Current Events 2005 Update
Medicare 2005 Update:
• New CMS project would ease supplemental
insurance claims submission
• Medicare Audit Proof of Medical Necessity
• MMA does mandate welcome to Medicare physical, screening patients for diabetes and cardiovascular disease
• Medicare pay for performance pilot links quality measures to paycheck
• Copies you submit of denied claims will be denied by your carrier July 1st
Increasing Revenue at the Practice
•
Insurance Contract Reimbursement Negotiation
• Insurance Verification
• Billing claims with proper modifiers
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Current Events 2005 Update
May 2005 Program Presented by
Michael J. McLafferty CPA, MBA, CHFP, FACMPE
Maureen Doherty CPC, CPC-H
Overview of Topics
Medicare 2005 Update
- MMA won’t end extrapolation, but should limit when it can be used
- MedPac advisory group may recommend limiting the specialties that can perform or interpret certain radiology tests
- MMA does mandate welcome to Medicare physical, screening patients for diabetes and cardiovascular disease
- Medicare Audit Proof of Medical Necessity
- Medicare pay for performance pilot links quality measures to paycheck
- Part B practices to get regular FFS payments for treating MA patients
- New CMS project would ease supplemental insurance claims submission
- Drugs currently reimbursed under Part B will continue to be reimbursed under Part B
- Copies you submit of denied claims will be denied by your carrier July 1st
Increasing Revenue at the Practice
- Insurance Contract Reimbursement Negotiation
- Practice Management Software Assessments
- Updating practice management software and encounter forms for code changes
- Correct and Updated Patient Demographics
- Patient Referrals / Authorizations
- Insurance Verification
- Collection of co-payments and co-insurance
- Collection of past due balances
- Billing claims with proper modifiers
- Obtaining Advance Beneficiary Notices (ABN’s) for non-covered services by Medicare
New/Revised ICD-9 Codes
New/Revised ICD-9 Codes for 2005 Became Effective October 1, 2004
- Codes were effective 10/1/04 with no grace period
- 171 New Diagnosis Codes
- 25 Deleted Diagnosis Codes
- 203 Definitions Changed for Diagnosis Codes
- Most significant additions
- Digestive System –78 New Codes
Diagnosis Coding Guideline Revisions were issued and effective April 1, 2005
- Diagnosis codes with more specificity
- Most significant revisions:
- Diabetes Mellitus
- COPD
- Asthma
2005 CPT Code Changes
157 New Codes;
- Most significant additions:
- Medicine –31
- Path/Lab –19
- Digestive –18
- Radiology –13
- Cardiovascular -10
- 74 Revised Codes and
- 46 Deleted Codes
- Codes were effective 1/1/05 with no grace period
New Preventive Services
“Welcome to Medicare” Preventive Exam
- For new Medicare patients
- Must be performed within six months of the date a patient enters the program –Payment $124.91
- Physicians must:
- Perform a comprehensive exam, which may include ordering of follow-up procedures based on any abnormalities uncovered
- Arrange for education, counseling & referral for those abnormalities
- Make patient aware of other screenings or immunizations that may be medically necessary
- Develop a written plan to coordinate all of the elements
Cardiovascular Screening
- Screening blood tests are covered once every five years for patients without signs or symptoms of heart disease
- Per CMS, the following codes should be done as part of a panel & with the patient fasting
- 82465 –Cholesterol, serum or whole blood, total
- 83718 –Lipoprotein, direct measurement; high density cholesterol, HDL cholesterol
- 84478 –Triglycerides, screening
- 80061 –Lipid Panel
- CMS suggests the following diagnosis codes
- V81.0 Special screening for ischemic heart disease
- V81.1 Special screening for hypertension
- V81.2 Special screening for other & unspecified cardiovascular conditions
Diabetes Screening
- Physicians allowed to bill Medicare twice annually for “pre-diabetic” patients
- Patients with a fasting glucose level of 100-125mg/dL or;
- Patients with a 2 hour post glucose challenge of 140-199mg/dL
- Physicians can bill once a year for patients who do not meet the clinical criteria for twice-yearly screening
- Diabetes Screening Codes
- 82947 –Glucose; quantitative, blood, except reagent strip
- 82951 –Glucose; tolerance test (GTT), three specimens, includes glucose
- Appropriate ICD-9 Code
- V77.1 Special screening for diabetes mellitus
New Preventive Exam
“Welcome to Medicare” Preventive Exam
- G0344 –Initial Preventive Physical Exam (IPPE)
- G0366 –EKG
- Routine EKG with at least 12 leads; with interpretation & report, performed as component of IPPE ($26.91
)
- G0367 –EKG
- Routine EKG with at least 12 leads; tracing only, without interpretation & report, performed as component of IPPE ($17.81)
- G0368 –EKG
- Routine EKG with at least 12 leads; interpretation & report only, performed as component of IPPE ($9.10)
Correct Coding Initiative (CCI) Changes
Version 11.1 effective 4/1/05
- 1346 Code-Pair Additions
- 286 Medicine
- 265 Anesthesia
- 242 Radiology
- 148 Digestive
- 109 HCPCS
- 223 Code-Pair Deletions
- 162 Mutually Exclusive Code Pair Additions
- 22 Mutually Exclusive Code Pair Deletions
HIPAA Security 2005 Update
- A covered entity must comply with the applicable standards, implementation specifications, and requirements with respect to electronic protected health information (PHI)
- General Rules –General Requirements
- Ensure the confidentiality, integrity, and availability of all electronic PHI the covered entity creates, receives, maintains, or transmits
- Protect against any reasonably anticipated threats or hazards
- Protect against any reasonably anticipated uses or disclosures not permitted
- Ensure compliance by its workforce
- General Rules –Flexibility of Approach
- Implementation Specifications
- Required or addressable
- Utilize decision criteria if addressable
- Implement recommended or alternative specification
- Document why it would not be reasonable and appropriate
- Maintenance
- Monitor
- Review and modify to protect electronic PHI
- General Rules –Flexibility of Approach
- Reasonable and appropriate approach
- Decide which security measures to use
- Size, complexity and capabilities of the organization
- Hardware, software and security capabilities
- Costs of security measures
- Probability and importance of risks to electronic PHI
- Comply with the standards
- Compliance Dates
- Health Plans –April 21, 2005 or April 21, 2006 if a small health plan
- Health care clearinghouse –April 21, 2005
- Health care provider –April 21, 2005
Summary of Topics
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