The following articles are written by your Academy's Coding and Billing Consultant, Joy Newby, LPN, CPC, of Newby Consulting, Inc.
July 2010
Fluzone High-Dose (Influenza Virus Vaccine) is Covered Under Medicare Part B
Fluzone® High-Dose is an inactivated influenza virus vaccine indicated for active immunization of persons 65 years of age and older against those virus subtypes A and type B contained within the vaccine. There have been no controlled clinical studies demonstrating a decrease in influenza incidence after vaccination with Fluzone High-Dose, when compared to standard dose flu vaccines.
There are two flu vaccines called Fluzone: Fluzone and Fluzone High-Dose. Fluzone is billed using CPT 90658, whereas Fluzone High-Dose is billed using CPT 90662.
Per the Food and Drug Administration’s approved labeling, Fluzone High-Dose is only covered by Medicare for beneficiaries age 65 or older.
Medicare’s reimbursement is $11.37 for Fluzone, CPT 90658. Recently, CMS published that $29.21 as the current fee schedule for Fluzone High-Dose, CPT 90662. Please remember that reimbursement for both vaccines may change when CMS issues the average sales price (ASP) drug pricing updates on October 1, 2010.
CMS is also reminding physicians that except for the H1N1 flu vaccine, Medicare normally covers only one administration of any influenza vaccine per flu season (July 1, 2010–March 31, 2011).
ICD-9 2011 Changes Effective October 1, 2010
The need to update ICD-9 codes is only two (2) months away. The entire list of new, revised, and deleted ICD-9 codes can be found here.
June 2010
July 6, 2010 – Are you ready???? - 6/29/10
By: Joy Newby, LPN, CPC, PCS
Newby Consulting, Inc.
The effective date for all referring/ordering physicians to be included in PECOS is fast approaching!
Beginning November 2009, we advised all physicians and nonphysician providers that they needed to verify they were in Medicare’s Provider Enrollment Chain Ownership System (PECOS). This requirement was also discussed at length during our Coding Seminars. Hopefully, you are not one of the physicians who have failed to heed the warnings.
The current deadline for physician and nonphysician practitioners to be enrolled in PECOS is July 6, 2010. Although it is possible that the Centers for Medicare & Medicaid Services (CMS) could delay implementation, we have not received any indication that CMS is leaning towards delaying implementation.
If CMS implements the Affordable Care Act provision on July 6, 2010, claims for all services requiring the name and National Provider Identifier (NPI) of the ordering or referring physician/provider will be rejected if that physician/provider is not personally enrolled in PECOS. Remember PECOS enrollment is required for payment of all services ordered or referred by a physician/provide.
This includes your professional claims!
The following is a link to AMA’s webpage on provider enrollment and PECOS: http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/medicare-enrollment-process.shtml. On the page you will find a direct link to CMS’ website to download the PDF file on whether you are enrolled in PECOS or not. It appears to be updated monthly so make sure to review every so often if you are not listed, but know you have submitted your re-enrollment information.
2010 Fee Schedule: Finally some good news – well at least for a while!!! - 6/25/10
By Joy Newby, LPN, CPC, PCS
Newby Consulting, Inc.
The Centers for Medicare & Medicaid (CMS) announced this morning (June 25, 2010) that President Obama signed the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010. Good news for physicians, you received a 2.2 percent increase in the 2010 conversion factor used to create the Medicare Physician Fee Schedule (MPFS). This new fee schedule is retroactively effective for dates of service on or after June 1, 2010. The Act mandates application of updated fee schedule through dates of service on or before November 30, 2010. Bad news is that we will go through all of this again between now and November 30.
In quick reaction to President Obama’s signature, CMS told its Medicare Claims Administration Contractors to immediately discontinue processing claims at the negative update rates and to temporarily hold all claims for services rendered June 1, 2010, and later, until the new 2.2 percent updated fee schedule is tested and loaded into the Medicare Contractors’ claims processing systems. Effective testing of the new 2.2 percent update will ensure that claims are correctly paid at the new rates. CMS expects Contractors will begin processing claims at the new rates no later than July 1, 2010. Claims for services rendered prior to June 1, 2010, will continue to be processed and paid as usual.
CMS has ensured all physicians that claims containing June 2010 dates of service which have been paid at the negative update rates will be reprocessed as soon as possible. Claims containing June dates of service that were submitted with charges greater than or equal to the new 2.2 percent update rates will be automatically reprocessed.
Under current law, Medicare payments to physicians and other providers paid under the MPFS are based upon the lesser of the submitted charge on the claim or the MPFS amount. Only those physicians submitting charges for dates of service on or after June 1 at a lower amount than the 2.2 percent update will need to contact their local Medicare Contractor to request an adjustment. In these situations, submitted charges on claims cannot be altered without a request from the physician to reprocess the claims. In this specific situation only, do not start the process of reopening affected claims until the new fee schedule has been fully tested and claims are being processed with the updated 2010 Medicare Physician Fee Schedule.
Regardless of what charges were initially submitted on claims with dates of service on or after June 1, physicians should not resubmit claims already submitted to their Medicare Contractor for processing.
As I look at what has been happening this year, it seems that the only thing physicians can count on is that it is increasingly harder to keep track of all the changes. More to follow as the saga continues!
Read more: see the AAFP's statement on this pay cut reprieve here.
URGENT UPDATE - 6/22/10
By Joy Newby, LPN, CPC
Newby Consulting, Inc.
Medicare processing claims with dates of service June 1 and after! Don’t we live in exciting times???
Congress failed to send legislation to President Obama in time to avert implementation of the scheduled 21+ percent payment cut. Although the House of Representatives had passed legislation last week that included a 19-month reprieve from Medicare cuts (over 21 percent starting June 1, 2010), the Senate could only agree to replace the 21+ percent reduction with a 2.2 percent increase to the physician fee schedule through November 30. 2010 when we will face this all over again! The increase is retroactive to dates of service on or after June 1, 2010.
Since the Senate’s bill is different from the 19-month reprieve passed by the House, the bill must go back to the House before it can be sent to President Obama to sign into law. As the House had already adjourned for the weekend when the Senate reached an agreement, the vote and bill signing should take place later this week.
In an attempt to avoid disruption in the delivery of health care services to beneficiaries and payment of claims for physicians, non-physician practitioners, and other providers paid under the MPFS, on May 27, CMS instructed its contractors to hold claims for services paid under the MPFS for the first 10 business days of June (i.e., through June 14, 2010). This hold only affected MPFS claims with dates of service of June 1, 2010, and later.
Given the possibility of Congressional action, last Monday, CMS directed its contractors to continue holding June 1 and later claims for another three days (through Thursday, June 17). CMS was doing everything it could to facilitate accurate claims processing at the outset and minimize the need for claims reprocessing if Congressional action changed the negative update.
It did not appear likely that the Senate would be able to agree on what to do about the fee schedule, so on Friday, June 18, CMS instructed its contractors to begin processing claims with dates of service on or after June 1, 2010 on a first-in/first-out basis. Physicians’ payments will reflect the 21+ percent reduction in the fee schedule for the first few payments; however, CMS is prepared to act as expeditiously as possible to make the appropriate changes to Medicare claims processing systems as soon as President Obama signs the legislation into law.
Claims paid at the lower fee schedule will be automatically reprocessed by the Medicare contractors, so other than having to double post payments, there will not be any loss of revenue due to the reduction.
Once the claims are processing correctly, enjoy it until November, no predictions about what will happen then!!!
URGENT UPDATE - 6/14/10
Medicare to hold claims with dates of service June 1 and after through Thursday June 17th
The Continuing Extension Act of 2010, enacted on April 15, 2010, extended the zero percent (0%) update to the 2010 Medicare Physician Fee Schedule (MPFS) through May 31, 2010. At this time, Congress is debating the elimination of the negative update that took effect June 1, 2010. The Centers for Medicare & Medicaid Services (CMS) is hopeful that Congressional action will be taken within the next several days to avert the negative update.
To avoid disruption in the delivery of health care services to beneficiaries and payment of claims for physicians, non-physician practitioners, and other providers paid under the MPFS, CMS had instructed its contractors on May 27th to hold claims for services paid under the MPFS for the first 10 business days of June (i.e., through June 14, 2010). This hold only affects MPFS claims with dates of service of June 1, 2010, and later.
Given the possibility of Congressional action in the very near future, CMS is now directing its contractors to continue holding June 1 and later claims through Thursday, June 17, lifting the hold on Friday, June 18.
This action will facilitate accurate claims processing at the outset and minimize the need for claims reprocessing if Congressional action changes the negative update. It also should minimize the provider and beneficiary burdens and costs associated with reprocessing claims.
We understand that the delayed processing of Medicare claims may present cash flow problems for some Medicare providers. However, we expect that the delay, if any, beyond the normal processing period will be only a few days. Be on the alert for more information regarding the 2010 Medicare Physician Fee Schedule Update.
Anthem Medicare Advantage (MA) Plan - 6/1/10 - Are you in compliance??
By Joy Newby, LPN, CPC, PCS
Newby Consulting, Inc.
Updates You Need to Know! - 6/1/10
By Joy Newby, LPN, CPC, PCS
Newby Consulting, Inc.
Do you feel Congress and Governmental Agencies can't make up their minds? If you said "Yes" you are not alone. Many "deadlines" continue to be a moving target. Read more.
May 2010
MEDICARE ENROLLMENT – PECOS DEADLINE NOW JULY 6, 2010
By Joy Newby, LPN, CPC, PCS and Connie Woods, CPC, CPC-I, CGSC, OCS
Newby Consulting, Inc.
The changes just keep on coming!
Newby Consulting, Inc. previously advised all physicians and nonphysician providers that they needed to verify they were in Medicare’s Provider Enrollment Chain Ownership System (PECOS). In all of our 2010 seminars, we urged physicians and providers not to wait to verify their enrollment. This article is to once again stress the urgency of ensuring you are in PECOS as the effective has changed yet again! Read more...
March 2010
Reimbursement Updates - 3/8/10
An array of updates from Joy Newby, on enrollment, CMS, and medical policy topics.
January 2010
2010 Medicare Fee Schedule Update - 1/4/10
By Joy Newby, LPN, CPC, PCS
Newby Consulting, Inc.
The president signed the Department of Defense Appropriations Act of 2010 which provides for a zero percent (0%) update to the 2010 Medicare Physician Fee Schedule for a two month period. This update is effective with dates of service on January 1, 2010 through February 28, 2010. Due to this action, the Centers for Medicare & Medicaid Services (CMS) has recalculated the 2010 fee schedule.
Fees have NOT been frozen at the 2009 fee schedule!
CMS used 2010 relative value units and geographic adjustment factors multiplied by the 2009 conversion factor to determine the interim 2010 fee schedule. This distinction is important due to CMS’ decision regarding the use of consultation codes.
As you know, consultation codes are not acceptable for billing Medicare patients as of January 1, 2010. According to CMS, the decision regarding consultation codes is budget-neutral because CMS increased the work relative value units for specific evaluation and management codes (E/M) used in lieu of consultation codes (e.g. new patient E/M, established patient E/M office and other outpatient service codes, initial hospital care, initial nursing facility care). By recalculating the 2010 fee schedule based on the 2009 conversion factor, the fee schedule for these codes has been increased. Thus, the decision to exclude consultation codes has NOT been modified for January and February 2010 dates of service.
Further, the increase in payment for the initial preventive physical exam (IPPE) is also noted on the interim fee schedule. The Indiana 2010 January through February fee schedule is available on the National Government Services website at http://www.ngsmedicare.com/content.aspx?CatID=2&DOCID=20817
Although the 21.2 percent fee schedule reduction is temporarily resolved, at the time this article was written, CMS is continuing to instruct its contractors to hold claims for services paid under the Medicare Physician Fee Schedule (MPFS) for up to the first 10 business days of January (January 1 through January 15) for 2010 dates of service.
CMS believes this action should have minimum impact on provider cash flow because, by law, clean electronic claims are not paid any sooner than 14 calendar days (29 days for paper claims) after the date of receipt. Meanwhile, all claims for services delivered on or before December 31, 2009, will be processed and paid under normal procedures.
The holding of claims allows Medicare contractors time to receive the new, updated payment files and perform necessary testing before paying claims at the new rates. CMS has instructed contractors to begin processing claims at the new rates no later than January 19, 2010. Please note that most contractors are closed on the January 18 Martin Luther King Day holiday. Therefore, even absent a new update, most claims likely would not have been paid any sooner than January 19, 2010, given the aforementioned statutory 14-day payment floor.
CMS has extended the 2010 Annual Participation Enrollment Program end date from January 31, 2010, to March 17, 2010– therefore, the enrollment period now runs from November 13, 2009, through March 17, 2010.
The effective date for any participation status change during the extension, however, remains January 1, 2010, and will be in force for the entire year. Contractors will accept and process any participation elections or withdrawals, made during the extended enrollment period that are received or post-marked on or before March 17, 2010.
December 2009
Requirement for Screening Excluded Individuals - 12/21/09
CMS recently issued a letter to remind providers of their responsibility and obligation to screen current and prospective employees and contractors for CMS/OIG exclusions.
Anthem Update: UAW Retirees Transfer to New Plan - 12/18/09
November 2009
Anthem Audits and FWA Training - 11/23/09
2010 CPT Coding Changes - 11/21/09
URGENT UPDATE! Are Your Physicians Enrolled in Medicare's PECOS? - 11/2/09
***Update: CMS decided to delay the implementation of this rule until April 5, 2010 instead of January 1, 2010!***
Billing Office Diagnostic Tests in 2010 Becomes More Difficult! - 11/2/09
By: Joy Newby, LPN, CPC, PCS
Newby Consulting, Inc.
The Centers for Medicare & Medicaid Services (CMS) announced new billing requirements for all tests having both a professional and technical component, e.g., x-rays, ECGs, etc. (This change DOES NOT apply to clinical laboratory tests).
Effective with dates of service on or after January 4, 2010, the appropriate date of service for the professional component is the ACTUAL calendar date that the interpretation was performed. For example, a single view chest x-ray (technical component) is performed on January 5, 2010 but the physician does not do interpretation until January 11, 2010, you must split bill the service!
01-05-2010 71010-TC
01-11-2010 71010-26
You do NOT have to individually itemize the components when the test is performed and interpreted on the same calendar date.
Start creating your process now to identify when the physician actually interprets tests performed in your office. It is not necessary to actually start splitting claims until January 4, 2010, but you will need to develop a process to identify those tests that are interpreted (including written interpretation) on the same day vs. tests that are performed on one day and interpreted on a different calendar day.
October 2009
Medicare Issues Coding/Billing Guidelines for the H1N1 Vaccine and its Administration
– Medicare Specific Administration Code Must be Reported (9/23/09)
Connie Woods, CPC, CPC-I, CGSC, OCS
Newby Consulting, Inc.
NOTE: Medicare will pay for seasonal flu vaccinations even if the vaccinations are rendered earlier in the year than normal. CMS understands that such preparations are critical for the upcoming flu season, especially in planning for the influenza A (H1N1) vaccine. Although Medicare typically pays for one vaccination per year, if more than one vaccination per year is medically necessary (i.e., the number of doses of a vaccine and/or type of influenza vaccine), then Medicare will pay for those additional vaccinations. In the event it is necessary for Medicare beneficiaries to receive both a seasonal flu vaccination and an H1N1 vaccination, Medicare will pay for both.
The H1N1 vaccine is available free of charge to hospitals, physicians, and other entities that administer immunizations to patients. Medicare fee-for-service will not pay for the H1N1 vaccine as it does not represent an expense to the hospital, physician, etc. However, Medicare will pay for the administration of the vaccine in accordance with existing rules. Payment for the H1N1 vaccine’s administration will be the same as the payment for administration of the seasonal flu vaccine.
Since the H1N1 vaccine is made available to providers free of charge, the HCPCS code for the vaccine need not be included on the claim submitted for payment of the administration of the vaccine. If the provider elects to bill for the vaccine, the claim will be accepted but any charge for the vaccine will be denied.
Physicians will use the following HCPCS codes to report H1N1
• G9141 Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family) (administration code)
• G9142 Influenza A (H1N1) vaccine, any route of administration (vaccine code)
CMS web site with Q&A's on the H1N1 vaccine and administration can be accessed here: http://www.cms.hhs.gov/H1N1/#TopOfPage
AMA H1N1 Coding Instructions
CMS instructions for coding Medicare claims differ from the coding instructions from the American Medical Association (AMA). We anticipate the AMA coding instructions will be pertinent to all other payers. The AMA recently released the following codes directly related to H1N1. The new codes were immediately effective upon release.
• 90470 H1N1 immunization administration (intramuscular, intranasal), including counseling when performed
• 90663 Influenza virus vaccine, pandemic formulation, H1N1
The AMA provided the following instructions for coding and payment from all payers other than Medicare. Physicians
“should bill CPT code 90663 (Influenza virus vaccine, pandemic formulation, H1N1) in conjunction with the immunization administration code 90470 (H1N1 immunization administration (intramuscular, intranasal), including counseling when performed). The 90663 code for the 2009 H1N1 vaccine itself should be billed for zero dollars, since the vaccine is provided free of charge by the federal government.”
September 2009
Superbills: Helpful or Harmful? Changes take effect October 1, 2009! - 9/16/09
August 2009
PQRI Teleconference, Private Fee-For-Service (PFFS) Medicare Advantage Request for Chart Reviews, and Recovery Audit Contractors Post First Set of Issues to be Reviewed - 8/31/09
May 2009
Private Fee-For-Service Plans - 5/13/09
February 2009
Anthem to No Longer Accept Legacy Numbers On Electronic Claims - 2/23/09
January 2009
2009 Update - CPT Coding Changes, Implementation of ICD-10, and Medicare Coverage and Fee Schedule Changes for 2009 - 1/26/09
November 2008
Medicare Coding, Coverage, and Fee Schedule Changes for 2009 - 11/16/08
August 2008
E-prescribing info - 8/20/08
Get Ready for the 2009 ICD-9 Coding Changes - Examples of New Codes Affecting PCPs - 8/13/08
Complete Listing of the 2009 ICD-9 Coding Changes
July 2008
2008 Annual Meeting PowerPoint Files - 7/31/08
Download Joy's PowerPoint presentations from the 2008 IAFP Annual Meeting here!
For physicians, Joy presented CMS Physician Quality Reporting Initiative: Family Physician Participation. (PowerPoint file, 2.75 MB)
For office staff, Joy presented a Reimbursement Update. (PowerPoint file, 936 KB)
Payment Updates including CMS news, Anthem fee schedule changes, and new CLIA Waived tests - 7/1/08
June 2008
PQRI Updates - 6/9/08
May 2008
Medicare Revises Advance Beneficiary Notice (ABN) - 5/12/08
ABN Revised Form
February 2008
Telephone Services - 2/18/08
Lumps and Bumps – 2/18/08
Family physicians treat numerous types of lesions using numerous treatment modalities. Coding for removal of skin lesions is one of the more challenging aspects of family practice coding. To assist physicians in reporting the appropriate codes for lesion removals, Newby Consulting, Inc developed an adjunct superbill (MS Excel file, 25 KB) of the different treatment modalities for removal of skin lesions. This additional superbill can be copied and available in your treatment room. When treating lesions simply attach the Lump and Bump superbill to the patient’s superbill for accurate coding.
January 2008
Changes to the 2008 Fee Schedule Explained - 1/3/08
November 2007
Update on Anthem/Wellpoint NP and PA Billing Requirements - 11/27/07
Medicare Coding, Documentation, and Compliance Related to CERT Requests
October 2007
A Member Wants to Know: Can a hospital employed NPs evaluate and admit patients for non-hospital employed
physicians under a hospital agreement?
September 2007
Indiana Flu and Pneumonia 2007 Reimbursements
Provider Enrollment Revalidation Effort
August 2007
Billing Services Performed by Nurse Practitioners and Physician Assistants
July 2007
PQRI Measure Coding and Reporting Principles
Common Billing Errors to Avoid when Billing Medicare Carriers
NPI: Get It. Share It. Use It.
August 2006
Are Your Fee Schedules Fair - by Thomas A. Felger, MD
Procedural Vs. Cognitive Reimbursement Microsoft Excel Spreadsheet