The CLIA regulations require a facility to be appropriately certified for each test performed. To ensure that the Medicare and Medicaid programs only pay for laboratory tests categorized as waived complexity under CLIA in facilities with a CLIA certificate of waiver, laboratory claims are currently edited at the CLIA
certificate level.
All CLIA waived tests here (pdf.) – updated July 6, 2010
Here’s your pop quiz:
The NCCI edits are:
A. pairs of services that should not be billed by the same physician for the same patient on the same day.
B. definition refinements for HCPCS codes.
C. diagnosis codes (ICD-9) that cannot be billed together on a CMS 1500 claim.
The answer is below the picture.
- Image by sxyblkmn via Flickr
If you answered “A”, you’re on top of your game! The King of the National Correct Coding Initiative (NCCI) quarterly analysis is Mr. Frank Cohen and he provides that analysis free of charge for all. Thank you, Frank! With his analysis, you have the opportunity to see what’s changed and what’s new, to tweak your system to catch the pairs, and to make sure you are providing the right care at the right time as well as maximizing your reimbursement.
The Cohen Report:
In summary, there are 16,843 new edit pairs, bringing the total number of active edit pairs to 653,718. Six of these are backdated to an effective date of January 1, 2010. The majority of these (75.17%) are associated to the edit policy “Misuse of column two code with column one code” with 12.82% associated to “Standard preparation / monitoring services for anesthesia”. There are 6,042 unique Column 1 codes and 274 unique Column 2 Codes within the new edits.
I have posted my analysis worksheets for those interested in the details. Go to www.frankcohen.com and click on the Download tab.
I don’t know about you but I am emotionally exhausted thinking about and worrying about the on-again off-again cuts in Medicare fees for physicians.
Here’s the scoop: late Thursday evening, June 24, 2010, the House of Representatives passed the ” Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 (H.R. 3962)” which includes a delay in the 21+% fee cut. Because the same legislation was already passed by the Senate, it now goes to the President for his signature and it becomes law. It is anticipated that this will happen quickly and CMS will have the MACs start processing new claims with dates of service of June 1, 2010 and later at the 2009 fee schedule plus a 2.2% increase. The MACs will also have to reprocess the claims already paid for dates of service June 1, 2010 and later that were processed with 2010 fee schedule and that big fat cut.
Q: What should we be doing for the next 5 months and 6 days?
- Image by Getty Images via @daylife
A: Have someone in your practice take a video of your providers introducing themselves, telling how many Medicare patients they have and how they can’t afford to see Medicare patients unless the SGR formula is replaced with something that works. The video doesn’t have to be slick – just real. Send it to your senators and representatives. Send it your local TV news. Post it on YouTube. Imagine hundreds of thousands of providers introducing themselves and talking about their patients. It would be powerful.
UPDATE: On June 24, 2010 the House and Senate passed legislation to further delay the Medicare cuts until November 30, 2010. More here.
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Congress has yet to pass a bill delaying the June 1, 2010 21.2% reduction in physician reimbursement, but most believe it will happen and be effective retroactively.
CMS has said it is anticipating a further delay in Medicare fee schedule cuts, so they have “instructed contractors to hold claims containing services paid under the MPFS for the first 10 business days of June.”
More information on my post here.
Stay tuned!
CMS held a two-hour Open Door Forum today and there was so much good information shared that I thought I’d pass my notes from the call along to you.
New EFT Form
The revised EFT (Electronic Funds Transfer) authorization form 588 is available here (pdf.) The old form will still work for a few months longer before it becomes invalid.
Changes to the Medicare Program Integrity Manual
The Program Integrity Manual (publication 100-80) will have revisions related to the changes in provider enrollment. The online-only manual here will have content moved from Chapter 10 to Chapter 15 and the provider enrollment information will be easier to understand. 
The Question on Everyone’s Lips
How do I know if I’m listed in PECOS (Provider Enrollment and Chain/Ownership System) and how do I know if others are listed in PECOS? A new downloadable file is now available here (12,000 pages!) and everyone listed in this Ordering/Referring file has approved enrollment status. Anyone not appearing on this list is not in approved status, or has opted completely out of the Medicare program.
Advanced Diagnostic Imaging
Beginning in January 2012, all diagnostic magnetic resonance imaging (MRI), computed tomography (CT), and nuclear medicine imaging such as positron emission tomography (PET) must be performed in a facility accredited by the American College of Radiology (ACR), The Joint Commission (TJC) or the Intersocietal Accreditation Commission (IAC) for the technical component of the test to be reimbursed by Medicare. This rule does not apply to x-rays, ultrasound, fluoroscopy, mammography or DEXA scans and does not apply to any professional component.
Hospital Revalidations
Hospitals not enrolled in PECOS or not receiving EFT (Electronic Funds Transfer) will be contacted by CMS in an attempt to get all hospitals revalidated.
PECOS (pronounced “pay-cose”)
CMS recommends that anyone with questions or just getting started in PECOS read the “Getting Started Guide”, of which there are two versions, both available here in pdf form. One is for providers and one is for suppliers of DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies.) You need to know your corporate structure before getting started because the business must enroll before the providers can assign benefits to the business. The 855I is for individual/solos providers and the 855B is for non-individuals (multiple owners) billing Medicare Part B and assigning benefits to a legal entity/corporation. Dentists and pediatricians who order or refer services for Medicare patients are required to have an enrollment record in the PECOS. Residents and interns are exempt from the enrollment requirement, but an attending physician needs to be identified on the claim when a service is ordered or referred. The main page for enrollment is https://www.cms.gov/MedicareProviderSupEnroll/
Two Ways to Get Into PECOS
One is to complete the paper form in BLUE INK (and if time is of the essence CMS suggests that you use the paper form) and let the MAC enter it into PECOS for you. The other is to use the internet-PECOS system directly, and sign, date and mail the certification statement to complete the process. Submit the participation form or EFT form if required. The certification form for the paper process is NOT the same as the certification from for the internet-PECOS process.
What is the 30-day rule?
The 30-day rule states that you can bill for services provided to Medicare patients up to 30 days prior to your filing date. The filing date is the date your enrollment is accepted, not the date you mailed it. Online it will say “Status Approved”, and you will receive an email, and then a letter confirming it. You will appear on the Ordering/Referring file on the CMS website.
What happens to payments for patients that were referred by a provider not enrolled on PECOS?
Even though you are enrolled, if the referring physician is not enrolled, you will not be paid for that patient’s services. However, if that referrer becomes enrolled, you can resubmit the claim and it will be paid.
What happens on July 6, 2010?
July 6, 2010 is the compliance date for Part A providers (hospitals, skilled nursing homes and home health agencies) and Part B providers (physicians, ambulance) must be enrolled in PECOS as ordering/referring physicians for payments to be made.
What happens on July 13, 2010?
DMEPOS (pronounced “demmy-pos”) providers must be enrolled in PECOS to receive Medicare payments.
What should be done if a provider leaves a group?
The provider or his Authorized Official (CEO, CFO, Manager) should file a 855R or make the change in PECOS as soon as possible.
Why do provider offices still request UPINs from our office?
Unclear. UPINs were no longer required as of May 23, 2008. The NPI is the only number accepted on Medicare claims.
Should the information submitted on a 855 be the same information in PECOS?
Yes, if it isn’t, contact the Help Desk. Their toll-free number is 1-866-484-8049 and their e-mail address is eussupport@cgi.com.
For more information on the nuts and bolts of PECOS, see my post here.
Physicians and “eligible” providers received a jolt today in the May 5, 2010 Federal Register as the date for enrollment in PECOS was moved up (pending the comment period and any changes resulting from the comment period) six months for providers that order or supply durable medical equipment (DME) for Medicare patients. Instead of the January 3, 2011 date previously announced by CMS, the Patient Protection and Affordable Care Act (Affordable Care Act or PPACA) has provisions to move the go-date to July 6, 2010, just 60 days away.
What does this mean to you? Unless something changes based on public comments, beginning July 6, 2010:
- Providers with a National Provider Identifier (NPI) must include it on their Medicare and Medicaid enrollment applications and claims.
- Providers of medical items/other items/services and suppliers that qualify for a National Provider Identifier (NPI) must include their NPI on all applications to enroll in the Medicare and Medicaid programs AND on all claims for payment submitted under the Medicare and Medicaid programs.
- The ordering/referring supplier must be a physician or an eligible professional with an approved enrollment record in the Provider Enrollment Chain and Ownership System (PECOS) thus changing the previously reported January 3, 2011 date given by CMS.
- Claims that do not meet these requirements will be rejected by Medicare contractors.
You can read the rule in its entirety here.
Want to read the comments on this interim final rule when they are published? Go here.
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HEALTHCARE BILL IMPACT ON INDIVIDUALS AND RAGE
A number of people asked me about the impact of health reform on them as individuals. Here is a great story from the Atlanta Journal-Constitution that takes specific examples of individuals and families and speculates on how the new bill(s) will impact them.
For 2010, the changes are minimal:
- Dependent children may be covered by their parents’ health insurance policies until age 26.
- A high-risk insurance pool will open for people with pre-existing conditions who have been uninsured for six months.
- In 2011 Medicare will pay for an annual checkup, and deductibles and co-payments for many preventive services and screenings will be eliminated. The Medicare prescription drug doughnut hole will gradually narrow every year until it is eliminated in 2020. People in the “doughnut hole” could receive a $250 rebate this year.
I have to say that I’ve been dumbfounded by the fury raised over the passage of the new healthcare legislation. I realize that the bills separate people into winners (uninsured, providers with uncompensated charity care, patients with pre-existing conditions, Medicare patients, providers who see Medicaid patients, families with adult children, etc.) and losers (companies who have to pony up more money for their retired employees, insurance companies, illegal immigrants, high wage earners, etc.), but this story placed the fury into a different perspective for me. It’s a good read.
CONCIERGE PRACTICES
What does healthcare reform mean for the physician practice? Many are predicting the rise of concierge practices (also called boutique medicine, retainer practices, VIP medicine and cash practices) as physicians find they cannot survive if their patient population is predominantly Medicare, Medicaid and uninsured patients. Concierge practices fall into two categories:
- The first operates on an insurance+ model, which means that the practice accepts and files the insurance for the patient, but also requires an additional out-of-pocket fee of anywhere from $1500 to $1800 per year to be a patient of the practice. The fee is to cover services that Medicare and commercial insurance do not, such as physicals, phone consultations, wellness counseling and patient education.
- The second operates on a strictly cash basis and the practice does not accept or file any insurance for the patient. The patient pays a flat fee per year for care (usually in the $5,000 to $15,000 range) and all primary care is provided for that amount. The patient still needs to carry insurance for prescriptions, hospital services and sub-specialist services. Imagine being a manager in this type of practice – no pre-authorizations, no insurance department, no eligibility checking, no refunds…
Concierge medicine has not been around that long, but it is growing in popularity by leaps and bounds. The first acknowledged concierge practice was formed in 1996 in the Pacific Northwest. In 2002, CMS (Centers for Medicare and Medicaid) published a memo stating that physicians may enter into retainer agreements with their patients as long as these agreements do not violate any Medicare requirements. In 2003, the Department of Health and Human Services ruled that concierge medical practices are not illegal. Today, there are approximately 5,000 physicians using the concierge model in the United States today.
MEDICARE CUTS, MEDICARE CLAIMS AND DON BERWICK
Shortly after all the shouting and voting on healthcare reform was over, Congress recessed for two weeks leaving the controversy over the 21.5% cuts required by the SGR formula still unsettled. CMS has advised the MACs to again hold claims for services provided from April 1 to April 10 to give Congress a chance to get back to work and back to voting for an additional delay (or not) for the cuts. If the cuts are allowed to stand, many physicians will start making their own cuts by minimizing the number of Medicare and Medicaid patients they will see.
Amidst this craziness, a voice of sanity is heard and it is Donald Berwick, MD, current President of the Institute for Healthcare Improvement (IHI) and probable Obama pick for the head of CMS. If you don’t know Don Berwick or the IHI, click here to read an interview with him about the IHI’s “100,000 Lives Campaign” or watch the video below of him speaking about the dimensions of quality. Good stuff!
The CMS (Centers for Medicare and Medicaid Services) developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The CMS developed its coding policies based on coding conventions defined in the American Medical Association’s CPT manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. The CMS annually updates the National Correct Coding Initiative Coding Policy Manual for Medicare Services (Coding Policy Manual). The Coding Policy Manual should be utilized by carriers and FIs as a general reference tool that explains the rationale for NCCI edits.
Carriers implemented NCCI edits within their claim processing systems for dates of service on or after January 1, 1996. More information here.
Version 16.1 of the CCI edit database is scheduled to be effective on April 1, 2010. There are 2,054 new edit pairs effective for this release. 35 of these are effective retroactive to October 1, 2009. This means that if you billed for and were paid on one or more of these retroactive edits, you may be subject to repayment.*142 edit pairs are reported as terminated (no longer effective) for this release. Four are terminated retroactive to December 31, 2005; four are retroactive to December 31, 2006 and 76 are shown as terminated retroactive to December 31, 2007. I guess this means that if you were denied due to a CCI edit pair during these periods, you should be able to resubmit the claim and get paid.*You can expect 1,947 changes with respect to the modifier indicator with 1,892 going from an indicator of 0 (no modifier permitted) to an indicator of 1 (modifier permitted). 55 edit pairs report a change in the modifier indicator from a 1 to a 0.*In total, there are 1,337 duplicate edit pairs in the database. These are records that were made effective at one point, then terminated and then made effective again. There are also currently 5,309 swapped pairs. These are edit pairs that were introduced in one order (i.e., 99350 as column 1 and 96416 as column 2), terminated and then re-activated in the opposite order (i.e., 96416 as column 1 and 99350 as column 2).
NOTE: On May 5, 2010 it was announced that the date would be moved forward to July 6, 2010, unless changes are made through public comment. See my May 5 post here.
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A collective sigh of relief was heard across the land as it was revealed today during the CMS Open Door Forum that the requirement for providers to be enrolled in PECOS has been delayed until January 3, 2011.
Part B MACs (Medicare Administrative Contractors) will be sending revalidation letters to all providers who have not updated their Medicare enrollment since November of 2003, asking them to submit a paper enrollment form or to use the electronic enrollment system PECOS (Provider Enrollment, Chain and Ownership System.) This proactive stance on the part of CMS should help the many managers who have been desperately trying to determine if their providers are in PECOS or not.
An audio recording of today’s call will be available on the ODF website here and will be accessible for downloading on or around Monday March 1, 2010 and available for 30 days.
For automatic emails of Open Door Forum schedule updates (E-Mailing list subscriptions) and to view Frequently Asked Questions click here.
