.

Related articles

• Providing and Billing for the Flu Vaccine: Guidance from CMS, the CDC and the Affordable Care Act (managemypractice.com)

In the book Primal Leadership Realizing The Power Of Emotional Intelligence, the authors Goleman, Boyatzis, and McKee discuss the importance of both personal competence (how we manage ourselves), and social competence (how we manage relationships), relative to achieving long-term success. Personal competence involves both self-awareness and self-management. Social competence deals with social awareness and relationship management.

Many people reading this may be wondering how these concepts link to business success. What does this have to do with achieving a positive bottom-line? Arent these the soft skills that are nice to have, but not essential to build profitability?

I recognize that many people want good hard data to back up the idea that leading with emotional intelligence is critical to build and sustain a business. Rather than present you with productivity and turnover data, employee satisfaction statistics, etc. I ask that you reflect on the following questions and come up with your own conclusion:

1. What happens when a leader yells and bangs the table when something goes wrong? What impact does this have on others? Who wants to do business with them?
2. What happens when a top performer is taken for granted, and not sincerely acknowledged?
3. What happens when a member of your team is going through a difficult personal situation and you dont take the time to listen and show empathy?
4. What happens when a leader says his/her employees are the most important asset, but rarely shows it?
5. What happens when the boss asks a direct report to get him/her a cup of coffee and never reciprocates?
6. What happens when a leader does not build team unity, but allows conflict amongst team members to grow?
7. What happens when a leader fails to build the competence and confidence of team members?
8. What happens when the leader is not aware of his/her strengths and limitations?
9. What happens when the leader is not able to handle adversity and change?
10. What happens when the leader is not transparent in communications, giving
others the feeling that the truth is being withheld?

The following are a few suggestions to enhance your emotional intelligence:

1. Keep disruptive emotions and impulses under control.
2. Show all employees that you value their contributions and respect them as individuals. Find ways to recognize and reward outstanding performance.
3. Pay attention to others emotions, understand their perspective, and show an interest in helping them whenever possible.
4. Recognize and meet others needs be willing to serve them.
5. Model what it means to be a good team player. Develop team standards and hold yourself and others accountable for living these behaviors.
6. Know your strengths and limits, and surround yourself with individuals with complimentary strengths. Great leaders know they are only as good as the team they surround themselves with.
7. Develop team members by giving honest and timely feedback, and offering guidance to help them to reach their full potential.
8. Demonstrate the ability to be flexible in handling changing situations. Help others to work with you to overcome obstacles, and move in a new direction when necessary.
9. Display transparency through communications and behaviors that demonstrate honesty, integrity, and trustworthiness.
10. Be optimistic, and help others to see both organizational and individual potential.

These are just a few issues to reflect on. These are important to employees, especially top performers. When I am asked about what I believe to be an acceptable turnover rate I always answer, It depends on whos leaving, and why they are leaving.

If you truly believe that employees make the difference, then you will want to make sure that all the above questions are addressed in a positive way.

The price an organization pays when it loses the heart and soul of its employees is beyond measure. Leaders who dont take these questions seriously, and violate the underlying principles, will lose their followers. Without followers, no real leadership exists. Without followers, your business becomes a house of cards ready to crumble. Its only a matter of time before you see an erosion of market share. If your competitors embrace these principles, and thus have loyal followers, they will deliver exceptional service, and develop more innovative products and services. I have witnessed CEOs and other executives removed because of a lack of emotional intelligence.

Creativity and innovation are unleashed by leaders who demonstrate high integrity, compassion, and show they truly care about their employees.

Leading with emotional intelligence makes good business sense. It is not a soft skill its the real truth.

Bob Cooper is the founder and president of RL Cooper Associates, an innovative healthcare organizational and management consulting firm. With over twenty-five years experience in people and organizational development, Mr. Coopers focus is placed on identifying strategies that maximize organizational effectiveness and fundamental transformation by enabling individuals and groups to reach their full potential. In addition to Heart and Soul in the Boardroom, Mr. Cooper is the author of Huddle Up Creating and Sustaining a Culture of Service Excellence, and Leadership Tips To Enhance Staff Satisfaction and Retention. Mr. Cooper holds an MS in Human Resource Management and a BA in Economics. He is also a member of Strathmores Whos Who. Bob can be contacted at rlcooperassoc@aol.com.

ELIGIBLE PROVIDERS

Complete EHRs for Eligible Providers (CCHIT)

1. ABEL Medical Software, Inc. for ABELMed EHR – EMR/PM, version 11
2. Allscripts, Allscripts Professional EHR, version 9.2
3. Aprima Medical Software, Inc. for Aprima, version 2011
4. athenahealth, Inc. for athenaclinicals, version 10.10
5. CureMD Corporation for CureMD EHR, version 10
6. The DocPatientNetwork.com for Doctations, version 2.0
7. Epic Systems Corporation for EpicCare Ambulatory – Core EMR, version Spring 2008
8. GE Healthcare for Centricity Advance, version 10.1
9. gloStream, Inc. for gloEMR, version 6.0
10. Intuitive Medical Software for UroChartEHR, version 4.0
11. MCS – Medical Communication Systems, Inc. for iPatientCare, version 4.0
12. Medical Informatics Engineering for WebChart EHR, version 5.1
13. meditab Software, Inc. for IMS, version 14.0
14. NeoDeck Software for NeoMed EHR, version 3.0
15. NextGen Healthcare for NextGen Ambulatory EHR, version 5.6
16. Nortec Software Inc for Nortec Ambulatory EHR, version 7.0
17. Pulse Systems for 2011 Pulse Complete EHR, version 2011
18. SuccessEHS for SuccessEHS, version 6.0

EHR Modules for Eligible Providers (CCHIT)

1. Allscripts for Allscripts Peak Practice, version 5.5
2. eClinicalWorks LLC for eClinicalWorks, version 8.0.48
3. NexTech Systems, Inc. for NexTech Practice 2011, version 9.7
4. nextEMR, LLC for nextEMR, LLC, version 1.5.0.0
5. Sammy Systems for SammyEHR, version 1.1.248
6. Universal EMR Solutions for Physician’s Solution, version 5.0
7. Vision Infonet Inc., for MDCare EMR, version 4.2
8. WellCentive for WellCentive Registry, version 2.0

Complete EHRs for Eligible Providers (Drummond)

1. ChartLogic, Inc for ChartLogic EMR 7, version not noted

EHR Modules for Eligible Providers (Drummond)

1. ifa united i-tech Inc. for ifa EMR, modules 170.302.A-J, 170.302.M, 170.302.O-V (specialized to ophthalmology)
2. QRS INC. for PARADIGM, version 8.3, modules 170.302.A-W, 170.304.A, 170.304.C-J

HOSPITALS

Complete EHRs for Hospitals (CCHIT)

1. Epic Systems Corporation for EpicCare Inpatient – Core EMR, version Spring 2008

EHR Modules for Hospitals (CCHIT)

1. Allscripts for Allscripts ED, version 6.3
2. Health Care Systems, Inc. for HCS eMR, version 4.0
3. PeriGen for PeriBirth, version 4.3.50
4. Prognosis Health Information Systems for ChartAccess, version 4
5. T-System Technologies for T-SystemEV, version 2.7
6. Wellsoft Corporation for WellsoftEDS, version 11