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This edition of the WESGRAM Online contains a number of important initiatives and changes which begin on July 1, 2007.
The Physicians Quality Reporting Initiative begins on that date, as does the new PEIA Advantra Freedom Program. Practices must also begin using the new CMS 1500 as of July 1, 2007. In addition, July 1, 2007 is the last date that physicians may make changes to their NPI Data Dissemination information. Aetna has a change in their lab services which begins on July 1, 2007, and lastly, Mountain State Blue Cross Blue Shield will increase their fee schedule as of July 1, 2007. These changes, as well as others, are discussed at length in this edition of the WESGRAM Online.
If you need further information on any of these changes, please contact Barbara Good, Physician Practice Advocate, at (304) 925-0342, ext. 11, or Barbara@wvsma.com.
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WVSMA's recently sponsored educational event, a conference call entitled "Are You Ready For PQRI", was well received by physicians, office managers and office staff throughout the state. Dr. Barbara Connors presented the PQRI information and held a question and answer session for attendees. The conference call was available for replay for three days after the call and many practices took advantage of the opportunity to listen to the replay.
The PQRI power point presentation utilized by Dr. Connors may be found on the WVSMA website, www.wvsma.com.
Also, the worksheets to facilitate documentation and coding for reporting PQRI are now posted on the CMS website. Click here to go to the CMS website, http://www.cms.hhs.gov/pqri, and from the upper left area, select PQRI Tool Kit. The worksheets are available in the Downloads section. (Please note that you will probably have to scroll down).
Remember that the PQRI initiative bonus program begins July 1, 2007 and continues through December 31, 2007. You do not need to register to participate in the bonus program. Don't miss your opportunity to participate in this important initiative!
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Eligible professionals interested in testing their billing system and practice their readiness for PQRI quality data code reporting will have a chance to do so. CMS has designated "G8300" as a test code for PQRI reporting prior to July 1, 2007, which is the start date for PQRI reporting. G8300 was formerly used in the 2006 PVRP program and will be retired on July 1, 2007. This means it will be rejected on any claims submitted for dates of service on and after July 1, 2007. In the interim, it can be used to test readiness as follows:
1. Add the G8300 test code as a line item on any claims for services. On the ASC X12N health care claim transaction (version 4010A1), submit the HCPCS code G8300 in the SV101-2 "Product/Service ID" Data Element on the SV1 "Professional Service" Segment of the 2400 "Service Line" Loop. It is also necessary to identify in this segment that a HCPCS code is being supplied by submitting the HC in data element SV101-1 within the SV1 "Professional Service" Segment. For claims submitted on the CMS 1500 Form, report the test code in field 24D.
2. Randomly enter "$0.00 or "$0.01" as the line item charge for the test code. This will confirm the ability of billing software or clearinghouses to accept either charge.
3. Check your Remittance Advice (RA) for these claims to assure the test code has been passed through and processed by the carrier or MAC. You should see Claim Adjustment Reason Code message 96, "Non-covered charge(s)." Also, you will see Remittance Advice Remark Code message N365, "This procedure code is not payable. It is for reporting/information purposes only." The remittance advice will serve as your feedback for the test. CMS will not issue any other feedback.
4. The remittance advice will indicate that the test code was denied. The test code will also show up on the beneficiary's MSN with the statement "This code is for informational/reporting purposes only. You should not be charged for this code. If there is a charge, you do not have to pay the amount." This same message will be appear on MSNs during the 2007 PQRI reporting period for designated 2007 PQRI codes. |
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Effective July 1, 2007, Laboratory Corporation of America (LabCorp) and its affiliates will no longer participate in the Aetna network. There will be no contractual arrangement between Aetna and LabCorp as of this date.
Effective July 1, 2007, Quest Diagnostics will be a preferred national laboratory for all Aetna members.
As of July 1, 2007, Aetna has entered into a new preferred, national agreement with Quest Diagnostics for all members in all Aetna benefits plans. Quest Diagnostics has more than 2,000 patient service centers nationwide, and offers data and technology solutions that support our initiatives to provide physicians and patients with detailed health care information. Quest Diagnostics is able to handle all laboratory testing needs.
For a list of Quest Diagnostics locations, visit www.questdiagnostics.com. To further supplement the extensive network, Aetna will be adding additional Quest Diagnostics locations to meet your laboratory testing needs. Aetna will continue to contract with local and specialty laboratories as well.
Please refer all Aetna patients to Quest Diagnostics or one of the other local and specialty laboratories that are currently participating in the Aetna network. This will help patients receive their highest benefit levels and minimize out of pocket expenses. Any payments to LabCorp or its affiliates after July 1, 2007 will be paid as out of network claims and your patients' out of pocket expenses will be impacted.
If you have additional questions about the new Aetna/Quest relationship, you may contact Elaine Rader, Senior Provider Relations Representative, at (304) 562-0824. |
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Quest Diagnostics has opened a new Charleston Patient Service Center to serve all your laboratory testing needs. Hours of service at the new facility are Monday-Friday from 8:00 AM -4:30 PM.
The new service center's location is: 2335 Chesterfield Avenue, Charleston, WV 25304, and the phone number is (304) 342-3516.
Quest plans to open several new Patient Service Centers in West Virginia within the next several months.
For more information, you may visit Quest online at www.questdiagnostics.com or call John Campbell, Quest Account Executive at (800) 366-7522, ext. 7696. John may also be reached via email at john.m.campbell@questdiagnostics.com. |
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PEIA Medicare eligible retirees will be automatically enrolled and effective in a new benefit plan as of July 1, 2007, when Advantra Freedom will replace the current PEIA PPB plan. Advantra Freedom is administered by Coventry Health Care, the parent company of Carelink Health Plan.
Physicians are not required to be participating Carelink providers or be credentialed with Carelink in order to participate with PEIA Advantra Freedom PFFS. When you see an Advantra member, you are deemed to be a participating provider.
When a PEIA Advantra Freedom member is seen as a patient in your office, you should review the ID card to verify eligibility. The Coventry website, www.directprovider.com, may be used to view eligibility, download an ID card, and confirm that PEIA Advantra Freedom is primary coverage. It is very important to remember that after July 1, 2007, all questions regarding PEIA retirees and their insurance must be directed to Coventry and not to PEIA.
One major difference for both physician practices and patients is that copays will be collected from PEIA Advantra Freedom subscribers. The copay is $10.00 for primary care and $20.00 for specialist visits. The copay amounts should be printed on the member's ID card.
Physicians will receive Medicare rates for treating Advantra Freedom patients. In addition to collecting a copay from the member, physicians may collect any remaining co-insurance after receipt of the remittance advice from Advantra Freedom.
The timely filing for Advantra Freedom is one year (365 days). Please be aware that the claims address for this new plan is different. All Advantra Freedom claims should be submitted to the following address:
Advantra Freedom
PO Box 7154
London, KY 40742-7154
Physicians are encouraged to bill claims electronically. The payor ID for Advantra Freedom is 25152. Other important payor IDs are 25139 for Carelink Commercial and 25140 for Carelink Medicaid.
For additional information on the new PEIA Advantra Freedom Plan, physician practices may visit the website www.advantrafreedom.com or call (800) 386-2335. |
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The NPI Data Dissemination Notice was published in the May 30, 2007, edition of the Federal Registry. The CMS data dissemination policy is of great importance to physicians since it identifies who will have access to NPI numbers, what information associated with each number will be available, and how the number and data may be accessed.
CMS announced in the Data Dissemination notice that the NPIs and the associated data will be available to the public at no charge through a "query-only" online database, as well as a downloadable file. CMS has determined that under the Privacy Act they will not release Social Security Numbers, Internal Revenue Service Individual Taxpayer Identification Numbers, and physicians' dates of birth. The notice is available at the CMS website. The database will be available July 1, 2007. Click here for the online and downloadable files.
Physicians who would like to delete other data deemed "optional" supplied on their NPI applications may do so prior to the time CMS makes its online database available on July 1, 2007. As you can see, this is a very short time frame during which you may make corrections and changes. Among the "optional" data that may be removed is the DEA number. Physicians may want to consider removing this information.
The American Medical Association has expressed concerns as to who will have access to physicians' NPI numbers and how their related data will be protected. The AMA advocated strongly for restricting access of the NPIs and the data associated with them to a very limited group of entities, while others in the healthcare field asked CMS to provide a "look up" function that was easily accessible.
The AMA also feels that this exceptionally short timeframe to remove information is unreasonable. The time frame did not allow adequate time for CMS to notify physicians of this policy or how physicians may exercise the option to remove data. Due to these and other concerns, the AMA recommends that, for security reasons, physicians should immediately check their data in the National Plan and Provider Enumeration System (NPPES) and remove any "optional" information that they do not want to have included in the public database.
In order to remove the information from the database, physicians must submit a change to NPPES. This may be done by accessing the NPPES website (https://nppes.cms.hhs.gov/NPPES) and using your already established User ID and password. This will allow you to make the changes online.
If you don't have a password, you may establish a User ID and password and then submit the info online.
In order to submit an update on paper, physicians must call the NPI Enumerator (800-465-3203) and request a paper NPI Application/Update Form and submit the updates on that form.
The AMA plans to further analyze the NPI data dissemination notice and its implications for physicians. The association will continue to strongly communicate concerns to CMS regarding the NPI data dissemination. The WVSMA will continue to communicate to our membership the information we receive regarding the National Provider Identifier. |
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As of July 1, 2007, the new 1500 claim forms must be used. Here are a few suggestions to ensure that your claims will process correctly.
1. The NPI number of the physician performing the service will go in Box 24j and the NPI number for the practice goes in Box 33b. If you are still using the legacy number (PIN/UPIN) than you will need to include qualifier 1G in Box 17a when reporting a physician's UPIN.
2. Submit only the original CMS-1500 forms that are printed with the special red ink. Copies will not be processed.
3. Ensure that any software used to print the new 1500 forms has been properly formatted so that the information prints in the correct boxes.
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The American Medical Association recently released a new survey on actions that physicians plan to take if the 10% Medicare cuts go into effect next year. The survey found that 60% of America's physicians will be forced to limit the number of new Medicare patients and that 40% of American physicians plan to limit the number of established patients they treat.
Furthermore, if the 10% cut does occur, more than two-thirds of physicians surveyed report that they will defer investments in their practice, including the purchase of information technology.
The AMA is assisting patients in sharing their concerns about the Medicare cuts via a website, www.patientsactionnetwork.org , as well as via a phone line (888) 434-6200, which puts patients in touch with their senators and congressional representatives. |
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Physicians may now resubmit their previously denied CAD mammography claims to CIGNA. Claims that are eligible for reprocessing are those that were submitted between January 1, 2004, when the CAD Mammography add-on codes became effective, and October 10, 2004, when CIGNA began paying the claims. The codes involved are CPT Codes 76082, or 76082 with add on codes with 76090, 76091, or 76092. These claims may be resubmitted from June 1, 2007 through December 1, 2007.
To resubmit claims, you should complete the spreadsheet and email it to CADMammoRebudsmit@CIGNA.com. You may also email questions regarding the CAD mammography to this address. Physicians without email access may mail their completed spreadsheets to CIGNA R&R Department P&C, P.O Box 9018, Sherman, Texas, 75091-9018. Compliance questions may be addressed to the CIGNA Compliance Dispute Facilitator, Deborah Winegard, at (404) 881-8900.
Also, CIGNA now maintains physician data in their Hooksett, New Hampshire office. Any changes in your practice demographics must be submitted to CIGNA in order for claims to continue to process without delay. There are now three ways to send updates to physician data. Please note that these options are only used to report changes to your provider data.
To make a change, you may either email CIGNA at ProviderData@CIGNA.com, fax the information to (877) 358-4301, or mail the information to the following address:
Attn: Provider Data
CIGNA Healthcare, R454
Two College Park Drive
Hookset, NH 03106-9985
If you need additional information about CIGNA, you may reach the Provider Resolution Unit by calling (800) 88CIGNA. |
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Medicaid is sending monthly mailings to physicians who have not yet submitted their NPI numbers to Medicaid. Although Medicaid is still accepting claims with the Medicaid ID numbers on them, physicians are encouraged to obtain and notify Medicaid of their NPI numbers as soon as possible. Please ensure that you have given your NPI number to Medicaid prior to submitting a claim with an NPI number.
Medicaid is attempting to clarify questions as to who should reimburse for mental health office visits when an HMO is one of the payors. The following paragraphs contain information about the guidelines that have been issued by WV Medicaid.
It is the responsibility of WV Medicaid to pay for office visits when performed by a Psychiatrist or Psychologist. This is for any service, even place of service 21. Medicaid will pay for inpatient claims when related to a psychiatric stay and all associated claims with place of service 21. Medicaid will also pay for Inpatient Psychiatric Facilities and all associated claims with place of service 51.
For Medicaid patients enrolled in an HMO, the HMO is responsible for covering outpatient services such as labs and x-rays, regardless of the diagnosis. Office visits with a mental health diagnosis (place of service 11) should be submitted to the HMO, unless treatment was performed by a psychiatrist or psychologist.
If you feel that you have mental health claims that may have denied in error, you may contact Unisys Provider Relations and request that the claims be adjusted.
WV Medicaid also reminds physicians that effective July 1, 2007 and thereafter, the appropriate NDC number must be billed when a drug is billed. The NDC number must be the actual NDC number on the package or container from which the medication was administered. The unit of measurement is also required when billing the NDC number.
NDC numbers are not required for inpatient services, immunizations or radiopharmaceuticals.
Medicaid agencies must collect the NDC information on claims for physician and outpatient facility administered drugs in order to continue to receive federal matching funds. |
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Mountain State Blue Cross Blue Shield recently announced an increase in the conversion factors, effective July 1, 2007, for services provided on or after this date. MSBCBS is also adopting the CMS Transitional RVU values and the Budget Neutral Work Factor as of July 1, 2007.
A summary of the new reimbursement methods and fees may be found on the MSBCBS website www.msbcbs.com. |
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The annual conference for the West Virginia Office Managers Association (OMA) is scheduled for Thursday, October 18th and Friday, October 19th in Bridgeport, WV. The conference is a wonderful educational event for office managers. Attendees not only attend seminars on a variety of topics but are also able to network with other office professionals from all over the state.
If your office manager is not a member of the OMA, you should encourage him/her to join one of the eleven chapters throughout the state. You may contact Barbara Good if you need an application for your office manager. |
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The American Association of Professional Coders (AAPC), Charleston Chapter, is sponsoring an all day workshop on Wednesday, September 12, 2007, at the Robert C. Byrd Health Science Center in Charleston. The workshop is open to both AAPC members and non-members and members may receive up to 6.5 CEUs. Early registration (before August 3, 2007) will be $20.00 for members and $30.00 for non-members.
For more information, contact Laura Sullivan (sullivanl@rcbhsc.wvu.edu).
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Volume VI
June 22, 2007
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Share this Newsletter with your Office Staff!
The WVSMA wants to serve you, our physicians, to the best of our ability. Some of the information included may also be of value to your office manager and staff. Please feel free to pass this newsletter on to them and encourage them to sign up to receive their own copy of the WESGRAM Online.
If you have comments or suggestions about the WESGRAM Online, please feel free to contact us and let us know how we can improve. You may contact Barbara Good, Physician Practice Advocate, at (304) 925-0342, ext. 11, or via email Barbara@wvsma.com
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WVSMA Contacts:
Executive Director
Evan H. Jenkins
Executive Director
Evan@wvsma.com
Phone ext: 15
Finance
Brian Purkey
Brian@wvsma.com
Phone ext: 28
Government Relations/WESPAC
Amy N. Tolliver, MS
Government Relations Specialist &
WESPAC Director/Treasurer
Amy@wvsma.com
Phone ext: 25
Medical Journal
Nancy Hill
Medical Journal Editor &
WVSMA Alliance Coordinator
Nancy@wvsma.com
Phone ext: 20
Member Services
Barbara Good
Physician Practice Advocate
Barbara@wvsma.com
Phone ext: 11
Mary Graham
Receptionist
Mary@wvsma.com
Phone ext: 10
Shirleen Lipscomb
Operations Manager &
CME Coordinator
Shirleen@wvsma.com
Phone ext: 12
Mona Thevenin
Membership Director &
Kanawha Medical Society Secretary
Mona@wvsma.com
Phone ext: 16
WV Medical Foundation
Helen Matheny
Chief Executive Officer
Helen@wvsma.com
Phone ext: 13
Anne Roberts
Project Coordinator
Anne@wvsma.com
Phone ext: 24
WV Medical Insurance Agency
Steve Brown
Agency Manager
Steve@wvsma.com
Phone ext: 22
Robin Saddoris
Account Manager
Robin@wvsma.com
Phone ext: 17
Megan Hughes
Administrative Assistant
Megan@wvsma.com
Phone ext: 29
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