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Correct patient name, and claim number is key to receipt of timely payment

     Your carrier will reject your claims if they don’t correctly list the following three elements: the patient’s last name, first initial and health insurance claim (HIC) number, CMS officials said during a recent teleconference.

CMS tightened the Common Working File (CWF) process due to concerns from the HHS Office of Inspector General (OIG). The OIG was worried that the CWF was improperly allowing payment for some claims that were being credited to the wrong patient.

The agency requires the patient’s last name, first initial and HIC number to match CMS records exactly or the claim will be rejected. It’s a rejection that doesn’t require formal appeal. You can correct the information and resubmit under the policies for claims resubmission established by your carrier.

MedPAC: Pay hike of 2.7% recommended for Medicare doctors

     Your Medicare payments next year should increase by 2.7%, instead of being cut, if Congress follows through on a Medicare Payment Advisory Commission (MEDPAC) recommendation. MedPAC went on record opposing the current Medicare payment update formula.

The recommendation could spur lawmakers to act, considering that the Medicare update is expected to be negative 5% next year. The commission made similar recommendations in the past two years, but Congress instead opted for a lower, 1.5% increase

Eased reassignment rules give you billing freedom, but a separate rule could take it away

     You were given the ability to accept reassignment of claims from off-site contracted physicians under the Medicare Modernization Act (MMA). However, make sure you don’t violate the Stark rules against physician self-referral with your reassignment arrangements.

Stark would forbid a group practice from using an off-site contractor to perform designated health services (DHS) for its patients. Stark defines an independent contractor performing DHS as a physician in the group practice A physician in the group practice is defined by CMS as literally a physician located in your group’s practice.

Medicare Audit Proof of Medical Necessity

You have a little more ammunition that you can use to prove the medical necessity of a service, if you’re targeted for pre- or post-payment review, thanks to recent CMS guidance to carriers.

The guidance language instructs carrier auditors that the treating physician can create this documentation after the date of service and it can include PT/OT evaluations, physician letters, other written physician evaluations or other documents intended to record relevant information about a patient’s clinical condition and treatments. CMS also instructs carrier auditors the date that an individual document was created, or the creator of a document, is not the sole deciding factor in determining if the documentation supports the services billed.

The transmittal is provider friendly because it adds on to what is very sparse guidance about what documentation you may use as defense in an audit. Reviewers must give appropriate consideration to documentation other than the progress note.

Medicare pay for performance pilot links quality measures to paycheck

A pilot program that ties performance and quality measures to Medicare reimbursements was rolled-out last week by CMS and is seen as one way the government can better reward quality care.

CMS announced the chronic care, pay for performance demonstration, required by the Medicare Modernization Act (Sec. 721), is on track to begin April 1, 2005 and continue into 2008. Ten large physician groups, have been chosen from 26 applicants. In all, the groups consist of more than 5,000 doctors and are expected to treat upwards of 200,000 Medicare patients.

The challenge for the groups will be to cut costs to the Medicare program overall by avoiding hospitalizations and improving fee-for-service patients’ health. If the clinics perform well, and the payment model works, MMA allows CMS to adopt it throughout the fee-for-service program. “We’re not taking away any fee for service payments for our beneficiaries, but rather adding in an opportunity for performance-based payments, for these groups, if they achieve improvements and high levels of quality on the clinical measures of quality and also cut the rate of growth in total Medicare costs,” according to CMS Administrator Mark McClellan.

Part B practices to get regular FFS payments for treating MA patients

You’ll be entitled to get the regular fee-for-service Medicare allowable when you perform a service on a Medicare Advantage (MA) patient – if you continue as a participating Part B provider and don’t have an agreement with an MA organization. That’s according to the just-released final rule on the new Medicare Part C MA program (Federal Register 1/28/05, pg. 4611), which will start covering patients on Jan. 1, 2006.

Medicare non-par physicians who don’t have a payment agreement with an MA organization must accept the amount they would have received under the traditional Medicare fee for service program and the “limiting charge,” according to the Jan. 28 rule.

Under this program, the following types of regional plans will be established: managed care plans; medical savings accounts; Medicare private fee for service; preferred provider organizations; specialty plans designed to patients with certain diseases. Patients will have the option to switch among plans or to or from original Medicare during the annual election period in November and December, CMS says.

Don’t let Medicare preventive visit structure keep your physicians waiting

Approach the “Welcome to Medicare” visit with a plan in place that allows your staff to work as a team to keep patients moving without delay. With the right plan, you may even find the payment for the visit to be profitable.

Consider having patients arrive at your office at least 30 minutes prior to the actual service. The patients will spend that time completing any screening tools or patient information forms that need to be done for the visit. If your practice has the resources, you can have a nurse or other assistant help patients with the forms.

You bill G0344 ($97.40, par, national, office) for the Welcome to Medicare visit. A separate EKG (G0366, $26.91, par, national, office) may also be billed with the exam in your office. Any appropriate diagnosis code would be acceptable for this service.

Copies you submit of denied claims won’t cut it with carrier

If you got paid once in a while for simply resending an exact match of a previously denied claim, be aware that new edits from CMS are about to stop these payments and guarantee your second claim will also be met with an unappealable denial. Duplicates of denied claims will be automatically denied by your carrier and you can’t appeal the duplicate unless you can prove it is different from the first claim, CMS says in a recent transmittal.

Beginning in July, carrier payment systems will deny automatically any claim when the patient’s name, service, dates of service and provider name match a previously processed claim that was denied, CMS states.

New CMS project would ease supplemental insurance claims submission hassles, maybe speed your payments

You may not have to submit supplemental insurance claims because these would automatically be funneled to the appropriate Coordination of Benefit (COB) insurers by a Medicare contractor, under a project set to begin with 10 large insurers in April.

Part B carriers will be provided with a list of Medicare patients who have active supplementary insurance from 10 insurers (see list below) participating in the project. When a claim is submitted to Medicare for any of these patients, the carrier’s system will automatically “crossover” the supplemental portion of the claim to the Coordination of Benefits contractor GHI (Queens, N.Y.). GHI will then pass the claim to the supplemental insurer in most cases (subject to the terms of a signed agreement), which will process its portion. The supplemental insurer will pay, or deny, depending on the claim, says CMS. Meanwhile, the carrier will process the Medicare claim as it normally would.

COB supplemental insurers participating in first wave of ‘crossover’ claims processing

1. Regence Blue Cross Blue Shield of Idaho
2. United Healthcare (AARP)
3. Wellmark (BC/BS)
4. Horizon (BC/BS N.J.)
5. Aegon (TransAmerica, Monumental Life)
6. Maryland Medicaid
7. Massachusetts Medicaid
8. InterPay Network (clearinghouse for Pipetrades and Superior Administrators)
9. WebMD (represents Aetna and Cigna)
10. GHI (HMO division)

New Medicare Rx benefits won’t take place of Part B coverage

Prescriptions you write for your patients with prescription drug coverage under Medicare’s new Part D plan that kicks in next year will be shared with CMS, the agency says in a recent final rule. The records can be used as a tool to detect fraud or abuse, such as excessively prescribing narcotics, CMS acknowledges.

The final rule details Medicare’s prescription drug coverage — known as Medicare Part D — for both fee-for-service and Medicare Advantage (formerly Medicare + Choice) patients (Federal Register 1/28/05, pg. 4194). This rule addresses only patient prescription coverage, and does not detail any of the competitive bidding for Part B drugs

The following are some of the other highlights of the Part D final rule that may affect your practice:

• Drugs currently reimbursed under Part B will continue to be reimbursed under Part B, including oral cancer drugs now covered as replacements for Part B drugs in Medicare’s cancer care demonstration. Oral cancer drugs not covered by Part B under the demo would be paid under Part D.
• Drugs covered by Part B carriers in their local medical review policies (LMRP) will be paid by Part B. But the same drug, if not covered by a Part B carrier in a different region, would be covered under Part D. Basically, if you get paid by Part B for a drug now, you’re likely to still get paid for it next year.
• Immunosuppressive drugs will be paid under Part B only if Medicare paid for the patient’s transplant. Otherwise, these drugs will be paid under Part D.
• Vaccines not currently covered under Part B will be covered by Part D. You may bill Part B for the administration of the vaccine, but the patient will have to pay you for the vaccine itself. The patient would then submit her own Part D claim for the vaccine. The agency eventually plans a crosswalk where you could bill Part B for both the vaccine and the administration, and your carrier would collect the vaccine fee from the patient’s Part D plan, but that won’t happen initially.
• You may appeal a drug plan’s formulary decision not to pay for a certain drug, or to switch a drug to a higher co-pay tier. You can provide information to support your appeal orally or in writing. The plan is required to reply within 72 hours for normal requests and 24 hours for expedited requests.

ICD-9 Update Guidance

New ICD-9 diagnosis coding guidelines to help you avoid denials and get paid correctly for the services you provide will take effect on April 1, CMS recently announced. The biggest changes to the guidelines address diagnosis coding rules for patients with diabetes mellitus, and those with conditions related to asthma and chronic obstructive pulmonary disease (COPD).

Use diagnosis code 58.67 (long term current use of insulin) only if the patient routinely uses insulin, not if the patient receives it temporarily to control blood sugar. Use as many codes from the 250 (diabetes mellitus) series as possible for each complication the patient has from diabetes. You must then pair each 250 series code with a corresponding code for associated conditions.

If your patient underdoses on insulin because of pump failure, use 996.57 as the primary code, followed by the appropriate 250 series code(s). But if the patient overdoses on insulin due to pump failure, the second diagnosis code should be 962.3 (poisoning by insulins and antidiabetic agents), and then the 250 series code(s).

Word definitions: When used in an ICD-9 code descriptor, the word “and” can also mean “or.” The instruction “see” means you must reference another term in the index. “See also” means referencing the additional term in the index is not necessary, but may be useful.

Sepsis: Codes from ICD-9 category 995.9 (systemic inflammatory response syndrome) cannot be used as principal diagnosis codes for sepsis. If the patient has sepsis as a principal diagnosis for admission, code the underlying systemic infection code as the primary diagnosis, followed by 995.91 (systemic inflammatory response syndrome (SIRS) due to infections process without organ dysfunction). If sepsis develops after hospital admission, use a secondary diagnosis from the sepsis code series (038). If it is not clear if sepsis was present on admission, you should ask the provider.

Septic shock: If the patient has septic shock, you must use a diagnosis code for initiating system infection first, then a code for SIRS (995.2), then a code for septic shock (such as 785.52). The septic shock code cannot be the principal diagnosis code and septic shock cannot occur without severe sepsis.

Cerebral infarction: A stroke (also known as a cerebral infarction or CVA) has 434.91 (cerebral artery occlusion, unspecified, with infarction) as its default code. Don’t use 436 (acute but ill-timed cerebrovascular disease) if the patient has a documented stroke. A cerebrovascular infarction of hemorrhage that occurs during a medical procedure should be diagnosis coded as 997.02 (iatrogenic cerebrovascular infarction or hemorrhage) and your documentation should show a cause-and-effect between the procedure and the stroke.

COPD and asthma: Chronic obstructive pulmonary disease (COPD) is composed of codes from 491.2 (obstructive chronic bronchitis) and 492 (emphysema). Asthma codes are in the 493 series. Use diagnosis code 496 (chronic airway obstruction, not elsewhere classified) only if the patient’s COPD type is not in the record. An acute exacerbation of a patient’s condition is the worsening of a chronic condition, not an infection superimposed on a chronic condition. Select codes for COPD and asthma based on terms documented in the record, as many of the conditions overlap between the two ailments.

Status asthmatica: A patient’s failure to respond to treatment during an asthma attack is known as status asthmatica. If this condition is documented along with COPD, then the status asthmaticus should come first. Don’t use an asthma code with the fifth digit of 2 along with status asthmaticus.

Acute bronchitis: When a patient has acute bronchitis and COPD documented, use only code 491.22 (obstructive chronic bronchitis with acute bronchitis).

Poisoning: If a patient has a toxic effect, known as ingesting or coming into contact with a harmful substance, the primary diagnosis code should be from that series (980-989), followed by any codes that describe conditions that result from the toxic effect. You should also use an appropriate E code if there was an external cause to the toxic effect. Choose from the following series: E860-E869 (accidental), E950.6 or E950.7 (intentional self harm), E962 (assault), or E980-E982 (undetermined).

Michael J. McLafferty CPA, MBA, FACMPE, CHFP
Director, Healthcare Services Group
Amper, Politziner & Mattia