The WVSMA’s Certified Medical Coder began on Friday, September 9, and will conclude on September 30 with the certification exam.  St. Francis Hospital in Charleston, WV, has hosted the class.  Twenty-seven brave and eager to learn students are in the class, which is being taught by Practice Management Institute (PMI) Consultant, Rhanda Granger, who comes from Charlotte, NC.  The class includes many personalities with a variety of skill sets, including office managers, certified coders, billers, medical assistants, and insurance payor management.  All are interested in furthering their knowledge of medical coding and its importance in today’s healthcare.

A Certified Medical Coder plays an integral role in a physician’s reimbursement process.  These persons ensure that proper documentation guidelines are followed and that codes are submitted to the highest degree of specificity.  This not only provides for the physician to receive the entitled reimbursement; it also ensures that coding is compliant with all rules and regulations.

The value of a certified coder in a medical practice cannot be over emphasized.  That is why the WVSMA felt so strongly that we should offer this class.  We commend the students in this difficult course, as well as the physicians who have made it possible for their staff members to attend and participate in the class. 

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Federal Agency for Healthcare Research and Quality (AHRQ) Offers Free Evidence-Based Resources for Clinicians and Patients
(information supplied by AHRQ)

Momentum is growing for a key component in the national strategy to improve health care quality: patient-centered outcomes research, also known as comparative effectiveness research. Patient-centered outcomes research informs health care decision making by comparing the evidence on the effectiveness, benefits, and harms of different treatment options for common health conditions.

The Federal Agency for Healthcare Research and Quality (AHRQ) [www.effectivehealthcare.ahrq.gov], the lead federal agency charged with conducting this research,  has launched a nationwide initiative to raise awareness of patient-centered outcomes research and to encourage its use. AHRQ provides clinicians and patients free materials that objectively summarize available evidence on various treatment methods to inform health care decision making. WVSMA is collaborating with AHRQ to provide our members quick access to these evidence-based resources and to announce new products as they become available.

In conducting systematic reviews, researchers synthesize the available evidence on drugs, medical devices, tests, surgeries, or ways to deliver health care. The research results are translated into practical clinician and patient resources, including executive summaries, clinician and consumer summary guides, CME/CE modules, podcasts, faculty slides and more.
 
All of these tools are designed to encourage and support shared decision making between clinicians and patients, with a goal of better care and increased patient satisfaction. Clinician materials [http://go.usa.gov/k3d] provide clinical bottom line information, citing research gaps, when applicable. Patient materials [http://go.usa.gov/k3p] are written in plain language and contain an overview of the condition in addition to the comparative effectiveness information.

Part of the U.S. Department of Health and Human Services, AHRQ Effective Healthcare Program supports research on 14 priority conditions, including cardiovascular diseases, diabetes, arthritis, mental health disorders, and pregnancy. In addition to the summary guides and other materials, the full research reports can be downloaded from AHRQ’s Effective Healthcare website.

To learn more about patient-centered outcomes research or to download materials, visit http://go.usa.gov/k3d. To order free printed copies, call the AHRQ Publications Clearinghouse at 1-800-358-9295. Use the promotional code C-02.

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These updates are applicable to both physicians and patients. 

CMS finalizes changes to 2012 Medicare ePrescribing penalty program
(information supplied by the AMA)

Physicians have until Nov. 1 to apply for an exemption and avoid financial penalties for failing to comply with Medicare's ePrescribing requirements. The AMA urges all physicians who have doubts about whether they met the program's requirements in the first six months of 2011 to review the allowed exemptions carefully and submit an online application for each of the exemption categories for which they qualify as soon as possible.

Under the Centers for Medicare & Medicaid Services (CMS) ePrescribing rule, physicians are required to have issued and reported at least 10 electronic scripts (e-scripts) by June 30 to avoid being penalized. The penalty reduces all their Medicare Part B claims paid under the 2012 fee schedule by 1 percent.

In November 2010 CMS made a sudden decision to require physicians to meet this criteria by June 30 in order to avoid 2012 penalties, and the AMA continually stressed that this last-minute requirement was unreasonable.

On Aug. 31, CMS released a final rule that allows qualifying physicians to avoid the 1 percent penalty by applying for one or more of six new ePrescribing penalty exemptions through a Web-based tool. (Note: If you have difficulty accessing the online application, email QualityNet, which runs the portal for CMS.)

Although the final rule does not include an additional reporting period in 2012, it does reflect several other significant improvements the AMA requested. For example, the regulation provides more flexibility under the exemption categories so that more physicians can qualify to avoid the 2012 ePrescribing penalty.
In addition, CMS extended the application deadline for one month to Nov. 1. However, physicians are encouraged to apply for an exemption as soon as possible to avoid claims reprocessing.

Physicians who found it difficult to meet the 10 e-script requirement during the first six months of this year can apply for one of the following exemption categories by Nov. 1:

• Your practice is located in a rural area without high-speed Internet access.
• Your practice is located in an area without sufficient available pharmacies for ePrescribing
• You are registered to participate in the Medicare or Medicaid electronic health record (EHR) incentive program and you adopted certified EHR technology by Oct. 1, prior to requesting an exemption.
• You are unable to ePrescribe because of local, state or federal laws or regulations. (CMS confirmed that physicians who mainly prescribe narcotics but cannot submit these prescriptions electronically because of certain limitations can apply for this exemption category.)
• You do not prescribe on a regular basis.
• There were too few opportunities for you to report the ePrescribing measure because of limitations of the measure's denominator. For example, you do prescribe electronically but your e-scripts are not related to qualifying visits or services.

Healthcare needs and healthcare benefits change from year to year. Open Enrollment is the one time of year when ALL people with Medicare can see what new benefits Medicare has to offer and make changes to their coverage.

There are several ways to check out Medicare coverage. There are new benefits available for all people with Medicare - whether they choose Original Medicare or a Medicare Advantage plan, including lower prescription costs, wellness visits, and preventive care.  Patients should be advised to take advantage of Open Enrollment.  By doing so, they may be able to save money, get better coverage, or both.

What is the benefit of having an earlier enrollment period?  Starting this year, Open Enrollment starts earlier - on October 15th - and lasts longer (7 full weeks) to give patients enough time to review and make changes to their coverage. Also starting this year, patients will need to make their final selection for next year's Medicare coverage by December 7th. This change ensures Medicare has enough time to process your choice, so coverage can begin without interruption on January 1, 2012.

Patients should be reminded that Medicare is available to help. They may visit www.medicare.gov/find-a-plan to compare current coverage with all of theoptions that are available in their area, and enroll in a new plan if they decide to make a change.

Patients may call 1-800-MEDICARE (1-800-633-4227) 24-hours a day/7 days a week to find out more about  coverage options. TTY users should call 1-877-486-2048.  Review the Medicare & You 2012 handbook. It is mailed to people with Medicare in
September.  Get one-on-one help from the state’s State Health Insurance Assistance Program (SHIP). Visitwww.medicare.gov/contacts or call 1-800-MEDICARE to get the phone number.

“Help Prevent Fraud” Campaign --Help Your Medicare Patients!
(This information prepared by the U.S. Department of Health and Human Services)

Medicare is fighting fraud and abuse and you can help!

Health care fraud drives up costs for everyone in the health care system and endangers Medicare’s ability to serve future generations. To address this growing problem, the federal government continues to expand efforts to recover improper payments and prevent fraud.

Significant progress in the fight against health care fraud has already been made as shown by the federal government’s recovery of a record $4 billion last year from people who attempted to defraud seniors and taxpayers. The Affordable Care Act provides additional resources and tools to enable the Centers for Medicare & Medicaid Services (CMS) to expand efforts to prevent and fight fraud, waste and abuse including:

•  Creating a rigorous screening process for providers and suppliers enrolling in Medicare to keep fraudulent providers out of the program.
•  Authorizing CMS to temporarily stop enrollment of new providers and suppliers when Medicare spots trends that may indicate health care fraud.
•  Authorizing CMS to temporarily stop payments to providers and suppliers suspected of fraud for investigation and case building.

Fraud prevention efforts focus on moving CMS beyond its former “pay and chase” recovery operations to a more proactive “prevention and detection” model that will help prevent fraud and abuse before payment is made. A good example is the recent CMS announcement that for the first time, through the use of innovative predictive modeling technology similar to that used by credit card companies, the agency will have the ability to use risk scoring techniques to flag high risk claims and providers for additional review and take action to stop payments and remove providers from the program when necessary.

Yet, as important as these aggressive new initiatives are, the first and best line of defense against fraud remains physicians and beneficiaries.  Here are a few ways patients can protect their Medicare benefits:

• Guard your Medicare number. Fraud schemes often depend on crooks first getting hold of people’s Medicare numbers. The number should be treated as you would a credit card. Don’t share it with anyone except your doctor or other Medicare-approved health care provider and don’t allow anyone else to use it.

• Look out for suspicious activities. Be wary of salespeople who knock on your door or call you uninvited and try to sell you a product or service. Don’t allow anyone except your doctor or other Medicare-approved provider to review your medical records or recommend services. And never let anyone give you “free” equipment or supplies in exchange for your Medicare number.

• If you have Original Medicare, check your Medicare Summary Notice. Use a calendar or personal journal to record all of your doctor appointments and tests. Then review your quarterly claims statement to make sure Medicare wasn’t billed for something you didn’t get. If you spot what you think is an error, call the doctor’s office or health care provider and ask about it. If they can’t resolve your questions or concerns, call 1-800-MEDICARE.

• Report suspected cases of fraud. If you think someone has misused your Medicare number, call 1-800-MEDICARE. If you suspect identity theft, or feel like you gave your personal information to someone you shouldn’t have, call the Federal Trade Commission’s ID Theft Hotline at 1-877-438-4338.

To learn more about health care fraud and ways to protect against it, visit www.stopmedicarefraud.gov or contact your local Senior Medicare Patrol (SMP) project. To find the SMP in your state, go to the SMP Locator at www.smpresource.org. More information about CMS fraud prevention efforts is available at www.cms.gov/Partnerships/04_FraudPreventionToolkit.asp.

 
Important 5010 Update

Summer has officially come to an end, and the Version 5010 transition deadline is now only three months away! As the January 1, 2012 deadline approaches, your transition should be well underway. There are certain steps to be taking now during the fall to make sure you are on track for a smooth transition.

If you are a provider, you should:

Continue external testing and making any revisions to systems based on previous internal testing and test those transactions that are used on a daily basis, such as claims and eligibility determinations.

You should expect your payors to:

Continue to coordinate the transition to the new formats and testing with providers, clearinghouses, billing services, and other business partners.

Complete external testing and their Version 5010 transition by December 31, 2011 to achieve Level II compliance.

You should expect your vendor to:

Continue to conduct external trading partner testing of Version 5010 with customers to achieve Level II compliance.

Conduct solution rollout and provide customer support for the Version 5010 transition through the January 1, 2012 compliance date.

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Medicare Overpayments and Immediate Offset Requests

This article discusses various advantages to requesting an immediate offset as opposed to repaying an overpayment to Medicare. It also provides step-by-step instructions to follow to ensure an immediate offset request is handled appropriately. Please keep in mind that immediate offset requests can only be honored if there are pending payments in the Medicare claims processing system from which to offset. If there is an insufficient amount of pending payments to satisfy the overpayment, interest may accrue. Click here to read the full article. 

Are You Ready for 5010?

All covered entities must submit Medicare electronic claims using  X12 version 5010 effective January 1, 2012. If you are not currently testing or sending production claims in the v5010 format, please review the ANSI 5010 information posted under www.PalmettoGBA.com/ANSI5010. Please contact the Technology Support Center at (866) 749-4301 if you have any questions regarding the v5010 transition. Don't risk payment interruption. Transition to v5010 now!  Click here to read the full article. 

Registration is now open for the ANSIv5010: Last Push for Late Implementers Webinar

All J11 and Railroad Medicare providers should register for the third installment of our 'EDI/ANSI v5010 Webinars, ANSIv5010: Last Push for Late Implementers'. This Webinar will be held on Wednesday, October 5, 2011, at 1 p.m. ET.  Click here to register.

Claim Adjustment Reason Code (CARC), Remittance Advice Remark Code (RARC), and Medicare Remit Easy Print (MREP) and PC Print Update

This article contains the latest update of Remittance Advice Remark Codes
(RARCs) and Claim Adjustment Reason Codes (CARCs) that are effective on October 1, 2011, for Medicare. Be sure your billing staffs are aware of these changes.  Click here for additional information. 

October 2011 Medicare Advisory

The October 2011 Medicare Advisory for J11 Part B is now available. This issue is packed full of useful information for submitting Medicare Part B claims.  Click here to download your copy.

Advanced Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131: Revised Effective November 1, 2011

The revised Advanced Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is now available for use by physicians, practitioners, suppliers and independent laboratories in situations where Medicare payment is expected to be denied. The revised form must be used effective November 1, 2011.  To see the revised form, click here. 

Claims Denied Incorrectly for Diagnosis

Palmetto GBA has identified a system problem that resulted in some claims denying incorrectly with the message code CO-11 which states 'The diagnosis is inconsistent with the procedure'. The system maintainer has developed a solution to correct these claims. Palmetto GBA will reprocess the impacted claims during the next two weeks. Please keep in mind that all claims which denied with message code CO-11 were not denied in error. Providers do not need to take any action.  The complete article may be found here.

Delay in Implementation of Automated Medicare Secondary Payer (MSP) Adjustments (CR 6625)

Due to system issues, Medicare contractors are unable to automatically reopen/adjust claims when action is taken to delete or terminate a previously existing MSP record. Physicians, providers and suppliers must begin to contact their Medicare contractor to request re-openings/adjustments of claims that were previously considered Medicare Secondary Payer claims. Therefore, if you have claims that were processed since July 1 that need to be reopened/adjusted due to Medicare now being the primary payer, you should contact your Palmetto GBA to request that action.  Click here to read the article. 

Update on Review Contractors

The Centers for Medicare & Medicaid Services (CMS) employs Medicare review contractors to measure, prevent, identify and correct improper payments.

Review contractors find the improper payments by requesting medical documentation from each provider who submitted a questionable claim.Medicare’s Electronic Submission of Medical Documentation (esMD) pilot will begin in September 2011 and will allow some providers to electronically submit requested medical documentation to review contractors. The primary intent of esMD is to reduce provider costs and cycle time by minimizing and eventually eliminating paper processing and mailing of medical documentation to review contractors.  Click here for more information. 

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Highmark is adding 15 Codes to Its List of Outpatient Procedures/Services Requiring Authorization.

Effective Oct. 3, 2011, Highmark will revise its list of outpatient procedures/services requiring authorization to add 15 codes. The procedure codes below will be added to the authorization list, effective Oct. 3, 2011. (Please note, the codes will not have authorization requirements and will not appear on the all-inclusive authorization list on the Provider Resource Center until the effective date, Oct. 3, 2011.)

During the year, Highmark makes several adjustments to the full list of outpatient procedures/services requiring authorization. To view the all-inclusive and most up-to-date list, please look under Administrative Reference Materials on the Provider Resource Center. The list of outpatient procedures/services requiring authorization applies to members enrolled in Direct Blue® (group only), Keystone BlueSM, Security BlueSM HMO and Freedom BlueSM PPO. As a reminder, NaviNet®-enabled providers should use NaviNet to obtain authorization for services. Providers who don’t have the Highmark NaviNet system can use the HIPAA Health Services Review (278) electronic transactions or call Highmark Medical Management and Policy (formerly known as Healthcare Management Services [HMS]), toll-free, at 1-800-547-3627, Option 2, to obtain authorization for services. Please have the following information available when you call for authorizations: the member’s ID number from the front of the member’s ID card, the member’s name, the date(s) of service and the provider ID number and name.

Additional Services That Continue to Require Preauthorization

In addition to the listing of outpatient procedures/services, the following items also continue to require preauthorization:

• all inpatient admissions
• potentially experimental, experimental and cosmetic procedures
• home health
• selected injectable drugs
• outpatient, non-emergency imaging procedures
• oxygen (all products)
• all therapies for Security Blue HMO and Freedom Blue PPO in-network • cardiac rehabilitation and pulmonary rehabilitation

Reminder: Certain procedures require benefit verification prior to performing the procedure. To verify benefits, providers should use NaviNet or the applicable HIPAA electronic transactions. Providers who don’t yet have NaviNet access should call 1-800-547-3627, Option 5. For Security Blue, call 1-866-517-8585. For Freedom Blue PPO, call 1-866-588-6967. If you have any questions about this information, contact your Provider Relations representative.

Codes to be Added to Highmark’s List of Outpatient Procedures/Services Requiring Authorization, Effective Oct. 3, 2011

Code       Description

Q2040     Incobotulinumtoxin A, 1 unit, injection (Medical Injectable Drug Program)
Q2042     Injection, Hydroxyprogesterone Caproate, 1 mg (Medical Injectable Drug Program)
Q2044     Injection, Belimumab, 10 mg (Medical Injectable Drug Program)
Q2043     Sipuleucel-T minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF, including leukapheresis and all  other preparatory procedures, per infusion
K0743     Suction pump, home model, portable, for use on wounds
K0744     Absorptive wound dressing for use with suction pump, home model, portable, pad size, 16 square inches or less
K0745     Absorptive wound dressing for use with suction pump, home model, portable, pad size more than 16 square inches but less than or equal to 48 square inches
K0746     Absorptive wound dressing for use with suction pump, home model, portable, pad size greater than 48 square inches
0262T     Implantation of catheter-delivered prosthetic pulmonary valve, endovascular approach
29914     Arthroscopy, hip, surgical; with femoroplasty (i.e., treatment of cam lesion)
29915     Arthroscopy, hip, surgical; with acetabuloplasty (i.e., treatment of pincer lesion)
29916     Arthroscopy, hip, surgical; with labral repair
J0718     Certolizumab Pegol, 1 mg (Medical Injectable Drug Program)
84999     Unlisted chemistry procedure
89240     Unlisted miscellaneous pathology test

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September 2011 Edition of the UnitedHealthcare Network Bulletin Available Now Available

The Sept. 2011 edition (Vol. 45) of the Network Bulletin and Supplement is now available online in the PDF version at the Network Bulletin page. The UnitedHealthcare Network Bulletin is a bi-monthly publication that serves as the primary means of communicating commercial, Medicare and Medicaid program and policy changes to UnitedHealthcare network providers. To subscribe to the Network Bulletin, please visit the UnitedHealthcareOnline.com > Network Bulletin Registration.

UnitedHealthcare Launches Annual Physician and Practice Manager Satisfaction Survey

On Aug. 25 UnitedHealthcare launched its annual physician and practice manager satisfaction survey. The survey is a randomly sampled, mail survey to network physicians and practice managers giving them the opportunity to provide feedback on UnitedHealthcare services.

Network feedback is important to UnitedHealthcare and will help to identify opportunities for improvements and assess the level of satisfaction with the health plan. This feedback is critical in helping us better meet the needs of practices. Past results have helped to design Physician Advocate programs, update the call center service and improve the issue resolution processes.

This year UnitedHealtcare also has a new option for additional feedback, should physicians or practice managers not be selected for the random survey. Please make sure to review the Sept. 2011 Network Bulletin to learn more.

UnitedHealthcare Medicare Name Change

As you may be aware, UnitedHealthcare is in the process of aligning all their Commercial, Medicare and Medicaid benefits businesses to support a single brand that people can turn to for health care benefits at all stages of life.

To facilitate a simpler, more efficient relationship with providers and our members effective January 1, 2012, we are changing the name of UnitedHealthcare's Medicare Solutions Medicare Advantage plans which include products carrying the SecureHorizons®, AARP® MedicareComplete® from SecureHorizons, and Evercare® names.

Earlier this month UnitedHealthcare mailed a letter to more than 149,000 Medicare & physicians and other health care professionals, advising them of the upcoming name change.

New Survey: Beneficiaries, Boomers Remain Confused by Medicare

The results of a survey released earlier this week by the National Council on Aging (NCOA) and UnitedHealthcare reveal that a large percentage of baby boomers and seniors ages 65 and over do not understand Medicare and are unaware of important recent or impending changes to the program.

The study results reinforce the need for more education regarding the nation's largest health insurance program. The need for greater understanding of Medicare will only grow during the next two decades as tens of millions of people are added to the program. Over the next 20 years, an average of 10,000 boomers a day will turn 65 and become eligible.
 
UnitedHealthcare and NCOA surveyed 1,000 seniors ages 65 and over and 500 "leading-edge" baby boomers ages 60 to 64 to gauge their understanding of the Medicare program. The survey was conducted as part of an ongoing partnership between the two organizations to help Medicare beneficiaries, their caregivers and baby boomers learn more about their health-care options now and in the years ahead.

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Everest Institute in Cross Lanes, West Virginia, offers a number of training programs for students interested in healthcare, computer and communications technology.   The institute provides externships (“160 hour interviews”) for medical practices.  This allows your practice to determine if you are hiring the right person (s) for the  practice’s needs.

A number of practices have hired good employees who have done externships in their medical practices. These practice managers report great success with these employees since they have assisted in their training.

For more information, or to request an extern, please contact Everest Career Services Representative, Brian Felker, (304-776-6290) or via email bfelker@cci.edu. 

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The West Virginia Medical Group Managers Association (MGMA) will hold their fall conference at Stonewall Jackson Resort, Roanoke, WV, on Thursday, October 6th and Friday, October 7th.   For additional information, you may contact President John Trout (jtrout@greenbrierphysicians.com). 

The West Virginia Office Managers Association (OMA) will hold their annual conference at Pullman Plaza in Huntington, WV, on Thursday, October 20 and Friday, October 21st.  For additional information, you may contact Pam Shafer (pamela.shafer@camc.org), Toni Charlton (toni1447@comcast.net), Vickie Garan (vicog2@comcast.net), or Donna Zahn (deez921@hotmail.com). 

Both these groups are excellent resources for your office administrator/manager. 

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• • Certified Medical Coder Class Off to a Great Start!
• • Federal Agency for Healthcare Research and Quality (AHRQ) News
• • Medicare News
• • Palmetto GBA News
• • Highmark BCBS Update
• • UnitedHealthcare News
• • Everest Institute Offers Employee Externships for Medical Practices
• • Register Now for These October Conferences!