May 13, 2013 | Uncategorized
nnA recent incomplete CMS listing is raising concerns, as the state of Colorado is missing from the listing annltogether, and this leaves no way for providers to check to see if they are due for revalidation. Welter Healthcare Partners works with over 150 providers and has had providers whose PTANs have been deactivated due to non-response to the revalidation request. Representatives at Novitas have stated that they are receiving many phone calls on this concern, and that they have escalated it from the inside. They have further stated that this issue is being addressed at each staff meeting, there has not been a definitive resolution presented. If you have any questions, or need any assistance with this process, contact us today.n
Medicare is continuing their efforts to revalidate ALL Medicare providers! There are 2 years left in their intended timeframe.
nYou will be receiving a notification letter (letters being mailed between late 2011 & March 2015). You (the provider) only have 60 days to complete and submit the proper forms that must be completed. The process is/was to be suspended until after completion of the new MAC transition. However, if you do/did receive a revalidation notice, don’t ignore it! PTANs will be deactivated if forms are not received and processed, which means your payments will stop!nnIf you need assistance, please don’t hesitate to contact Welter Healthcare Partners’s dedicated credentialing department at 303.534.0388.nnSection 6401 (a) of the Affordable Care Act established a requirement for all enrolled providers and suppliers to revalidate their enrollment information under new enrollment screening criteria. This revalidation effort applies to those providers and suppliers that were enrolled prior to March 25, 2011. Newly enrolled providers and suppliers that submitted their enrollment applications to CMS on or after March 25, 2011, are not impacted. Between now and March 23, 2015, MACs will send out notices on a regular basis to begin the revalidation process for each provider and supplier. Providers and suppliers must wait to submit the revalidation only after being asked by their MAC to do so. Please note that 42 CFR 424.515(d) provides CMS the authority to conduct these off-cycle revalidationsnnWere you sent a Medicare revalidation request?nnIn the “Downloads” section (found here) is a listing of all providers and suppliers who have been mailed a revalidation notice. The files are broken down by the month in which the revalidation request was mailed. CMS will add lists on a bimonthly basis. If you are listed, and have not received the request, please contact your Medicare contractor. Their contact information can be found in the Downloads section, herennWould you like to learn more?nnIn the “Related Links Inside CMS” section, here, you will find the transcript of the October 27, 2011 National Provider Call about the Revalidation of Medicare Enrollment. You will also find helpful articles about the revalidation process, enrollment provisions of the Affordable Care Act and how to pay your enrollment application fee.nnStill have questions?nnQuestions concerning provider enrollment policy or your provider’s situation should be referred to your MAC. Their contact information can be found in the “Downloads” section below. Questions concerning a system issue regarding PECOS should be referred to the CMS EUS Help Desk at 1-866-484-8049, or send an e-mail to EUSSupport@cgi.com.nnSource: www.cms.gov; April 15, 2013.
May 3, 2013 | Uncategorized
Cerveza intoxication, uncomplicated — F10.120nnMontezuma’s revenge, bad tacos: T62.8X1A – Toxic effect of other specified noxious substances eaten as food, accidental, initial encounternnInjury due to falling piñata: W20.8xxA — Struck by falling object, initial encounternn nn[hr]nnIn 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, 2014 implementation date. Please don’t hesitate to contact us for all of your training and education needs!
May 3, 2013 | Uncategorized
While most hospital leaders see the advantages of moving to bundled payments for an episode of care, many are unprepared either for the mindset or the mechanics required to implement the emerging reimbursement model. Here are the concerns and possible strategies you should consider. n
FRAMING THE ISSUE
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- Momentum is building to replace the fee-for-service payment system with one that emphasizes value over volume. Bundled payment is one strategy being tested by hospitals around the nation.
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- Bundled payments require hospitals to align incentives by contracting with physicians and to share risk. But many providers are not yet ready to determine a fixed cost for an episode of care.
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- Hospitals will need historical data on care for patients with similar medical situations as well as analytical data on what to pay individual clinicians.
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- Early adoption of bundled payment may be an advantage for hospitals by solidifying their place in the market and attracting docs and insurers.
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nAt Geisinger Heart Institute in Bloomsburg, Pa., unraveling the mysteries of bundled payment was a breeze compared with what other health care organizations will face. The institute has offered bundled payments for cardiac surgery since 2005, and Alfred Casale, M.D., who is chairman of surgery and co-director of the cardiovascular service line, says establishing the process was relatively painless because the organization employed the cardiologists and other clinicians involved, and because Geisinger Health Plan owned the hospital and had a robust electronic health record system.nnFor most hospital leaders, setting a bundled price on an episode of patient care will be much more complex. Administrators and their physician partners must collect reams of patient data, spend hours identifying best practices and develop teams of clinicians to run these programs. Unlike Geisinger Heart Institute, they are likely to contract with physicians they may or may not employ and work with health plans with which they are otherwise unaffiliated. For everyone, including Casale’s organization, bundled payment represents a different way of thinking and poses significant challenges.nn[vc_toggle title=”Aligning Financial Incentives” size=”sm” el_id=””]Hospitals and health systems have several reasons to pursue bundled payment. For one, the Centers for Medicare & Medicaid Services support the approach, approving more than 500 organizations for its Bundled Payments for Care Improvement initiative in January. Other hospitals want to replace fee-for-service payment and move toward full-risk contracting. Still others see an opportunity to align incentives by contracting with physicians and health plans so that all parties are working to improve care quality, eliminate unwarranted variation and lower costs.nn”Bundles facilitate the alignment of incentives for providers to work together across the continuum of care, resulting in the collaboration of partners across all specialties and settings to maximize quality and efficient care,” says Mike O’Boyle, president and CEO, Parallon Business Solutions, a consulting firm. “For those hospitals and physicians that have not had experience with population health, bundled payments are mechanisms to allow for their evolution into shared-risk arrangements.”nnUnder bundled payment, a hospital and physicians assume the financial risk for delivering all care for one price for one patient episode over a set period — usually 30, 60, 90 or 120 days. Most bundled payment programs today are for acute care episodes, such as hip or knee replacement or spine or cardiac surgery. Some health plans are making bundled payments to providers for patients with asthma, diabetes, cancer and other chronic conditions. In these cases, the episode of care is usually for one year.nn”Bundled payments are incredibly effective in transforming care because they focus providers on areas where there are unwarranted variations and realizable savings,” says Jay Sultan, associate vice president and general manager of payment reform at the TriZetto Group, a consulting firm. “Bundled payment brings alignment with physicians that allows hospitals to cut their variable costs and reduce postsurgical complications, pharmacy costs and length of stay.”nnManaging the financial risk is the key challenge of bundled payment because hospitals and physicians guarantee to deliver all services for each patient’s full episode of care, including any complications. In this way, bundled payment comes with a guarantee: The physicians and hospitals cover the costs of postsurgical infections or the need for rework or a readmission.nn”If a hospital and the physicians are unable to successfully work together to reduce the average cost of the episode, they would be at risk for those costs above the negotiated budget,” O’Boyle explains.[/vc_toggle]nn[vc_toggle title=”Working Through Uncertainty” size=”sm” el_id=””]n
The at-risk nature of bundled payment may leave hospital administrators feeling somewhat unsure about how to proceed, as Casale did in 2005. “We were preparing a presentation for the board of directors about bundled payment, which Geisinger calls ProvenCare,” he says. “We decided to offer one price for a package of services to include everything from the first office visit through the surgery and for 90 days postsurgery.”nnInstitute leaders had two and a half years of data that showed what GHP paid for coronary artery bypass grafts. They also knew that related complications tended to occur within four weeks of the operation and that by 90 days, 99 percent of all complications had occurred. That’s why they set the episode duration at 90 days.nn”Then we had to set a price,” Casale says. “We had never done this and our presentation was the next day. There was no calculus or even any science involved. We just took the average cost and decided to charge half. At the board meeting the next morning, we said, ‘Give us half of the average charges in a package price and we’ll immunize you for the cost of care for any related complications at a Geisinger facility for 90 days.’ “nnSince then, the program has worked so well that it was cited as an example of the effective use of evidence-based protocols in the Institute of Medicine’s report, Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, published last September. The report shows that Geisinger cut operative mortality by 67 percent and length of stay by 1.3 days. Revenue minus expenses improved by more than $1,900 per case and the cost per case dropped by 4.8 percent. Also, GHP had a 23 percent increase in profit for each episode of cardiac care, the IOM reports.nnAlthough the results are dramatic and demonstrate how physicians armed with data and a willingness to assume risk can effect change, Geisinger is not representative of the kinds of bundled payment arrangements hospitals typically make with physicians and health plans. Health plans are unlikely to send unaffiliated hospitals the data they need on costs and complications. Without that data, hospitals may find it difficult to analyze past expenses because most hospitals do not have a true understanding of the cost of episodes of care, O’Boyle says.[/toggle]nn[vc_toggle title=”Spreadsheets Required” size=”sm” el_id=””]n
“Many hospitals have yet to determine the best process to allocate fixed costs to an episode to determine a fully loaded cost per episode,” O’Boyle says. “Most hospitals will need to undertake a process like activity-based costing to understand their costs per episode. That costing process will need to include all care providers and settings, which can be cumbersome and time-consuming.”nnMost hospitals have not changed their revenue-cycle management process for many years and have systems that are not designed for bundled payment, says Shannon Dauchot, Parallon’s senior vice president of corporate operations and client relations. Most payers don’t have the systems they need to make bundled payment work either. “That means hospitals might have to use spreadsheets to collect all the numbers they’ll need,” she says. “By starting small, they can sort through each bundle until they figure out what can be automated. But we’re not aware of a one-size-fits-all system that does all that because every bundle and every group of providers will be different.”nnIndeed, when collecting the data it needed for bundled payments for hip and knee replacements, Crozer-Keystone Health System used spreadsheets.nn”We spent an incredible amount of time and resources looking at financial modeling and getting people to help us do the modeling for bundled payment,” says Susan L. Williams, M.D., Crozer-Keystone’s senior physician for clinical integration. “Starting in 2008, our strategy was to build primary care around patient-centered medical homes, and so we had a fair amount of experience with collecting the data and building the data systems required to pull out quality metrics on individual physicians or physician groups for bundled payment. And, our finance people are great at calculating costs. But marrying all the data on costs and quality has been a journey.”nnElizabeth Jaekle, Crozer-Keystone’s vice president for business development, agreed. “There is a level of nuance that we had not counted on with bundled payment,” she says. “Our cost accounting system was not set up to facilitate bundled payment or any kind of gainsharing because it collected data in aggregate and averages, which is fine for most of the work we do. But when you’re compensating for quality improvement, you need to measure the rate of change and differentials at an actual point in time.”nnMost cost accounting and information systems are not oriented to measure and report such data. “So, first we had to use spreadsheets to collect what we needed and then we put the data into various working documents that we could evaluate,” Jaekle adds. “From there, you can start to put together the infrastructure to automate these systems.”nnOvercoming these hurdles helped Crozer-Keystone learn enough that CMS approved its application in January to implement bundles for hip and knee replacements under the BPCI.nnHospitals also face challenges in collecting data on each provider who will deliver care in a bundle, says Joseph J. Fifer. Before he became president and CEO of the Healthcare Financial Management Association last June, Fifer was vice president of hospital finance at Spectrum Health in Grand Rapids, Mich., where he implemented four bundled payment programs.nn”Collecting all the data elements that span across multiple providers might be a bigger hurdle to clear than the accounting issues,” he says. “There aren’t any systems today that can easily gather data on a patient-specific basis and that span the entire episode of care from the first primary care visit to the last exam. By its nature, bundled payment covers everything, meaning you have to include costs for post-acute care, rehabilitation and physical therapy.”nnHaving the data on costs and quality is critical to the success of a bundled payment initiative, agrees James T. Caillouette, M.D., surgeon-in-chief at Hoag Orthopedic Institute in Irvine, Calif. Hoag has a bundled payment program for hip and knee replacement surgery. “The key to success or failure hinges on alignment with the participating physicians,” he says. “Everyone needs full cost transparency because you are going to be accountable for the cost of care in a way that you have never before been accountable. Typically, this kind of accountability is difficult because hospitals and health plans are not readily going to share their costs with physicians and other providers.”nnBefore allowing its doctors to participate in the bundled payment program, Hoag examines physicians’ past results. “We’re looking for costs, infection rates, outcomes and the reasons behind any readmissions. You have to set the bar high because those who can achieve that bar will participate in the bundle and those who haven’t achieved that bar need to work toward it so they can participate,” Caillouette says.nnFor Hoag, gathering information on its physicians is relatively easy because the institute is a collaboration between the orthopedic physicians and Hoag Memorial Hospital Presbyterian.nnWhen separate entities develop bundled payment initiatives, collecting information from outside providers can be difficult, says Caroline Steinberg, vice president of trends analysis for the American Hospital Association. “Hospitals have never had any information on what happens to patients outside their doors,” she explains. “There are a lot of tricky issues with bundled payment because hospitals have never taken on responsibility for care across the continuum.”nnNot only does the hospital need historical data on care for similar patients so that it can decide what to charge, it also needs to know how much to pay each individual physician and other clinicians delivering care in the bundle.nnCollecting that data for each episode of care is just part of the solution. “The real trick to make bundled payment work is that information must be readily available to the various providers on a need-to-know basis virtually in real time as opposed to what we have now,” Fifer says. “You’re pricing based on last year’s numbers but you’re doing the surgery this year and paying out on this year’s numbers. Making all the data available in real time today is a huge challenge.”[/vc_toggle]nn[vc_toggle title=”Fewer Heads In Beds” size=”sm” el_id=””]nOnce a hospital standardizes care and cuts lengths of stay, it could create a new problem: reduced revenue. That’s leading some observers to question whether bundled payment works against a hospital’s best interests. “If we go down this path in any material way, what does that mean about how many beds we need?” Fifer asks. “What does it mean for the pure existence of many hospitals, especially those in small, rural communities?”nnBecoming an early adopter may be one answer. “The hospitals that are the first movers get an advantage by seizing the opportunity to acquire volume,” TriZetto’s Sultan says. “Bundles for cardiac or orthopedic surgery can be the most profitable cases in hospitals, making them crucial for hospital success. Plus, getting a higher fee in a bundled payment is a profound financial incentive for surgeons to refer patients.”nnEarly adoption has another advantage. “Bundled payment not only allows hospitals to transform the delivery of care, but also to solidify their place in the market,” Sultan says. “Once the program is running smoothly, other physicians, such as oncologists, will want to develop bundles. And health plans may start coming to you as well.”nnJoseph Burns is a freelancer writer in Falmouth, Mass., specializing in health care strategies.[/vc_toggle]nn
nn[vc_toggle title=”How Bundled Payment Differs From Global Payment” size=”sm” el_id=””]nnBoth bundled and global payment systems provide financial incentives for hospitals and physicians to deliver better care and control costs. Though similar, the two forms of reimbursement differ in significant ways.nnBundled payment is for a specific set of services, such as an episode of care for hip or knee replacement or all services for one year of care for a patient with asthma or diabetes. A hospital and physicians would work together to care for a health plan’s patients and may share in any savings if costs are lower than a specified target. The providers also are required to care for patients who have complications during the episode of care, usually 30 to 120 days for acute conditions or a full year for chronic care.nnGlobal payment, also called capitation, is for all care for a patient for a month or a year. Physicians are responsible for all primary care to these patients and may share in any savings at year end. Hospital and specialist care may or may not be included in the global budget.nnFor Blue Cross Blue Shield of Massachusetts, choosing bundled or global payment hinged on the willingness of physicians to accept financial risk, says Deborah Devaux, senior vice president of network & service integration. “We’ve seen how the various bundled payment approaches are being implemented. But for acute conditions, we already pay a fee based on diagnosis-related groups, which is a form of bundled payment,” Devaux explains. “For surgery, we also pay a DRG.”nnUnder its global payment initiative, called the Alternative Quality Contract, BCBSMA pays provder organizations for all care delivered to a patient for a year. Physicians can share any bonuses with the affiliated hospitals, Devaux says. She believes the AQC allows the Blues plan to control costs more closely than it could under bundled payment while also providing an incentive for quality improvement.nn”The AQC creates an environment where hospital administrators have to consider how to support physicians in avoiding unnecessary admissions, readmissions and emergency room visits,” she says.nnPlus, for patients with multiple chronic conditions, bundled payments may require multiple bundles, which can be confusing and may lead to global payment anyway, she adds.[/vc_toggle]nn
nn[vc_toggle title=”Physician–Hospital Integration Is Key” size=”sm” el_id=””]nn[toggle title_open=”” title_closed=”Physician–Hospital Integration Is Key” hide=”yes” border=”yes” style=”default” excerpt_length=”0″ read_more_text=”Read More” read_less_text=”Read Less” include_excerpt_html=”no”]When contracting for bundled payment, Blue Cross and Blue Shield of Florida closely examines the legal entities in its bundled payment contracts, says Andy Marino, the health plan’s vice president of network development.nnSince March 2011, Florida Blue has had a bundled payment program for laparoscopic radical prostatectomy surgery with Mobile Surgery International and two bundled payment programs for knee replacements. One is with the Mayo Clinic and one is with the Florida Orthopaedic Institute.nn”It’s easy for us to contract with the Mayo Clinic because Mayo’s physicians and the hospital facility are fully integrated,” he explains. Florida Orthopaedic Institute is similar in that it employs anesthesiologists and has an outpatient surgery center. “Therefore, it can bring the facility component all under one tax identification number,” Marino says.nnAlthough hospitals have asked Florida Blue about bundled payment, not all are ready to do so. “A hospital needs to be able to take a lump sum payment and then pay some of those dollars to the surgeon and everyone else involved in the care,” he explains. “But if they don’t have the legal structure to do that, then it creates problems for us.”[/vc_toggle]nn
nn[vc_toggle title=”Report Outlines Steps For Facilities Adopting Bundled Payment” size=”sm” el_id=””]nn[toggle title_open=”” title_closed=”Report Outlines Steps For Facilities Adopting Bundled Payment” hide=”yes” border=”yes” style=”default” excerpt_length=”0″ read_more_text=”Read More” read_less_text=”Read Less” include_excerpt_html=”no”]
A January issue brief from the American Hospital Association, Moving Towards Bundled Payment, explains the steps hospitals and health systems would take to develop such programs. By examining how to define an episode of care and how to evaluate the distribution of costs across service lines, the brief offers a starting point and guide for hospital administrators in how to manage costs, risk and unwarranted variation.nn”Understanding where the costs are concentrated helps identify where cost-reduction opportunities are likely to be found and where partnerships with other providers or specific types of interventions may be most important,” the brief states.nn”Bundled payment comes down to the opportunity to improve quality and efficiency,” says the report’s author, Maulik S. Joshi, Dr.P.H. President of the Health Research & Educational Trust and senior vice president of research at the American Hospital Association, Joshi calls bundled payment a vehicle to manage financial risk and care across various care delivery settings. “The triggers that allow bundled payment to succeed are improved quality and improved efficiency. As a natural artifact of those two aims, you have to address unwarranted variation and you have to address care coordination,” he says. Bundled payment also gives hospital administrators a new and perhaps more complete view of the full continuum of care than they normally have. “The fact that hospitals have not looked at the continuum of care is not a knock on hospitals. It’s just a reality,” Joshi comments.nnAnother issue that may be new to hospital administrators is the link between risk and high levels of unwarranted variation. “The ability to identify, understand and eliminate variation in care practices will be critical to success under bundled payment,” the report adds. Hospitals that measure variations in cost may be better able to manage risk. For example, the report shows how the difference in costs between the 25th and 75th percentile (the interquartile range) for a percutaneous cardiovascular procedure with drug-eluting stent is approximately $3,251, or about 28 percent of the median episode cost. But the same difference in costs for chronic obstructive pulmonary disease is about $3,884, or 80 percent of the median episode cost. Administrators may want to select episode types that have enough variation to provide opportunities for cost-reduction, but not so much variation that they pose excessive risk to the organization. “We are still early in our ability to measure risk,” Joshi explains. “Therefore, maybe it’s better to figure out why the variation is so high rather than put it into a bundled payment program.”[/vc_toggle]nnSource: www.hhnmag.com; Joseph Burns; April 4, 2013.
Apr 22, 2013 | Uncategorized
With the news that CMS has started conducting pre-payment audits to monitor meaningful use payments, some providers have been worried about what it means if they get a letter in the mail. Below, Rob Anthony, Deputy Director of the HIT Initiatives Group, Office of E-Health Standards and Services at CMS, discusses how CMS is handling its EHR audits of potential meaningful users, and to give some tips to providers about what to have on hand if an auditor comes knocking on the door.nn[vc_toggle title=”What’s the purpose of meaningful use audits, and how do they help CMS and providers?” size=”sm” el_id=””]As a government agency, we do an audit for anything where we’re disbursing funds. We obviously want to be sure that the right people are getting paid who should get paid, and that people have done what they said they did. So we take the oversight of the payment pretty seriously, and a robust audit program is really an essential component of that oversight. And really, the purpose of the audits is partially to detect inaccuracies in things like eligibility or reporting and payment information, ensuring that the providers who are participating in the Medicare EHR Incentive Program are only receiving payment if they successfully demonstrated meaningful use and met the other program requirements.nnBut also, as we’re moving into years where the payment adjustments take effect, we’re moving into a time where providers, if they’re not meaningful users, will receive payment adjustments. So we want to ensure that, as we move forward, everybody who is actually attesting to meaningful use is really a meaningful user so that they can avoid those adjustments moving forward. Incentives are great, but we want to make sure that people aren’t subject to those payment adjustments when they don’t have to be.[/vc_toggle]nn[vc_toggle title=”The OIG made some strong recommendations last year about how CMS should improve their oversight of EHR Incentive Payments. How are you addressing these concerns?” size=”sm” el_id=””]We’ve instituted the pre-payment audit program, after initially only doing post-payment audits. It should be noted that at the time the OIG report was initially compiled, we really were at the very beginning of our audit program. We were really just establishing the audit protocols that we use to determine what documentation to ask for, what to look for, and how we go out and talk to providers, so we really didn’t have a developed audit program at the time those recommendations were released. As we have moved forward, I think that we have been able to really figure it out.nnWe do both random and targeted audits, and we’ve figured out the type of things that are anomalous and raise a red flag for us to start taking a look at, so that allows us to be much more robust in our oversight. And now, with the introduction in January of the pre-payment audits, we’re doing that random and targeted check of providers to look at their attestation before they actually receive payments. We think that appropriately addresses the OIG recommendations.[/vc_toggle]nn[vc_toggle title=”What are some of the things you look for, and how can providers satisfy the audit requirements?” size=”sm” el_id=””]nnWe can’t really tell you exactly what we’re looking at, because it’s an audit program. But I can tell you one of the primary areas to look at is documentation. This is an attestation program, and when we come to look at someone, we want to see that they have documentation that supports the attestation information that they entered. And that’s why we’ve released the documentation guide on our website that goes through each of the objectives and gives a suggested documentation example, whether that’s a screenshot from a certified EHR system that’s dated, or whether it’s a report for your clinical quality measurements.nnMake sure you have that type of documentation on hand. I always tell people that when you go through and attest, not everybody’s system is able to provide a snapshot in time. Not everybody’s system is able to go back to the date you attested and show what the data looks like. They may have a system that has rolling data, which means that information that you’ve entered long after the close of the reporting period could actually affect the measurement that your system does when you make a subsequent report. So I always suggest that providers make a print or electronic copy of the actual report that they used for attestation so they can show those numbers when an auditor requests supporting documentation.nnThe other area that I can say where there’s great confusion is the security risk analysis. We always suggest they make sure they know what they have to do as part of a security risk analysis with their EHR system. A lot of people don’t realize that analysis is the same type of thing that they should be doing under HIPAA for all privacy and security. This one is just specific to their EHR system. So familiarize yourself with those HIPAA requirements, make sure you have some type of security risk analysis specific to your EHR, and be sure it’s dated. And be sure that if you have not been able to address all of the concerns raised in the risk analysis, that you at least have a plan to address those concerns.[/vc_toggle]nn[vc_toggle title=”What advice do you have for providers who might be nervous about the audit process?” size=”sm” el_id=””]nnI’ve talked to several vendors and consultants, and they tell their clients this same thing: make sure that you enter the accurate information. Make sure that you have the documentation to support it. If you have those things, then you’re a meaningful user, and you don’t have anything to worry about. This is one of those areas where prevention is truly the best way to address this. So just make sure that you have the documentation ahead of time. The information we’ve put out on supporting documentation is a great place to find out what you need and what has to be there. Make sure everything is dated and that it specifically shows that it’s for you. You should have your NPI or provider name to show that this is evidence that supports your EHR system.[/vc_toggle]nnSource: www.ehrintelligence.com; Jennifer Bresnick; April 15, 2013.
Apr 18, 2013 | Uncategorized
T88.4xxA – Failed or difficult intubation, initial encounternnT42.5X6A – Underdosing of antiepileptics, initial encounternnT82.515A – Mechanical breakdown of cardiac umbrella device, initial encounternn nnIn 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, 2014 implementation date. Please don’t hesitate to contact us for all of your training and education needs!
Apr 10, 2013 | Uncategorized
Saturday:
nL55.9 – SunburnnR61 – SweatingnW29.3xxA – Contact with powered garden tools, initial encountern
Tuesday:
nT33.90 – FrostbitenX37.2xxA – Injury due to blizzard, initial encounternW29.8xxA – Contact with snow shovel, 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, 2014 implementation date. Please don’t hesitate to contact us for all of your training and education needs!
Apr 10, 2013 | Uncategorized
To All Health Care Professionals, Providers, and Suppliers:n
Mandatory Payment Reductions in the Medicare FFS (Fee-for-Service) Program – “Sequestration”
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The Budget Control Act of 2011 requires, among other things, mandatory across-the-board reductions in Federal spending, also known as sequestration. The American Taxpayer Relief Act of 2012 postponed sequestration for 2 months. As required by law, President Obama issued a sequestration order on March 1, 2013. The Administration continues to urge Congress to take prompt action to address the current budget uncertainty and the economic hardships imposed by sequestration.nnThis listserv message is directed at the Medicare FFS program (i.e., Part A and Part B). In general, Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment. Claims for durable medical equipment (DME), prosthetics, orthotics, and supplies, including claims under the DME Competitive Bidding Program, will be reduced by 2 percent based upon whether the date-of-service, or the start date for rental equipment or multi-day supplies, is on or after April 1, 2013.nnThe claims payment adjustment shall be applied to all claims after determining coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments.nnThough beneficiary payments for deductibles and coinsurance are not subject to the 2 percent payment reduction, Medicare’s payment to beneficiaries for unassigned claims is subject to the 2 percent reduction. The Centers for Medicare & Medicaid Services encourages Medicare physicians, practitioners, and suppliers who bill claims on an unassigned basis to discuss with beneficiaries the impact of sequestration on Medicare’s reimbursement.nnQuestions about reimbursement should be directed to your Medicare claims administration contractor. As indicated above, we are hopeful that Congress will take action to eliminate the mandatory payment reductions.
Apr 3, 2013 | Uncategorized
Medicare PECOS Edits Begin May 1, 2013 – Claim Denials Possible
nEffective May 1, 2013, the Centers for Medicare & Medicaid Services (CMS) will turn on the Phase 2 denial edits. This means that Medicare will deny claims for services or supplies that require an ordering/referring provider to be identified and that provider is not identified, is not in Medicare’s enrollment records, or is not of a specialty type that may order/refer the service/item being billed.nnThe Affordable Care Act, Section 6405, “Physicians Who Order Items or Services are Required to be Medicare Enrolled Physicians or Eligible Professionals,” requires physicians or other eligible professionals to be enrolled in the Medicare Program to order or refer items or services for Medicare beneficiaries. Some physicians or other eligible professionals do not and will not send claims to a Medicare contractor for the services they furnish and therefore may not be enrolled in the Medicare program. Also, effective January 1, 1992, a physician or supplier that bills Medicare for a service or item must show the name and unique identifier of the attending physician on the claim if that service or item was the result of an order or referral. Effective May 23, 2008, the unique identifier was determined to be the National Provider Identifier (NPI). The Centers for Medicare & Medicaid Services (CMS) has implemented edits on ordering and referring providers when they are required to be identified in Part B, DME, and Part A HHA claims from Medicare providers or suppliers who furnished items or services as a result of orders or referrals.nnThis means that starting May 1, Medicare will deny claims for Medicare-covered services ordered/referred by a physician for durable medical equipment, prosthesis, orthotics and services (DMEPOS), clinical lab, radiology services and certification of home health if the physician does not have a Medicare profile in the Medicare enrollment system, PECOS. The Centers for Medicare & Medicaid Services (CMS) says physicians who order such services and are not enrolled should do so immediately, or the applications may not be processed before May 1.nnSo if you order or refer items or services for Medicare beneficiaries and you do not have a Medicare enrollment record, you need to submit an enrollment application to Medicare. You can do this using the Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) or by completing the paper enrollment application (CMS-855O). Review the background and additional information below and make sure that your billing staff is aware of these updates.n
The Ordering and Referring Files n
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The downloads below contain the National Provider Identifier (NPI) and legal name (last name, first name) of all physicians and non-physician practitioners who are of a type/specialty that is legally eligible to order and refer in the Medicare program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS).nnA new file will be made available periodically that will replace the posted file; at any given time, only one file (the most recent) will be available. The file can be downloaded by users with technical expertise and further sorted or manipulated. It can also be used to search for a particular physician or non-physician practitioner by NPI or by name. Please note the following: (1) Records are in alphabetical order based on the surname of the physician or non-physician practitioner. (2) Name suffixes (e.g., Jr.), if they exist, are not displayed. (3) There are no “duplicates” in the file. Many physicians or non-physician practitioners share the same first and last name; their corresponding NPIs are the assurance of uniqueness. (4) Deceased physicians and non-physician practitioners are not included in the file.nnThere are two file formats for the Medicare Ordering and Referring File below. The first is a PDF format. This file will allow a user to verify that an individual physician or eligible professional has an approved enrollment record in PECOS using Adobe Acrobat Reader. The second file is a ZIP file. The ZIP file contains the same information as the PDF, however, the file is a CSV format. The CSV file will allow users to open the Ordering and Referring data in Excel, Notepad and other software formats that could be easier for users to search/sort.nnIn order to use the CSV file, please left-click on the “Medicare Ordering and Referring File [ZIP, 64400KB]” and save the CSV document contained in the zipped download. Right-click on the saved CSV file, select “Open With” on the task bar and select the program through which you would like open the Medicare Ordering and Referring File.nnUsers must have the most recent version of Adobe Acrobat Reader and/or Excel in order to open the PDF and/or CSV file.nnThe new Initial Physician and Non-Physician Applications Pending Contractor Review files are lists of applications pending contractor review. These pending applications have NOT been processed by the CMS contractors. These lists have been compiled to allow individuals the ability to verify that an application has been submitted and is awaiting processing.nnThe downloads below are the most recent versions of the O&R file. For a specific create date, please review each document individually.n
Educational Material MLN Matters® article #SE1305 Full Implementation of Edits on the Ordering/Referring Providers in Medicare Part B, DME and Part A Home Health Agency (HHA) Claims.
nMedicare Enrollment Guidelines for Ordering/Referring ProvidersnnThe Basics of Medicare Enrollment for Physicians Who Infrequently Receive Medicare Reimbursementn
Downloads
nMedicare Ordering and Referring File – PDF [ZIP, 32MB] nnMedicare Ordering and Referring File – CSV [ZIP, 9MB] nnInitial Physician Applications Pending Contractor Review [ZIP, 228KB] nnInitial Non Physician Applications Pending Contractor Review [ZIP, 92KB]nn[hr]Click here for more information.n
Need help with PECOS enrollment? Call us today!
nSource: www.envoynews.com; April 3, 2013.
Apr 3, 2013 | Uncategorized
J30.1 – Hay fevernnJ30.81 – Rhinitis due to animal dandernnJ30.2 – Seasonal allergiesnnJ30.89 – Rhinitis due to feathersnnL23.7 – Allergic Dermatitis due to plantsnnIn 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, 2014 implementation date. Please don’t hesitate to contact us for all of your training and education needs!
Mar 29, 2013 | Uncategorized
W61.33xA – Pecked by Easter chick, Initial EncounternnT62.8x1A – Food Poisoning, accidental, Initial Encounter, old hard-boiled Easter EggnnF40.218 – Easter Bunny Phobiann nnIn 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, 2014 implementation date. Please don’t hesitate to contact us for all of your training and education needs!
Mar 29, 2013 | Uncategorized
CAQH recently launched a new solution to enroll in EFT with participating payers through a universal process! Enrollment is easy!nnUsing CAQH’s EFT Enrollment utility, providers can securely enroll in electronic payment programs with payers. The site streamlines enrollment in these programs by eliminating the multiple and different forms required by each payer, and centralizing EFT enrollment between multiple payers. Once the information is entered, making changes for your practice can be done quickly and easily.n
Go to https://solutions.caqh.org for more information.
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Source: www.caqh.org; January 30, 2013.
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Healthcare and Reimbursement Updates
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Mar 29, 2013 | Uncategorized
On March 13, 2013, the Centers for Medicare & Medicaid Services (CMS) issued a ruling contrary to its traditional billing policy regarding payment of Part B inpatient services following denial of a Part A claim. Ruling CMS-1455-R came about in response to an increasing number of Administrative Law Judge (ALJ) and Medicare Appeals Council decisions relating to RAC audit appeals which, while upholding Part A denials based on determinations that inpatient admissions were not reasonable and necessary, ordered payment under Part B as if services were rendered at an outpatient or “observation level” of care. The Ruling allows providers to submit Part B inpatient claims for a more expansive range of services upon denial of Part A claims during RAC appeals.nnUnder the Ruling, a hospital may submit Part B inpatient claims for services beyond those listed in the Medicare Benefit Policy Manual (MBPM) when:n
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- A Medicare review contractor denies the Part A inpatient claim upon finding that the inpatient admission was not reasonable and necessary;
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- The Part B services would have been payable to the hospital if the beneficiary was treated initially as an outpatient; and
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- The billed services do not require outpatient status, e.g. outpatient visits, emergency department visits, and observation services.
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nThe Ruling allows hospitals to submit Part B claims for payment provided the hospital withdraws its appeal on the corresponding Part A claim. The Ruling applies to Medicare claims denied by RAC auditors after March 13, 2013, or Medicare claims in a pending RAC appeal at any level as of March 13, 2013. Going forward from this Ruling, the scope of RAC appeals will be limited to review of Part A inpatient claims, and ALJs are not to order Part B payment or remand for consideration of Part B payment.nnLastly, the Ruling sets forth the time period within which a provider must bill the Part B claims. Generally speaking, hospitals must submit Part B claims within 180 days of receipt of an appeal dismissal notice, final or binding unfavorable appeal decision, or determination of a Part A inpatient claim for which there is no pending appeal and for which the hospital does not appeal. Further, Part B inpatient and outpatient claims filed later than one year after the date of service will not be rejected as untimely, provided the denied Part A inpatient claim was timely filed.n
CMS Proposed Rule
nConcurrent with the Ruling, CMS released a proposed rule on Part B inpatient billing that would apply on a prospective basis. Following a Part A claims denial due to inpatient admissions that are not reasonable and necessary, the proposed rule similarly allows payment for reasonable and necessary Part B services had the beneficiary been treated as an outpatient. Likewise, the proposed rule excludes payment for services that require outpatient status. However, unlike the Ruling, the proposed rule also applies when a hospital determines after discharge that a beneficiary’s inpatient admission was not reasonable and necessary. Further, the proposed rule continues to apply timely filing restrictions on Part B billing for inpatient services; contrary to the Ruling, any Part B services must be filed within one year from the date of service.n
What Providers Should Know
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- Providers should keep this Ruling in mind when reviewing RAC denials to make strategic decisions, that is, the choice between 1) pursuing Part A payments by arguing that inpatient admission was reasonable and necessary versus 2) dropping the appeal and re-billing the claim as Part B inpatient.
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- Because hospitals still cannot bill for observation services when an inpatient admission is denied, the Ruling will not significantly affect medical services billing but may affect billing for procedures.
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nSource: www.polsinelli.com; March 13, 2013.n
Healthcare and Reimbursement Updates
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Mar 29, 2013 | Uncategorized
Health care providers are REQUIRED to complete Compliance Certification! The Centers for Medicare & Medicaid Services (CMS) requires that all Humana business partners, including health care providers, complete required compliance training and certifications.
nHealth care providers can complete this information online via Humana’s secure Compliance website, which requires internet access. To access the website, health care providers must be registered on Humana.com or Availity.com. Detailed instructions and additional information on completing these requirements, including registration, are available here. While health care providers are encouraged to complete the compliance requirements within 30 days of notification, these requirements must be completed no later than December 31, 2013.nnSource: www.humana.com; February 2, 2013.n
Healthcare and Reimbursement Updates
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Mar 29, 2013 | Uncategorized
In what appears to be a shift in policy, the Centers for Medicare & Medicaid Services has begun auditing providers attesting to Meaningful Use of their electronic health record systems before doling out incentive payments, according to a report from the American Academy of Family Physicians (AAFP).
nCMS has targeted 5 to 10 percent of those who attested to Meaningful Use in January 2013, according to Elizabeth Holland, director of the Health IT Initiative Group’s Office of E-Health Standards and Services. Eligible professionals selected for audit were chosen both “randomly” and “based on protocols that identify suspicious or anomalous attestation data,” according to the AAFP News Now article.nnAn additional 5 to 10 percent of physicians and others will be subject to post-payment audits, according to Holland. The audits are being conducted by Garden City, NY-based CPA firm Figliozzi and Company.nnCMS is required to conduct audits of providers attesting under the EHR incentive program, and began postpayment audits in July 2012. However, the U.S. Department of Health & Human Services’ Office of Inspector General (OIG) chastised CMS in November 2012 for poor auditing of the incentive program, a concern echoed by the Government Accountability Office.nnOIG specifically recommended that CMS conduct prepayment audits of a select number of providers before issuing their incentive payments. At that time, CMS would not concur with the OIG’s recommendation, saying that prepayment audits would impose a “huge new burden” on providers and impede EHR adoption.nnOther CMS programs are moving from “pay and chase” to prepayment review. GAO recently reported that expanding prepayment audits could save Medicare $115 million.nnTo learn more, here’s the AAFP New Now articlennSource: www.fierceemr.com; Marla Durben Hirsch; March 24, 2013.n
Healthcare and Reimbursement Updates
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Mar 29, 2013 | Uncategorized
Be on the lookout! Humana staff members regularly conduct medical record audits in randomly selected physician offices to help satisfy regulatory compliance by evaluating physician compliance with adopted medical record documentation guidelines. The minimum passing score is 85 percent compliance with the guidelines, with a goal of 90 percent. These guidelines are available for downloading and printing at Humana.com; click on the PDF entitled “Medical Records Guidelines” under the list of Clinical Practice Guidelines.nnSource: www.humana.com; February 2, 2013.n
Healthcare and Reimbursement Updates
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Mar 21, 2013 | Uncategorized
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Reimbursement Issues (denials, late payments, incorrect payments, inaccurate information)n
- Expanded insurance coverage provisions through the Affordable Care Act (ACA)
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- Data collection for meaningful use and reimbursement incentives
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- Expanded credentialing requirements create a new and more complex environment for providers and healthcare facilities
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Reimbursement models are changing and Payer Relationship Management (PRM) is more important than ever!
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- A strategic approach to understanding and cultivating payer relationships is the key to success. They need you and you need them!
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- Understanding your own data will assist in cultivating financially positive relationships – knowledge is power!
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Take control of your Payer Relationships!
nPRM supports your providers, practices and facilities to capture, store, monitor, track and leverage all information related to the billing and reimbursement processes. This information includes detailed and up-to-date provider profiles (credentialing), practice profiles (leverage), payer profiles (market research), reimbursement activities (proper payments), and patient care activities and efforts (data collection).n
PRM is the lifeline of your practice and facility—
n—and requires expertise, knowledge, and a multidisciplinary approach of professionals who understand and stay ahead of the changing healthcare environment and requirements. Every practice and facility should focus on PRM to maximize revenue by:n
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- Incorporating tools and systems to report and understand your practice’s financial health, financial needs, and patient care data
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- Understanding the current relationship with reimbursement sources (i.e. payers), including language, rates, etc.
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- Understanding your market, your competition, and most importantly your value!
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- Identifying opportunities to increase reimbursement (leverage)
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- Verifying all provider and contract information is loaded correctly in payer systems to ensure proper and timely payments (credentialing)
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- Understanding new reimbursement models to obtain additional payments (i.e. incentive payments), and avoid penalties that will decrease revenue
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- Ensuring efficient reimbursement processes to maximize cash flow (i.e. EFT, ERA)
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nNeed Assistance with your PRM? Click here…
Mar 21, 2013 | Uncategorized
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While there’s no code for Spring Fever, many people can’t wait for:
nY93.52 – Activity, horseback ridingnY93.83 – Activity, roughhousing and horseplaynY93.66 – Activity, soccernY93.53 – Activity, golfnY93.01 – Activity, walking, marching and hikingnnIn 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, 2014 implementation date. Please don’t hesitate to contact us for all of your training and education needs!
Mar 15, 2013 | Uncategorized
T65.6X1A – Poisoning from green dye in beer, initial encounternR53.83 – Fatigue due to exhaustively searching for 4-leaf clovernY00.xxxA – Assault by blunt object (pot o’gold) thrown by leprechaun at the end of the rainbow, initial encounternW22.02xA – Injury incurred by walking into lamppost during St. Patty’s Day Parade, initial encounter.nnIn 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, 2014 implementation date. Please don’t hesitate to contact us for all of your training and education needs!
Mar 15, 2013 | Uncategorized
Last week at the Annual HIMSS13 conference in New Orleans, Marilyn Tavenner, Acting CMS Administrator, confirmed that the ICD-10 implementation date of October 1, 2014 will stand!nnProviders, practices, hospitals and other healthcare entities need to start their preparation and training efforts NOW! CMS has released ICD-10 resources, including timelines and checklists, to help with a successful transition and implementation.n
Upcoming Free ICD-10 Seminars and Webinars
nEnglewood, CO: Swedish Medical CenternSpruce C Conference Roomn501 E Hampden AvenuenEnglewood, CO 80113nnDate: Wednesday April 10, 2013nTime: 2-4pmnn
Mar 7, 2013 | Uncategorized
The New Era of Healthcare and the Affordable Care Act (ACA) is bringing monumental changes and obstacles to physician and hospital reimbursement and operations – expanded insurance coverage through Medicaid and Health Insurance Exchanges, data collection including ICD-10 transition and meaningful use, and payer audits to ensure proper provider documentation and coding.nnStay up to date with these recent payer announcements:nnMedicaid Primary Care Payment IncreasenThe Affordable Care Act (ACA) enacted changes to Medicaid primary care reimbursement. Eligible physicians will receive supplemental payments for services rendered between January 1, 2013 and December 31, 2014. These supplemental payments will raise the Medicaid reimbursement to Medicare rates. To be eligible for the supplemental payments, physicians must self-attest as having a specialty in family medicine, general internal medicine, and/or pediatric medicine. Only physicians can complete the attestation! Staff or other representatives are not allowed to complete the attestation on the provider’s behalf.nClick here to complete provider attestation.n
Centers for Medicare and Medicaid Services (CMS) – Transmittal 1165, Change Request 8109
nImplementation Date: April 1, 2013nnEffective Date: October 1, 2014nnSubject: ICD-10 Conversion from ICD-9 and Related Code Infrastructure of the Medicare Shared Systems as They Relate to CMS National Coverage Determinations (NCDs).nnSummary: To both create and update national coverage determination (NCD) hard-coded shared system edits that contain ICD-9 diagnosis codes with comparable ICD-10 diagnosis codes plus all associated coding infrastructure such as procedure codes, HCPCS/CPT codes, denial messages, frequency edits, POS/TOB/provider specialties, etc.nnThe implementation date is prior to the effective date in order to be prepared to meet the timeline to implement the new ICD-10 diagnosis codes on October 14, 2014. The shared systems began implementation of the necessary changes to the NCDs in the January 2013 systems release and continue with CRs in subsequent releases.nnClick here for full content of CMS Transmittal 1165, and spreadsheet showing all affected ICD-9 codes and their corresponding ICD-10 codes as they relate to their respective NCDs, in addition to the rest of the coding infrastructure specific to each NCD.nn[vc_toggle title=”Medicare (Novitas)” size=”sm” el_id=””]n
Novitas is resuming with the revalidation process as of March 1, 2013.nnNovitas average processing time for applications has increased to 90 days—as a result of incentive program deadlines and transition from Trailblazer.[/vc_toggle]nn[vc_toggle title=”Anthem BCBS (CO) – Change to Imaging Guidelines” size=”sm” el_id=””]n
Effective April 15, 2013 the following AIM clinical appropriateness imaging guidelines will be revised for the purpose of expanding requirements to increase conservative therapy prior to imaging; clarify appropriate imaging for inflammatory and infectious etiologies; and to expand guidelines for the work-up of tumors:n
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- CT Cervical Spine, Thoracic Spine and Lumbar Spine
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- MRI Cervical Spine, Thoracic Spine and Lumbar Spine
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- CT Upper Extremity
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- MRI Lower Extremity
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nThese clinical guidelines can be accessed on AIM’s website at www.aimspecialtyhealth.com.nnDrug fee schedule update: CMS average sales price (ASP) first quarter fee schedule (effective 1/1/13) will go into effect on February 1, 2013. To view the ASP fee schedule, go to CMS website at www.cms.hhs.gov [/vc_toggle]nn[vc_toggle title=”Anthem BCBS – Central Region (IN, KY, MO, OH, WI)” size=”sm” el_id=””]n
Robotic Assisted Surgery – Facility ReimbursementnnEffective May 8, 2013, Anthem will not allow additional payment for charges associated with robotic technology. The use of robotic technology is considered integral to the primary surgery being performed and not eligible for separate reimbursement.[/vc_toggle]n[vc_toggle title=”UnitedHealthcare” size=”sm” el_id=””]nn
TRICARE West Region: UnitedHealthcare Military and Veterans launched the TRICARE West Region website www.uhcmilitarywest.com on February 15, 2013. The website will be updated with new information for TRICARE network providers until the contract transitions to UnitedHealthcare on April 1, 2013. Contracting is underway! Practices/providers will need to return the Demographic Form and/or Service Code Listing as these are important components of your agreement with UnitedHealthcare Military and Veterans.nnRevision to Documentation Requirements for Modifier 22: Effective June 2013, UnitedHealthcare will follow CMS guidelines and require a concise statement outlining how the service differs from the usual service performed, in addition to the operative report before the additional 20% in reimbursement will be considered.nnRevision to Speech Therapy Policy (Physical Medicine and Rehabilitation): Effective the second quarter of 2013, the Speech Therapy Policy will be revised to deny reimbursement for CPT codes 99201-99499 when reported by speech and language therapists/pathologists.nnChanges to Prior Authorization List: Effective for dates of service on or after April 1, 2013, UnitedHealthcare West and commercial plans will require prior authorization for skilled nursing and private duty nursing in addition to nutritional services for home health coverage.[/vc_toggle]nn[vc_toggle title=”Cigna” size=”sm” el_id=””]n
Coming soon – One website for all Cigna Patient information: CignaforHCP.com. Practices will be able to verify eligibility and benefits, precertification requirements and submit requests, checking claim status, check details of processed claims, important updates and more![/vc_toggle]n[vc_toggle title=”Aetna” size=”sm” el_id=””]n
Specialists need to be on the lookout for requests from Aetna to review selected medical records for office visits. The purpose is to compare the provider’s documentation and the coding that was submitted on the claim form. Requests are based on provider trends in coding relative to his peers in the same specialty, and the characteristics of the claim. The affected specialties are:n
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- Dermatology
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- ENT
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- Hand surgery
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- Neurology
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- Neurosurgery
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- Orthopedic surgery
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- Pain management
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- Physiatry
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- Plastic surgery
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- Podiatry
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- Sports medicine
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- Urology
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nAetna will also review medical records for procedures in Dermatology and Urology.[/vc_toggle]
