Aetna and Chiropractic Authorizations

The American Chiropractic Association met with Aetna regarding their auth and claims processing.


Dear Colleagues:

Yesterday, Ray Tuck, Ed Nielson and Karen Silberman met with Aetna and Magellan/NIA employees.  The meeting was scheduled in response to the October 2018 letter that was jointly signed by the ACA, PCA, NYSCA, NYCC and WVCS.  The meeting was productive.  We discussed Aetna’s payment policies and documentation standards, data sharing for better understanding of clinical pathways, the opportunity to collaborate on model payment policies and how to build trust between chiropractors and Aetna.

Aetna shared that the majority of denials are not related to specific care delivered, but a result of documentation errors centered around incomplete descriptions of services rendered and content of notes not supporting the treatment plan.  This lead to a conversation about the importance of agreeing on a clear standard of documentation requirements and how best to educate doctors.  Magellan and the ACA agreed to explore collaborating on defining these standards and in the creation of a series of documentation webinars.  Additionally, the group discussed one of the ACA's potential initiatives of creating a universal model payment policy that would include specific and reasonable quality care metrics to ensure access for patients.  Everyone in attendance agreed that would be a great resource for all parties and would be supportive in its creation.  Aetna is meeting with the APTA in March and would like to further discuss collaborative opportunities after that has occurred. 

The meeting attendees include two chiropractors Robert Frank, Aetna’s Medical Director and Kathy Norman, Magellan’s Chiropractic Services Director.  Additionally, two PT’s attended, Justin Clifford, Magellan’s Senior Provider Relations Manager and Hanna Hartung, Magellan’s Director of Product Innovation.   We will ask Aetna to provide the same physical medicine provider balance and professional courtesy at their meeting with APTA.

Aetna and Magellan will share the outcomes of the meeting with their teams as will the ACA.  We will reconnect in February to update one another on our respective leadership’s support of the education and payment policy projects. In late March, Aetna will include the PT’s if appropriate.

Karen Silberman, CAE

Executive Vice President

ACA Association

FIND MORE DETAILS HERE: https://www.acatoday.org/

Opioids Training Modules for CEU credits

Opioids Training Modules

The Centers for Disease Control & Prevention (CDC) launched two new opioid trainings that support providers in safer prescribing of opioids for chronic pain. The modules are part of a series of interactive online trainings that feature recommendations from the CDC Guideline for Prescribing Opioids for Chronic Pain, clinical scenarios, tools, and resource libraries to enhance learning. The modules offer free continuing education.

View additional modules in the series on the CDCInteractive Training Serieswebpage.


This link will take you to the courses and CE values: https://www.cdc.gov/drugoverdose/training/online-training.html

ICD 10 changes October 1, 2019

Hello!

Every year the ICD 10 diagnosis book releases its annual updates.  This year there are 71932 codes with 279 additions, 51 deletions and 143 revised codes.

Of all the changes, one of the most common codes that is changing is MYALGIA.

Please note that M79.1 will no longer be a valid code on 10/1/18!  Instead, it will require a 5th digit extender.

M7910    Myalgia, unspecified site

M7911    Myalgia of mastication muscle

M7912    Myalgia of auxiliary muscles, head and neck

M7918    Myalgia, other site

If you have any questions or would like to inquire on any of the other code changes, send me an email!

Thanks!

CMS Proposes Changes to Evaluation & Management Requirements

CMS may be changing the E & M code family in 2019.  At this time, the changes are open for debate and feedback.

 

The link to the CMS announcement is here:  CMS Announcement

 

You may review the changes yourself by clicking here  DEPARTMENT OF HEALTH AND HUMAN SERVICES and starting at page 374.

 

Some of the key changes that are proposed could have dramatic affects to providers in a variety of different ways.  Ultimately, the proposed E/M changes impact physicians differently. Physicians that see more complex patients—level 4 and 5 E/M visits—are impacted more than those who typically see levels 1, 2, and 3. CMS argues the negative financial impacts will be offset by the reduction in administrative burdens as outlined in the proposed rule. This may ultimately be true for some specialties, but for others it comes at a price.

 

Specifically, CMS has said “most specialties would see changes in their overall Medicare payments in the range of 1-2 percent up or down from this policy, but we believe that any small negative payment adjustments would be outweighed by the significant reduction in documentation burden. If you add up the amount of time saved for clinicians across America in one year from our proposal, it would come to more than 500 years of additional time available for patient care, ” as Administrator Verma wrote in her letter to physicians.

 

 

Some of the proposed changes:

 

1. Lifting Restrictions Related to E/M Documentation

 

a. Eliminating Extra Documentation Requirements for Home Visits: Required documentation showing medical necessity for home visits rather than an office visit will be eliminated.

 

b. Eliminate Restriction of only one E/M visit per day: As integration of care from multiple specialties into one organization has expanded, this has created problems.

 

2.  Changing Documentation Requirements for Office or Other Outpatient E/M Visits and Home Visits

 

a. Flexibility in Documentation Options: Providers may choose either Medical Decision Making (MDM), time, or current guidelines (1995 or 1997) as the basis to determine the appropriate level of an E/M visit. Regardless of the method chosen, the payment rate is the same.

 

b. New Specialty-Specific E/M Codes: Some specialties will have their own E/M codes assigned (new G codes) to describe their services. For example, the proposed rule has two new codes for podiatry E/M services for the initiation of treatment which will be priced similar to ophthalmological service codes 92004 and 92012.

 

c. Value of Time: Providers may use time as the determining factor regardless of whether or not counseling or care coordination was more than 50 percent of the face-to-face encounter. They are still determining how to best report situations where the time is significantly higher than the two tier payment rate being proposed. It might require the use of the Prolonged Services or other new codes.

 

d. Less Documentation Required: Providers only need to meet the documentation requirements of a level 2 visit for history, exam, and/or MDM (unless using time) to meet audit requirements. However, for clinical, legal, and operational purposes, it is wise to continue to meet current requirements.

 

Note: Even though there are reduced requirements, there are still basic standards that are expected for quality of care. Take social history for example. Even though it will no longer be required, it remains an important component to understand the patient's needs and situation to ensure that proper care is provided.

 

3. Removing Redundancy in E/M Visit Documentation: Remove the requirement to re-document information that is already in the patient's medical record. These aren't required changes. Providers may choose to continue to do things as they are currently doing them.

 

For established patients, the provider needs to only review and verify information and only document any new or changed elements of the review of systems (ROS) and/or past, family, and/or social history (PFSH) that are already in the record.

For both new and established patients, practitioners would no longer be required to re-enter information in the medical record regarding the chief complaint and history that are already entered by ancillary staff or the beneficiary. Instead, the provider will indicate that they reviewed and verified this information.

 

4. Minimizing Documentation Requirements by Simplifying Payment Amounts: There will only be two payment rates for E/M visits - Level 1 and Levels 2-5. There will be "new add-on codes to better capture the differential resources involved in furnishing certain types of E/M visits". 

 

You will still bill the applicable level with the same CPT codes (99202-99205, 99212-99215), they will just be paid at the same rate. They basically averaged the rates currently being paid to come up with a single rate. While this may decrease revenues, the benefit is that it reduces the problem of audits and payback requests on these codes.

 

According to the proposed rule, there are three unique E/M visits (listed below) which do not fall under the basic E/M guidelines. There will be new HCPCS G codes assigned to report these services: 

 

separately identifiable E/M visits furnished in conjunction with a 0-day global procedure

primary care E/M visits for continuous patient care

certain types of specialist E/M visits, including those with inherent visit complexity

 

If you would like to participate and provide feedback, you may do so in the following ways:

 

1. Submit electronic comments on this regulation to www.regulations.gov. Follow the instructions for “submitting a comment.”

 

2. Mail written comments to:

CMS-1676-P 2

Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1676-P

P.O. Box 8016

Baltimore, MD 21244-8013.

Allow sufficient time for mailed comments to be received before the close of the comment period.

 

3. By express or overnight mail. You may send written comments to:

Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1676-P

Mail Stop C4-26-05

7500 Security Boulevard

Baltimore, MD 21244-1850.

 

4. Deliver (by hand or courier) written comments before the close of the comment period to:

Centers for Medicare & Medicaid Services, Department of Health and Human Services,

Room 445-G, Hubert H. Humphrey Building,

200 Independence Avenue, SW., Washington, DC 20201

cited links: 

https://www.chirocode.com/blog/274 

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2018-Press-releases-items/2018-07-12.html

https://www.policymed.com/2018/07/cms-proposed-evaluation-and-management-e-m-documentation-and-payment-changes-are-sparking-backlash-and-may-hurt-patients.html

https://www.aapc.com/blog/39245-cms-considers-revising-em-documentation-guidelines/

Medicare Market Saturation tool

Fact Sheet

FOR IMMEDIATE RELEASE
April 13, 2018 

Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries

 

Market Saturation and Utilization Data Tool 

The Centers for Medicare & Medicaid Services (CMS) has developed a Market Saturation and Utilization Data Tool that includes interactive maps and a dataset that shows national-, state-, and county-level provider services and utilization data for selected health service areas. Market saturation, in the present context, refers to the density of providers of a particular service within a defined geographic area relative to the number of the beneficiaries receiving that service in the area.

The seventh release of the data tool includes a quarterly update of the data to the fourteen health services areas from release 6, and also includes Federally Qualified Health Centers and Ophthalmology data. Release 7 will therefore include seven, twelve-month reference periods and the following health service areas: Home Health, Ambulance (Emergency, Non-Emergency, Emergency & Non-Emergency), Independent Diagnostic Testing Facilities (Part A and Part B), Skilled Nursing Facilities, Hospice, Physical and Occupational Therapy, Clinical Laboratory (Billing Independently), Long-Term Care Hospitals, Chiropractic Services, Cardiac Rehabilitation Programs, Psychotherapy, Federally Qualified Health Centers, and Ophthalmology. Also new to Release 7 is a trend analysis graphing tool that allows users to graph the percentage change and trend over time at the national level for the available metrics and health services areas.

The Market Saturation and Utilization Data Tool is one of many tools used by CMS to monitor and manage market saturation as a means to help prevent potential fraud, waste, and abuse. The data can also be used to reveal the degree to which use of a service is related to the number of providers servicing a geographic region. Provider services and utilization data by geographic regions are easily compared using an interactive map. There are a number of secondary research uses for these data, but one objective of making these data public is to assist health care providers in making informed decisions about their service locations and the beneficiary population they serve. The tool is available through the CMS website at: https://data.cms.gov/market-saturation. Future releases may include comparable information on additional health service areas.

Methodology

NEW MEDICARE ID CARDS BEING RELEASED SOON!

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, requires clinicians to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019. 

 

A new Medicare Beneficiary Identifier (MBI) consisting of alpha numeric identification will replace the SSN-based Health Insurance Claim Number (HICN) on the new Medicare cards for Medicare transactions like billing, eligibility status, and claim status.   This will be known as the members MBI moving forward. 

 

See the new flyer here: https://www.medicare.gov/Pubs/pdf/12002-New-Medicare-Card-flyer.pdf

 

The New Medicare cards will start being mailed out in April 2018.

 

Please make sure your patients are aware of these changes!!

 

Here are some Resources to Download to assist in the transition.  Please provide these to your patients:

 

Here is a poster you can print and display in your treatment rooms to better inform your patients about the upcoming cards:

Medicare Poster

 

Here is a flyer for you and your patients to understand the 10 most important issues with the new Medicare identification cards:

Medicare Flyer

 

For those of you with digital information screens in your reception areas, you can download this video from here:

Medicare Video

2018 Medicare Physical Therapy Cap Update

The Physical Therapy cap for Medicare increased in 2018 to $2010.00

 

However, Congress broke for break this year without addressing the therapy cap exceptions. 

 

On Friday 1/26/18, CMS/Medicare released a “rolling hold” to minimize impact if legislation to extend the outpatient therapy caps exceptions process is enacted.

 

The government has a 2/8/18 deadline to determine how to proceed with the therapy cap exceptions this year.   Updates will follow as the rules are released.

 

It is unknown how the KX modifier and exception to the therapy cap will play out in 2018 yet. 

 

As of right now, 

 

• The therapy caps exceptions process ended Dec. 31, 2017.

 

• Medicare beneficiaries are limited to $2,010 of therapy under each therapy cap in 2018.

 

• Therapy over the cap is statutorily excluded as a Medicare benefit in the absence of an exceptions process.

 

• The therapy caps apply to all therapy service locations, with the exception of hospitals. The therapy caps do apply to critical access hospitals (CAHs).

 

• Beneficiaries are financially responsible for all therapy costs over the therapy cap (again, with the exception of services provided in hospitals).

 

• Providers should issue a mandatory advanced beneficiary notice of non-coverage (ABN) to advise beneficiaries of non-coverage of therapy over the cap.

Medicare Low Volume Appeals Initiative

Low Volume Appeals Settlement Option Call – February 13

 

Tuesday, February 13, from 1:30 to 3 pm ET

 

Register for Medicare Learning Network events.

 

As part of the broader HHS commitment to improving the Medicare appeals process, CMS will make available the Low Volume Appeals (LVA) settlement option onFebruary 5, 2018. LVA is for providers and suppliers (appellants) with fewer than 500 appeals pending at the Office of Medicare Hearings and Appeals (OMHA) and the Medicare Appeals Council (the Council) at the Departmental Appeals Board.

 

During this call, learn more about LVA, the current status, and how the settlement process works. CMS speakers discuss how to identify whether you are eligible and which of your pending appeals may be settled. Visit the Low Volume Appeals Initiative webpage for more information.

 

A question and answer session follows the presentation; however attendees may email questions in advance to MedicareSettlementFAQs@cms.hhs.gov with “Low Volume Appeals Settlement February 13 Call” in the subject line. These questions may be addressed during the call or used for other materials following the call.

Target Audience: Medicare fee-for-service providers, physicians

CMS to announce Job Training Required for Medicaid Enrollment

PRESS RELEASE

FOR IMMEDIATE RELEASE
Jan 11, 2018 

Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries

 

                                

CMS announces new policy guidance for states to test

community engagement for able-bodied adults

 Will support states helping Medicaid beneficiaries improve well-being and achieve self-sufficiency

 

CMS today announced new guidance that will support state efforts to improve Medicaid enrollee health outcomes by incentivizing community engagement among able-bodied, working-age Medicaid beneficiaries. The policy responds to numerous state requests to test programs through Medicaid demonstration projects under which work or participation in other community engagement activities – including skills training, education, job search, volunteering or caregiving – would be a condition for Medicaid eligibility for able-bodied, working-age adults. This would exclude individuals eligible for Medicaid due to a disability, elderly beneficiaries, children, and pregnant women.

The new policy guidance sent to states is intended to help them design demonstration projects that promote the objectives of the Medicaid program and are consistent with federal statutory requirements. To achieve the objectives of Medicaid, state programs should be designed to promote better physical and mental health.

“Medicaid needs to be more flexible so that states can best address the needs of this population. Our fundamental goal is to make a positive and lasting difference in the health and wellness of our beneficiaries, and today’s announcement is a step in that direction,” said Seema Verma, CMS Administrator.

To date, CMS has received demonstration project proposals from 10 states that include employment and community engagement initiatives: Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah and Wisconsin.

“Our policy guidance was in response to states that asked us for the flexibility they need to improve their programs and to help people in achieving greater well-being and self-sufficiency,” said Verma.

Announcement of the new guidance delivers on the commitment made by Administrator Verma in her address to state Medicaid directors last November, to “turn the page” in the Medicaid program and give states more freedom to design innovative programs that achieve positive results for the people they serve and to remove bureaucratic barriers that block states from achieving this goal.

Criteria and Parameters of the New Policy Guidance

CMS has identified a number of issues for states to consider in the development of proposals to promote work and other community engagement among working-age, non-pregnant Medicaid beneficiaries not eligible for Medicaid on the basis of a disability.

Meeting work and community engagement requirements should take into consideration areas of high unemployment or caregiving for young children or elderly family members. States will therefore be required to describe strategies to assist eligible individuals in meeting work and community engagement requirements and to link individuals to additional resources for job training, provided they do not use federal Medicaid funding to finance these services.

CMS will support state efforts to align Medicaid work and community engagement requirements with SNAP or TANF requirements, where appropriate, as part of this demonstration opportunity. Aligning requirements across these programs may streamline eligibility and reduce the burden on both states and beneficiaries and help beneficiaries succeed in meeting their work and community engagement responsibilities.    

States must also fully comply with federal disability and civil rights laws and ensure that all individuals with disabilities have the necessary protections to ensure that they are not inappropriately denied coverage. States will be required to offer reasonable modifications to individuals with disabilities, and will be required to exempt individuals determined to be medically frail or who have an acute condition that a medical professional has determined will prevent them from complying with the requirements.

Administrator Verma cited the Administration’s firm commitment to combat our nation's opioid crisis and the letter outlines that CMS will require states to make reasonable modifications for individuals with opioid addiction and other substance use disorders. These modifications may include counting time spent in medical treatment toward an individual’s community engagement requirements or exempting individuals participating in intensive inpatient or outpatient medical treatment, as well as supporting other state efforts.

CMS also encourages states to consider a range of activities that could satisfy work and community engagement requirements. States should ensure that career planning, job training, referral, and volunteering opportunities considered to meet the community engagement requirement, and job support services offered in connection with the requirement, take into account people’s employability and potential contributions to the labor market.

“States have the opportunity to help individuals improve and enhance the skills that employers truly value,” said Verma. “People who participate in activities that increase their education and training are more likely to find sustainable employment, have higher earnings, a better quality of life, and, studies have shown, improved health outcomes.”

Medicaid Demonstration Projects

Section 1115 of the Social Security Act gives the Secretary of Health and Human Services authority to approve experimental, pilot, or demonstration projects determined by the Secretary to be likely to assist in promoting the objectives of the Medicaid program. Demonstrations, which give states additional flexibility to design and improve their programs, are also designed to evaluate state-specific policy approaches and better serve Medicaid populations.

Administrator Verma also announced that CMS has updated Medicaid.gov to give states a clearer indication of how their reform strategies under section 1115 should align with a core objective of the Medicaid program: serving the health and wellness needs of the nation’s vulnerable and low-income individuals and families. The revised website content signals a new, broader view of these demonstrations in which states can focus on evidence-based approaches that drive better health outcomes, and quality of life improvements, and support upward mobility and self-sufficiency.

On March 14, 2017, the Department of Health and Human Services and CMS issued a letter to the nation’s governors affirming the federal government’s partnership with states to improve the integrity and effectiveness of the Medicaid program for low-income people with Medicaid. The letter encourages states to bring forward proposals grounded in ideas that reflect the dynamics and culture of a state.

“This new guidance paves the way for states to demonstrate how their ideas will improve the health of Medicaid beneficiaries, as well as potentially improve their economic well-being,” said Brian Neale, CMS Deputy Administrator and Director for the Center for Medicaid and CHIP Services.  

To view a copy of the SMD letter # 18-002, please click here.

CMS announces new payment model to improve quality, coordination, and cost-effectiveness for both inpatient and outpatient care 

CMS NEWS

FOR IMMEDIATE RELEASE
January 9th, 2018 

Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries

 

CMS announces new payment model to improve quality, coordination, and cost-effectiveness for both inpatient and outpatient care 

Today, the Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (Innovation Center) announced the launch of a new voluntary bundled payment model called Bundled Payments for Care Improvement Advanced (BPCI Advanced).  Under traditional fee-for-service payment, Medicare pays providers for each individual service they perform.  Under this bundled payment model, participants can earn additional payment if all expenditures for a beneficiary’s episode of care are under a spending target that factors in quality.

Bundled payments create incentives for providers and practitioners to work together to coordinate care and engage in continuous improvement to keep spending under a target amount. BPCI Advanced Participants may receive payments for performance on 32 different clinical episodes, such as major joint replacement of the lower extremity (inpatient) and percutaneous coronary intervention (inpatient or outpatient). An episode model such as BPCI Advanced supports healthcare providers who invest in practice innovation and care redesign to improve quality and reduce expenditures.

Of note, BPCI Advanced will qualify as an Advanced Alternative Payment Model (Advanced APM) under the Quality Payment Program.  In 2015, Congress passed the Medicare Access and Chip Reauthorization Act or MACRA.  MACRA requires CMS to implement a program called the Quality Payment Program or QPP, which changes the way physicians are paid in Medicare.  QPP creates two tracks for physician payment – the Merit-Based Incentive Payment System or MIPS track and the Advanced APM track.  Under MIPS, providers have to report a range of performance metrics and then have their payment amount adjusted based on their performance.  Under Advanced APMs, providers take on financial risk to earn the Advanced APM incentive payment. 

“CMS is proud to announce this Administration’s first Advanced APM,” said CMS Administrator Seema Verma.  “BPCI Advanced builds on the earlier success of bundled payment models and is an important step in the move away from fee-for-service and towards paying for value.  Under this model, providers will have an incentive to deliver efficient, high-quality care.”

In BPCI Advanced, participants will be expected to redesign care delivery to keep Medicare expenditures within a defined budget while maintaining or improving performance on specific quality measures.  Participant bear financial risk, have payments under the model tied to quality performance, and are required to use Certified Electronic Health Record Technology.  By meeting these requirements, the model qualifies as an Advanced APM.  The 32 types of clinical episodes in BPCI Advanced add outpatient episodes to the inpatient episodes that were offered in the Innovation Center’s previous bundled payment model (the Bundled Payments for Care Improvement initiative), including percutaneous coronary intervention, cardiac defibrillator, and back and neck except spinal fusion.

CMS designed this model taking into account rigorous evaluation results from previous CMMI models, industry experience with bundled payment, and stakeholder input from healthcare providers at acute care hospitals, physician group practices, and other providers and suppliers.  BPCI Advanced seeks to support and encourage participants who are interested in:

  • continuously redesigning and improving care,
  • decreasing costs by eliminating care that is unnecessary or provides little benefit to patients,
  • encouraging care coordination, and fostering quality improvement,
  • participating in a payment model that tests extended financial accountability for the outcomes of improved quality and reduced spending,
  • creating environments that stimulate rapid development of new evidence-based knowledge, and
  • increasing the likelihood of better health at lower cost through patient engagement, education, and on-going communication between doctors and patients.

The Model Performance Period for BPCI Advanced starts on October 1, 2018 and runs through December 31, 2023. Like all models tested by CMS, there will be a formal, independent evaluation to assess the quality of care and changes in spending under the model.

For more information about the model and its requirements, or to download a Request for Applications document (RFA), the application template, and the necessary attachments, please visit: https://innovation.cms.gov/initiatives/bpci-advanced. Applications must be submitted via the Application Portal, which will close on 11:59 pm EST on March 12, 2018. Applications submitted via email will not be accepted.

The CMS Innovation Center will hold a Q&A Open Forum on Tuesday, January 30, 2018 from 12 pm – 1 pm EDT. This event is open to those who are interested in learning more about the model and how to apply. Please register in advance here - https://preaward.adobeconnect.com/e3cdwg6hgx9f/event/registration.html

###

Get CMS news at cms.gov/newsroom, sign up for CMS news via email and follow CMS on Twitter CMS Administrator @SeemaCMS, @CMSgov