It’s the Fall Season (Pun Intended)…
W06.XXXA — Fall from bednW15.XXXA — Fall from cliffnW12.XXXA — Fall from scaffolding
Only Credentialed Medical Assistants Can Enter EHR Orders
Q: One of my colleagues says that only “credentialed medical assistants” are permitted to enter orders in electronic health records (EHR) per Meaningful Use Stage 2. Can you explain?nnA: As of January 2013, only credentialed medical assistants have been permitted to enter medication, radiology, and laboratory orders into the EHR to count toward meeting the Meaningful Use thresholds under the Medicare and Medicaid EHR Incentive programs.nnAccording to Meaningful Use 2 core measure 1, any licensed healthcare professionals can enter orders into the medical record for purposes of including the order in the numerator for the objective of computerized physician order entry (CPOE).nnThe order must be entered by someone who could exercise clinical judgment in the event that the entry generates any alerts about possible interactions or other clinical decision support aids. This necessitates having the CPOE occur when the order first becomes part of the patient’s medical record, and before any action can be taken on the order.nnThe Centers for Medicare and Medicaid Services (CMS) did not specify any particular credentialing agency for medical assistants, but did say that the credentialing would have to be obtained from an organization other than the employing agency.nnMany working medical assistants have not graduated from an accredited program and thus are not eligible to sit for a certification examination offered by some agencies. The American Association of Medical Assistants (AAMA), the certifying agency for medical assistants, says these individuals are not eligible for certification by the AAMA, but they may be eligible for certification through other agencies.nnAccording to CMS, a non-certified individual, such as a scribe, is not qualified to enter these orders in the computerized provider order entry because there is no licensing or credentialing of scribes, so there is no guarantee of their qualifications for accuracy in such a position.nn
Documentation requirednnTo qualify for payments under the EHR incentive programs, providers will be required to present documentation of all entries, many of whom are automatically entered by the EHR system.nnCMS auditors have the authority to determine the entry of medication. Laboratory and radiology orders have been made by the licensed healthcare professional or credentialed medical assistant.nnIf the auditors find that the order entry was performed by an individual other than a licensed professional or credential medical assistant, it could constitute a violation. In that case it is possible that the order entry by the individual would not be counted toward meeting the Meaningful Use thresholds.nnConsequently, the eligible professional may not meet all the core objectives and as a result would not receive the incentive.nnSource: www.modernmedicine.com; Maxine Lewis; March 10, 2014.
Welter Healthcare Partners Celebrates its 20 Year Anniversary!
As we celebrate this 20th anniversary we acknowledge the fact that you, our clients and friends, are responsible for our success and longevity. We express our sincere thanks and appreciation to you for your business, your loyalty and your support during the past 20 years.nnFrom the very beginning we have understood: Our client’s success is literally our success!nnThe business of healthcare continues to create new challenges, obstacles, and opportunities! We look forward to another 20 years of helping our clients survive and thrive!
ICD-10, Dual Coding, and Dual Processing
Discussions of ICD-9 and ICD-10 often include mention of the terms dual processing and dual coding. Different people use these terms to mean different things, but in general, dual coding or processing refers to the use of ICD-9 and ICD-10 codes at the same time. So, when can you expect to use dual coding and processing and when can’t you?nnTesting to Prepare for ICD-10nDual coding and dual processing can be useful tools to prepare for ICD-10 by testing whether you are able to prepare, send, receive, and process transactions with ICD-10. However, ICD-10 can be used for testing purposes only before the compliance date; providers and payers cannot use ICD-10 in “live” transactions for dates of service before the ICD-10 compliance date.nnDual Coding and Dual Processing After the Compliance DatenFollowing the ICD-10 compliance date, providers and payers must use:n
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- ICD-9 in transactions for services provided before the compliance date
- ICD-10 in transactions for services provided on or after the compliance date
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nWhile providers and payers must be able to use both ICD-9 and ICD-10 codes after the compliance date to accommodate backlogs in claims and other transactions, they will not be able to choose to use either ICD-9 or ICD-10 for a given transaction. The date of service determines whether ICD-9 or ICD-10 is to be used.nnWhen Is the ICD-10 Compliance Date?nThe Department of Health & Human Services (HHS) has released a final rule that included a new compliance date that would require the use of ICD-10 beginning October 1, 2015. The new compliance date gives providers an extra year to prepare. The final rule also requires the continued use of ICD-9 for services provided through September 30, 2015.
The Sun Is Still Shining, Don't Forget Your SPF…
C43.31 – Malignant melanoma of nosennC43.11 – Malignant melanoma of right eyelid, including canthusnnD03.4 – Melanoma in situ of scalp and necknnD03.59 – Melanoma in situ of other part of trunknnIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2015 implementation date. Please don’t hesitate to contact us for all of your training and education needs!
School Is In Session…
Z02.0 — Encounter for examination for admission to educational institutionnnZ55.3 — Underachievement in schoolnnY92.157 — Garden or yard of reform school as the place of occurrence of the external causennY99.8 — Student activity as the external cause statusnnIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2015 implementation date. Please don’t hesitate to contact us for all of your training and education needs!
Registration for the Colorado Prescription Drug Monitoring Program
Legislation passed this year (House Bill 14-1283, now CRS 12-42.5-403) requires all Colorado prescribers who possess a DEA registration and all Colorado licensed pharmacists to register an account with Colorado’s Prescription Drug Monitoring Program (PDMP). Prescribers with a DEA registration and pharmacists must register an account by the corresponding deadlines below:n
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- Pharmacists and DEA-registered Advanced Practice Nurses: September 30, 2014
- DEA-registered Dentists, Veterinarians, Optometrists and Podiatrists: October 31, 2014
- DEA-registered Physicians and Physician Assistants: November 30, 2014
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nPrescribers and pharmacists are encouraged to register an account early but must do so prior to the respective deadlines above.n
Click here to register a PDMP account and for more information about the PDMP in general.
nAccount creation normally takes less than 5 minutes. Questions regarding how to register a PDMP account may be directed to the PDMP Help Desk at 1-855-263-6403.nnThe Colorado Prescription Drug Monitoring Program is a public health tool providing prescribers and pharmacists a secure database with immediate access to their patients history of controlled substance prescriptions (Schedules II – V) that they otherwise may not have.nnThe information in the PDMP can help prescribers and pharmacists make more informed decisions when considering prescribing or dispensing controlled substances.The secure database provides a more comprehensive health record and connects practitioners to their patients other prescribers and dispensers.nnSource: www.cdn.colorado.gov; 2014.
Rates and Volume, Volume or Rates
The fee-for-service world of professional reimbursement (compensation for services) is, essentially, the following economic transaction between payer and provider:n
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- Provider point of view: In exchange for patient volume being directed (Steered) into my practice I will allow for a discount off my billed charges.
- Payer point of view: we will direct patients into your practice via patient cost share amounts, in and out of network benefit differentials, etc. in exchange for an agreed to reimbursement schedule.
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nReimbursement amounts are sensitive to, among other things, the law of supply and demand. In larger urban areas the supply of a given specialty needed for the payers network dictates the reimbursement level. Where providers are in perceived short supply the price goes up. Where they are perceived to be in overabundance the prices go down or stay stagnant.nnIn some markets and specific to some specialties there is an overabundance of providers in a given specialty that has been tolerated for a variety of reasons: it keeps patients happy (patients like choice), it spreads out risk, it allows for stagnation of reimbursement, etc.nn
There is a tipping point however! Payers, who have fully insured customers, partially funded and self-funded customers (Employers and increasingly Affordable Care Act/Exchange membership) simply pass along the cost of care, one way or another, to their customers. Those customers (i.e. employers) have for far too long simply absorbed the increasing costs (or they have passed it along to their employees in the form of higher premiums, higher and higher cost share, deductibles, co-payments, etc.) and now we are seeing a rebellion. Why?…because they now can!nnThe payers and the traditional way their “product” (health insurance coverage) and “services” (paying claims, developing a network, medical management, etc.) are sold is going through just as much change as is being felt on the provider side. The brokers and direct sales people are having their commissions cut, employers are revolting – threatening to just allow their employees to go at it alone through the ACA and all of this is combining with the latest generation of work force who no longer stay with an single employer for very long and thus do not value the very expensive benefits lavished upon them. The young and healthy (those we need in the insurance system so desperately) tend to be very transient and don’t feel the handcuffs of great benefits.nnThe market is changing! The tipping point has arrived (depending on your specific location and your specialty). Health plans no longer want or need a large network of providers. They never did need a large network they just tolerated it for patient convenience and for rate pressure. The trouble with allowing large networks for so long (especially in a market that is more PPO than HMO) is that it is hard to dismantle it. Employers and more so patients have enjoyed having a lot of choice. Today (the tipping point) employers and patients pay more attention to the intolerable cost of premiums! Rates are out of control!nnIf and when a payer can shrink its network they will, especially if the payer can take credit for it. (“look at us, we dropped the most expensive providers from our network” or “We have identified for you the most expensive providers with our rating system”) Once upon a time providers could (and some did so successfully) get together in larger groups and use market dominants to demand higher fee-for-service reimbursements. Today (with some latitude to the specific market) that strategy only allows a health plan an excuse, the chance and the positive public relations to shrink its network size and push more volume into fewer providers.nn
Change always brings opportunity: The fee-for-service “beat our chests” and demand more days are over for most specialties, especially those which are in abundance. Such chest beating will simply play into the hands of the payers who are looking for an excuse to shrink their big networks.nnThe real opportunity exists in looking not at the rates providers receive but rather at the much larger overall Spend. Physicians receive roughly 16% of the Spend on any case, diagnosis, course of treatment (rough number). Physicians (and other provider colleagues) have, however, control of the other 84% of the Spend! Control it, take credit for its control and demand a piece of the larger number! The play is not in trying to make the smaller number bigger…The real play is getting a piece of the larger number.nnMore to come…
Are you ready for some football…
Y93.61 — Activity, American tackle footballnnY93.62 — Activity, American flag or touch footballnnW21.01XA — Struck by football, initial encounternnW21.81XA — Striking against or struck by football helmet, initial encounternnIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2015 implementation date. Please don’t hesitate to contact us for all of your training and education needs!
School Is In Session…
Z02.0 — Encounter for examination for admission to educational institutionnnZ55.3 — Underachievement in schoolnnY92.157 — Garden or yard of reform school as the place of occurrence of the external causennY99.8 — Student activity as the external cause statusnnIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2015 implementation date. Please don’t hesitate to contact us for all of your training and education needs!
Cash Flow Is Not Just Important, It's Everything
Cash flow is often the difference between keeping a private practice private and looking for an alternative situation that may not be quite as palatable to the doctors.
nTo us, Cash Flow is not just important… it is EVERYTHING. The staff and management of AMRS work very hard to generate regular, predictable cash flow including working with the practice staff to get the right information at the right time to the payers so they will be able to pay the claim quickly. Clean claims are the goal and we will do what is necessary to get a clean claim to the payer quick! Working with your staff to explain, coach and even prod to get the right information out the door fast. Billing is easy! Getting the right information to the right place is hard for some practices (maybe they have training issues or a lot of staff turnover or a thin labor pool), it is something we pride ourselves in.n
Q: You make it sound so easy, why do so may have problems with cash flow?
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A: It is often attention to detail and a training issue. Staff turnover causes disruption and “brain drain.” The Revenue Cycle requires constant attention, like riding a bike. It is easy but it has to be done right and constantly for the results to be good. Think of all the muscles, tendons, bones, joints and nerves working together to ride a bike, balance, eye sight, awareness and anticipation. Seems so easy when it is going well. When you have a broken leg or have lost your balance it then becomes incredibly difficult. Just one component not working well with all the others will make you crash your bike or crash your cash flow!
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Q: Everyone wants to be paid, why is Cash Flow itself so important?
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A: Cash Flow is everything in a service business. Cash Flow is the life blood of every service business. There are salaries and rent to pay whether one patient is seen or one hundred. The constant and predictable flow of reimbursement is critical.
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Q: Doctors (and other medical professionals) work as hard now as they always have (in some cases more so) but taking home less money. How can AMRS make a difference?
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A: Fee-for-service revenue, for procedures (what used to be the big ticket items), is under constant downward pressure. Some services are paid more and a lot are constantly being paid less. A good billing service understands this and works to help their customers to also understand it. At AMRS we not only bill and collect, we analyze billings and collections to help the providers maximize their revenue where ever possible. We are ready and able to work with and help our clients with other reimbursement methods. We are not only knowledgeable, we are excited to work with Capitation, Bundled payments, Risk adjusting and others. n
When it’s 90 degrees, everyone’s sweaty…
L75.0 – Bromhidrosis (Body Odor)nnL75.1 – Chromhidrosis (Colored Sweat)nnR61 – Excessive SweatingnnIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2015 implementation date. Please don’t hesitate to contact us for all of your training and education needs!
CMS Officially Sets ICD-10 Transition For October 1, 2015
The Centers for Medicare and Medicaid Services (CMS) has issued its final rule officially setting the ICD-10 transition date for October 1, 2015. Asserting that the new date “allows ample time” for the healthcare industry to prepare for the change, the final rule confirms what the agency told the industry in May after the one-year delay was voted through as part of the Protecting Access to Medicare Act of 2014.n
“ICD-10 codes will provide better support for patient care, and improve disease management, quality measurement and analytics,” said Marilyn Tavenner, Administrator of CMS in a press release announcing the finalization. “For patients under the care of multiple providers, ICD-10 can help promote care coordination.”
nAfter being blindsided by the unanticipated delay, CMS has only provided sporadic updates to the industry as it reworked its timelines, testing, and transition plans. Earlier in July, six Congressional leaders asked Tavenner for details about any newly laid plans for the conversion even as healthcare providers have been largely forging ahead with education and technical activities on their own.nnThe final rule has been published in the Federal Register and is available in full here.nnSource: www.ehrintelligence.com; Jennifer Bresnick; July 31, 2014.
Patient Eligibility
“Eligibility” is not what it once was! Commercial health plans have HMO’s and PPO’s and various other plan types, they also have various products within those categories, and just to make it more complicated some plans have plans within the plan specific to a given employer or group’s requirement. The Affordable Care Act has added to this confusion by adding more plan types, and those plans have various benefit calculations and yes, provider networks.nnEven Medicare and Medicaid have plans within plans. A patient who presents with “Medicare” could have straight/traditional Medicare but they could also have a Medicare Advantage plan with a specific network. Medicaid now has commercial carriers and many have very specific networks of providers, and patients can move in and out of these plans frequently. All of these changes are designed to help control costs and direct patients to the right place.nn(It’s not all bad thing – there is opportunity here – see below.)n
Performing patient eligibility checks, in real time, is more important than ever:
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- Does the patient have the insurance they think they have?
- Do they have the coverage they think they have?
- Are they seeking care from the right provider?
- Is your provider/practice in-network with the patient’s insurance?
- Is the patient on an exchange plan? Have they paid their premiums (to ensure your provider will be paid for the services they provide)?
- What is the patient’s co-pay, deductible and co-insurance, and what have they already met?
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nThe good news: Most of this can now be automated! Many of the good clearinghouses have a component that checks patient eligibility. Most can be done in real-time with up to the minute check of benefits and participation in a specific plan. Most can also check to see if your specific services are in-network, allowed and payable. This can now be done with the click of (a few) key strokes and fast internet connectivity.nnIt takes good and conscientious staff, constant training of your staff (to stay on top of changes), and the re-design of some work flows and seamless systems that talk to each other. The other great thing about clearinghouses is that they report mistakes – those reports just have to be read, analyzed and used as a tool for process improvement.n
Opportunities:
nWith such sophisticated systems out there, practices now have the opportunity to collect for services up front (if deductibles and co-insurance are not met) instead of tracking down payment from the patient afterwards. This will result in increased revenue and cash flow for the practice! Dentist offices have done this forever – it is time for medical practices to do the same!nnHealth plans and payers of all sorts are looking for those who can be and are willing to be “Eligible” to provide cost effective care. It may not be reimbursed in the traditional fee-for-service method but these niche opportunities do exist!
Don’t forget the SPF…
L55.0 — First degree sunburnnnL55.1 — Second degree sunburnnnL55.2 — Third degree sunburnnnIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2015 implementation date. Please don’t hesitate to contact us for all of your training and education needs!
Close Encounters Of The Camping Kind…
W55.52XA — Struck by raccoonnnL23.7 — Contact with poison ivynnT62.1X1A — Toxic effect of poisonous berries
VA Announces More Veterans May Seek Private Medical Services
It appears that the Veterans Administration will allow Veterans to seek care from private providers!
nWe need to look into how this will be done, to be prepared. n
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- How does a provider contract for this?
- Credentialing?
- Possible volume and where?
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nnUnder pressure to improve care, the Department of Veterans Affairs will allow more veterans to use private medical services to meet growing demands for healthcare, the department announced Saturday. Veterans Affairs Secretary Eric K. Shinseki said in a brief statement that as part of an expansion of services, veterans will be able to seek care at private clinics and hospitals in areas where the department’s capacity to expand is limited. In such situations, the VA “is increasing the care we acquire in the community through non-VA care,” Shinseki said.nnThe agency will provide more specifics on these options in the next few days, said Victoria Dillon, a department spokeswoman. It is unclear how much this service expansion will cost. The VA already spends about 10% of its budget on private care, which cost $4.8 billion last year. The new directive comes as Shinseki faces calls for his resignation amid allegations that VA employees have been covering up long wait times for medical care and falsified appointment records to hide the delays. A number of Republicans, at least two Democratic lawmakers and the commander of the American Legion have called for Shinseki to step down.nnTwenty-six VA facilities — including sites in Phoenix, San Antonio and Fort Collins, Colo. — are under federal investigation. Shinseki is expected to present President Obama a preliminary report on the facilities in the coming week. Rep. Jeff Miller (R-Fla.), chairman of the House Veterans’ Affairs Committee, said he was pleased by the policy change to allow private care, but thought it should have come earlier.nn”It appears the department is finally taking concrete steps to address the problem,” he said in a statement. He called the move “a welcome change from the department’s previous approach, which was to wait months for the results of yet another investigation into aa problem we already know exists.” Miller supports legislation that would let veterans turn to private care when the VA can’t meet their needs within 30 days.nnThe idea of increased private care has been embraced by some Republicans and Democrats as a possible response to the growing issue of shortcomings in the department’s care. Sen. John McCain (R-Ariz.) has embraced the idea, and House Minority Leader Nancy Pelosi (D-Calif.) has said she is open to it. Amid the allegations of treatment delays, the administration is scrambling to show a new responsiveness to criticism of how it handles the growing number of injured and ill veterans.n
nSource: www.latimes.como; Paul Richter; Richard Simon; May 24, 2014.
Notice of Material Change
Seems to be the Season for the Notice of Material Change!
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The health plans are required to send out a NOMC anytime there is a change that may affect provider compensation. nnTimes, must be a changing, as we are seeing an unprecedented number of NOMC notices.nnManaged care contracting is, increasingly, more about strategy than just rates, fee schedules and dates on a page. The health plans now have more competition: more plans, payment models and methodologies. They are also competing not just for the traditional employer business, but also for individuals. We (yes We – as you are a part of it, like it or not) are in a mad race to create and market plans that sound like PPO (with open networks) but are in reality very narrow networks with very specific patient cost share and steerage components.nnNavigation of these wild times requires strategy (both contracting strategy and billing know how)! Let us help you navigate the treacherous currents and eddies and help you be successful…after all it is a $2 Trillion industry, there is plenty of money, it’s just in different places than it used to be.n
It’s pool season, no diving in the shallow end…
S06.0X0A — Concussion without loss of consciousnessnnS01.01XA — Laceration of scalpnnW16.022A — Fall into swimming pool, striking bottom and causing injurynnY93.12 — Platform divingnnIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2015 implementation date. Please don’t hesitate to contact us for all of your training and education needs!
May in Colorado…
L55.2 — Sunburn of third degreennY93.17 — Water skiingnnT33.531A — Frostbite of fingersnnY93.23 — Snow skiingnnIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2015 implementation date. Please don’t hesitate to contact us for all of your training and education needs!