Current Events 2005 Update
Medicare 2005 Update:
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
Healthcare News
Increasing Revenue at the Practice
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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