News
THE HEALTH PLAN HAS UPDATED ITS TIMELY FILING TO 180 DAYS
Effective 1/1/2020, the timely claims filing deadline for professional and facility claims submitted to The Health Plan (THP) will be 180 days from date of service (DOS). This includes medical, behavioral health, vision, dental and pharmacy claims. Make sure to view the complete announcement below for all information regarding the change.
Humana is having a new auth requirement effective 1/1/2020.
- Skin and Skin substitute. All Q CPT codes WILL REQUIRE PRIOR AUTH
- Physcial, Speech and Occupational Therapy. All 97 & 92 CPT codes WILL REQUIRE PRIOR AUTH
- Neurostimulators, including Batteries L8683, WILL REQUIRE PRIOR AUTH
Learn more here: Humana.com/PAL.
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/
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.
Determining Whether to Initiate Opioids for Chronic Pain: Identify and consider important patient factors when starting or continuing opioid therapy
Implementing CDC’s Opioid Prescribing Guideline into Clinical Practice: Walk through a quality improvement process using the set of 16 clinical measures outlined in Quality Improvement and Care Coordination: Implementing the CDC Guideline for Prescribing Opioids for Chronic Pain
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
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 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/
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.
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:
Here is a flyer for you and your patients to understand the 10 most important issues with the new Medicare identification cards:
For those of you with digital information screens in your reception areas, you can download this video from here:
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.
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
