Ultimately, the focus is turning to clinical quality measure data collection which will shift payment methodology to performance improvement. Clearly, the slow migration has begun to establish a pay-for-performance reimbursement system where clinical data will help drive quality improvement in health care. CMS is required to develop a plan by 2010 outlining how to integrate the PQRS measures with the EHR meaningful use incentive program. The 2011 proposed rule specifically sought comments on how best to align the two incentive programs and stated:

“In an effort to align PQRI with the EHR incentive program, we propose to include many American Recover and Reinvestment Act (ARRA) core clinical quality measures in the PQRI program to demonstrate meaningful use of EHR and quality of care furnished to individuals. We propose the selection of those measures to meet the requirements of planning the integration of PQRI and EHR reporting.”

Although claim based reporting is still allowed, CMS has reported there is only a 50% success rate (in 2009), while using a registry the success rate jumped to 90%. What’s the better option of the two? Both have negatives and positives. See the chart (as printed in AAPC) below. Decide which will work best for your practice.

To learn more about PQRS codes, go to: www.cms.ggov/PQRI/15_MeasuresCodes.asp#
Go to the link labeled “Additional 2011 Physician Quality Reporting System Measure Documents” – open 2011 PQRS measures groups specifications manual.

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FDA regulations direct providers to monitor a patient for six hours after the initial dose of Gilenya because of potential bradycardia or AV block. And, because it is newly approved, there isn’t a specific code for this service.

For now, you will report the appropriate level E/M code (99212-99215 – documentation dependent) and the prolonged visit code 99354 for the first hour, then 99355 for each addition 30 minutes. Your documentation must clearly indicate the time units and any exam you performed during this time period.

Because Gilenya is an oral medication, payers consider it ‘self-administered’; therefore will not reimburse you for providing the medication. Some practices write scripts and have the patient bring the medication to the office; others will refer the patient to an infusion center or provide the service in an outpatient hospital setting if their office is not prepared to deal with the potential side effects.

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CMS has announced that effective April 4, 2011; they will recognize both Cardiac Electrophysiologists and Sports Medicine specialties with distinct designations.

The new specialty codes:

  • 21 Cardiac Electrophysiology
  • 23 Sports Medicine

The EP designation will allow for two cardiologists (the EP with additional training) to treat the same patient with the same diagnosis, but each will provide different services.

Sports Medicine will cover a much broader spectrum that includes such specialties such as orthopaedics, cardiology and primary care, according to the Academy of Sports Medicine.

The new designations will allow, under Medicare rules, these physicians to bill a new patient visit, if they are part of a group practice and the patient has been seen by another member within the same tax ID. If however, the physician with the new designation has seen the patient within the last 3 years, he/she must report an established patient visit.

We will be updating all provider enrollments for those clients who hold these specialty designations. If we need additional education information and/or copies of certificates, we will contact you.

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Preventative Care Wellness Visit Code

On March 8th, 2011, posted in: Industry News by

If you are treating patients specifically for the annual/preventative care physical please use the appropriate wellness visit code. If you are only performing a ‘preventative care’ visit some carriers (Amerihealth and BS Alabama) now what the modifier ‘33’ appended to the claim.


Commercial Carriers

G0438 – 1st annual visit

99365    18-39 years

99367    65+ years

HOWEVER, if you are also providing a ‘medical’ service, you may bill and E/M 99201-99205 – 99212-99215 for the condition you are treating. We will append the appropriate modifier. Your job is to make sure you clearly indicate both services in your documentation.

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Medicare Annual Wellness Visit

On March 8th, 2011, posted in: Industry News, Tips by

Don’t say ‘yippee’ yet, but CMS confirmed that local Medicare Contractors have the ability to determine if they will allow LPN’s and RN’s to perform annual wellness visits. That’s the scoop from the February 22nd CMS open door forum. The question was posed, “Can the LPN perform the entire annual wellness visit?” The answer:” YES, an RN or LPN can perform the visit. They need to be under the direct supervision of a physician and the state license needs to allow for them to do al the components of the service.” (www.wpsmedicare.com/part_b/education/awv-faq.shtml). The caller then asked “is this a general CMS policy or MAC specific?”

The reply: “Remember, the LPN’s not billing, said CMS’s William Rogers, MD, reminding the caller that the visit would be billed under the physician’s NPI incident-to”. He then went on to state “It’s a different sort of service; there’s not really any clinical judgment involved. It’s a service which includes a lot of administrative steps, verifying that people have made certain preventative services done and things like that, and so it is intended to be a collaborative service.”

So like I said, don’t yell ‘yippee’ yet. The Medicare carriers which serve PMA clients have not yet announced if they will agree with this determination. But if they do, it will certainly help take the burden of the extensive documentation from you.

What you need to remember, patients have been educated about this visit and they know the deductible and co-insurance amounts do not apply – they may request this service.

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If you recall, in my last luv note I told you about the new signature ruling for any lab study you order and how it would affect your daily practice habits. Because of protests by physicians and the American Clinical Lab Association, CMS is expected to withdraw the signature rule before the April 1 implementation date. A CMS official reported to Part B News that “the agency is taking another look at the policy and considering next steps.”

This ruling if it goes into effect will potentially cause significant disruptions to your day, as you will either have to sign test orders immediately or staff will have to chase you down for your signature.

Societies are hopeful that the coalition pushing CMS will have this ruling rescinded before April 1st. I’ll keep you updated.

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Medicare Advantage Plans

On March 8th, 2011, posted in: Industry News by

Recently Medicare Advantage Plans have been requesting charts for audit. If you receive a request from one of these plans, please call our office before you send any documentation. In many instances, we can opt out of the audit as they are not necessarily mandatory. The audits occur because the commercial carrier is trying to comply with the regulations the Federal Government has imposed on them. PLEASE let us review the request first; we may save you a visit from an auditor.

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Ready to reduce your Pennsylvania, Maryland or Ohio practice medical billing expenses? The following article written by Daniel Casciato was featured on Medical Office Today and sheds light on some great ways your medical practice can save.

“Better patient care always leads to payoffs for both tangible and intangible”.

Outsourcing some of your medical office tasks can not only reduce your salary costs, but it can also decrease your rental expenses since you can work within the confines of a smaller space.

In fact, experts contend that outsourcing your IT, medical billing and coding, medical transcription, electronic filing, collections and even customer support can net immediate savings for your practice.

Not only does outsourcing allow you to use your space more efficiently, but outsourcing will allow you the time you need to concentrate on your practice and patient care, says Shilonda Downing owner of Flossmoor, Ill.-based Virtual Work Team, LLC, a remote business administration team that works with organizations, including medical offices.

Reducing space and improving efficiencies

Many practices that have outsourced their IT needs have reduced their space needs significantly. “Many of our medical clients have reclaimed two full rooms by going to electronic record-keeping,” says Gail Merz, director of business consulting for the Pacific Crest Group a Larkspur, Calif.-based consulting group that provides HR, financial services, and IT consulting services to small businesses, including a number of medical practices.

A number of Pacific Crest’s recent projects have included helping doctors migrate to an electronic medical record system which has not only improved efficiencies but created a lot of extra office space.

“These same practices are abandoning the old bulky computer workstations in favor of portable tablet computers that give them secure access to patient records on the go, which also reclaims a lot of space,” Merz adds.

Another IT strategy that her company has initiated for a number of their medical practice clients is shared workstations. Using a terminal server strategy, any doctor, nurse, or administrator in the practice can sit down to a computer and log in to access files and records.

“This also eliminates the overhead of additional workstations hardware and frees up office space by eliminating the need for dedicated workstations,” she says.

Outsourcing administrative tasks

Beyond IT outsourcing, many practices are choosing to outsource traditional administrative tasks including medical transcription, billing and collections and customer service.

“The decision to outsource is initially driven by economics, but practices quickly realize that it’s just easier to outsource many of these responsibilities because they don’t have to worry about in-house training and managing so many different tasks,” says Mary Fisher, director of customer support for AmeriScribe, an Argyle, Texas-based medical transcription firm.

Fisher notes that outsourcing specialized tasks such as medical transcription and medical billing and coding also allows practices to receive better services and products. “Because we are experts and focus 100 percent of our energy on this one particular business, we can do it better and more efficiently than an in-house staff that is pulled in many different directions,” she explains.

Moreover, Fisher also points out that outsourcing allows healthcare organizations to reduce the number of full-time employees they have on staff, thereby minimizing associated costs such as worker’s compensation and health insurance.

If you decide to outsource any tasks, make sure the company you choose is not only qualified, but that it is insured against any liabilities regarding HIPAA and follows the industry’s best practices.

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ENT – Epley Maneuver – good news

On December 15th, 2010, posted in: Industry News, Tips by

After two years of arguments, you will finally get paid for this procedure. CPT code 95992 (Canalith repositioning procedures(s) (e.g. Epley maneuver, Semont maneuver), per day). The code will have a 0.75 RVU value.

Remember if you perform and document a medically necessary E/M that is different from the maneuver, you may bill the E/M code, modified appropriately.

However, Medicare will not reimburse for audiologist performed Epleys- physicians only please.

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Medicare pay cut fix passes Senate

On December 15th, 2010, posted in: Industry News by

The Senate agreed to a 12 month Medicare pay fix. The House adopted the bill on December 9th. President Obama has indicated he will sign the bill but has not done so as of this writing, December 10, 2010 2:15 p.m.

Details of the bill that will affect your bottom line:

  • Reverses the 30% reduction and extends current Medicare payment rates through December 31, 2010
  • Extends the existing floor of 1 for work RVUs index through December 31, 2011. Physicians practicing in areas of the country with GPCI work values are below 1 stand to benefit from this provision. Those practicing in areas with work GPCI above 1 will not be affected.
  • Extends the use of KX modifier , for use with therapy claims in those patients who have exceeded the $1,870 cap through December 31, 2011
  • Extends the ability of independent labs to receive direct payment for the technical component for certain pathology services through December 31, 2011
  • Extends the 5% increase in payment for certain Medicare mental health services through December 31, 2011

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