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As of March 1, 2008, physicians billing Medicare were no longer permitted to submit paper or electronic claims using just their legacy (old) numbers. All Medicare claims must now include the physician's NPI or the physicians NPI plus the legacy number.
As of May 23, 2008, physicians will be required to use only their NPI numbers on all electronic claims sent to government or commercial payors. As of May 23, 2008, no legacy numbers will be permitted on any electronic claims or on any Medicare claims.
For claims submitted with dates of service of March 1 and after, Palmetto GBA will reject claims that contain ONLY a PTAN in the billing and rendering provider fields (also called "primary provider fields"). If practices have been submitting claims with both an NPI and PTAN combination, nothing will change. For practices that have been successfully submitting claims with NPIs only, nothing will change.
If claims are rejected (electronically through GPNet, or if you are notified on your Remittance Advice), please have a copy of the reject message and a copy of the NPPES file (your NPI credentialing information, filed with the NPI Enumerator) available before calling Palmetto GBA. This will allow Palmetto to research the issue thoroughly and assist your office as quickly as possible.
Palmetto GBA also processes claims for Railroad Medicare through their Augusta, GA office. Railroad Medicare follows the same NPI requirements as the Palmetto GBA Ohio/West Virginia office. Before enrolling with Railroad Medicare, providers must be enrolled (credentialed) with their local carrier.
The AMA is advising physicians and office staff to check for any NPI informational warnings on reject reports from Medicare to billing agents so that corrections may be made. Practices will want to work closely with clearinghouses and billing agents to fix future claims.
It is also recommended that physicians begin using only their NPI numbers immediately by sending a few claims through to ensure they process correctly. If claims are rejected, check to see that the correct legacy number is on file with CMS by visiting their website https://hppes.cms.hhs.gov or by calling (800) 465-3203. If the information that appears in the "other provider identification numbers" field is correct, then contact your Medicare contractor (Palmetto GBA) and ask Palmetto to validate what is appearing in their system.
By checking your NPI information early, physicians should have ample time to make corrections so that reimbursement is not delayed by the upcoming deadline. |
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The Centers for Medicare and Medicaid has found a significant number of instances where either the Legal Business Name (LBN) and/or Employer Identification Number (EIN) of an organization health care provider who has been assigned an NPI do not match the Internal Revenue Service (IRS) records. In some cases, this is caused by health care providers who are individuals who erroneously applied for NPIs as organizations and who reported their Social Security Numbers in the EIN field. As a first step to improving the quality of information in the National Plan and Provider Enumeration System (NPPES), CMS is requesting that organization health care providers verify their Legal Business Name and EIN within NPPES. This is especially important if the organization health care provider is experiencing any Medicare claims processing issues.
You may access the NPI registry at no charge and query by entity type, NPI, physician name, zip code or staff. The website to access is https://nppes.cms.hhs.gov.
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Mountain State Blue Cross Blue Shield has announced that effective May 23, 2008, they will reject all electronic claims that don't contain NPIs in the billing, rendering provider and service facility field.
Providers who have registered a National Provider Identifier (NPI) number or numbers with Mountain State Blue Cross Blue Shield (MSBCBS) and who electronically submit claims should begin immediately submitting their NPIs in the billing, rendering provider and service facility field (when applicable) of all claim submissions, if they aren't already doing so.
Effective May 23, 2008 - the date on which the Centers for Medicare & Medicaid Services' (CMS) contingency guidelines for HIPAA-covered entities will expire - Mountain State will reject electronic claim submissions that don't contain an NPI in the billing, rendering provider and service facility field and will return the claims to the provider. Additionally, Mountain State will reject electronic inquiry transactions - such as eligibility, authorization and claims status inquiries - that do not contain NPIs. This action is being taken to comply with the CMS HIPAA mandate and enforcement of the NPI Final Rule.
In order that your claims are processed correctly when the May 23, 2008, deadline arrives, and to help ensure seamless revenue flow, please begin immediately to include your NPI in the billing, rendering provider and service facility field on all electronic claims. Additionally, please be sure to contact your software vendor, clearinghouse and/or trading partner to ensure that they can send and receive transactions with the NPI to avoid delays in payment of your claims.
For more information, please consult the "Provider EDI Reference Guide," which is available via Mountain State's Web site at www.msbcbs.com/msbc_trading.htm.
Mountain State reminds physicians that non-compliance with NPI regulations could mean federal penalties. CMS initiated the contingency guidelines for those HIPAA-covered entities who were not NPI compliant as of the original NPI compliance deadline of May 23, 2007. The contingency guidelines provided relief from penalties for HIPAA-covered entities who continued to demonstrate good-faith efforts to become HIPAA NPI compliant by May 23, 2008. CMS has stated that HIPAA-covered entities who are not HIPAA NPI compliant or haven't shown good faith efforts to become compliant by May 23, 2008, could face civil monetary penalties. For more information, visit: www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPI_Contingency.pdf to read the CMS contingency requirements in detail via a document titled "Guidance on Compliance with the HIPAA NPI Rule".
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As you are aware, all written prescriptions for Medicaid recipients will soon be required to be written on mandated tamper resistant prescription pads in order to be eligible for reimbursement. This action is required by section 7002(b) of the U.S. Troop Readiness, Veterans' Care, Katrina Recovery, and Iraq Accountability Appropriations Act of 2007, which was signed into law on May 25, 2007.
As of April 1, 2008, all prescription pads or printer paper for prescriptions written for Medicaid members are required to have at least one of the recognized characteristics. By October 1, 2008, prescription pads and paper will be required to have all 3 of the features as listed below:
1. Industry-recognized features (s) designed to prevent unauthorized copying
2. Industry-recognized feature (s) designed to prevent erasure or modification of information written by the prescriber, or
3. Industry-recognized feature (s) designed to prevent use of counterfeit prescription forms
According to the ruling, physicians who use computer generated prescriptions for Medicaid patients will also need to ensure that the paper being used in their printers is compliant and tamper resistant.
The WVMSA has worked diligently with the WV Bureau for Medical Services in order to assist physicians in their efforts to ensure compliancy with the federal mandate. We have met with BMS to choose security features that are economical and reasonable to implement. Physicians will soon be receiving correspondence from BMS describing the required features.
Over the past few months, the WVSMA has also been actively involved with obtaining price quotes from print vendors for tamper resistant prescription pads. These vendors include both instate and national firms. We have found a company who can not only supply quantity pricing for both the tamper resistant prescription pads and the tamper resistant printer paper for computer generated prescriptions, but also has committed to supplying physicians with the highest level of tamper resistant prescription pads. The company has pledged to meet and exceed the requirements set by WV State Medicaid for the tamper resistant prescription pads
In addition to providing the tamper resistant paper/pads, all West Virginia pharmacies will be contacted and advised that any prescription written on this vendor's prescription pads or paper will be compliant with any state requirements, thereby reducing the number of phone calls and questions from pharmacists who are filling prescriptions for Medicaid patients.
As you can see, the WVSMA has plans in place to move quickly once Governor Manchin signs the bill which will appropriate the grant money to the WVSMA. As soon as the grant money is available, we will communicate to our physicians the process for obtaining a complimentary supply of tamper resistant prescription pads and paper.
If you need more information or have additional questions, please contact Barbara Good, WVSMA Physician Practice Advocate, at (304) 925-0342, ext. 11 or via email (Barbara@wvsma.com).
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It's not too late to begin participating in the CMS PQRI for 2008. There are 119 measures listed for the 2008 PQRI program, including several measures related to electronic health records and e-prescribing.
PQRI is a claims based reporting program; therefore, no registration is required. The recording process requires the use of CPT Category II codes (or temporary G codes where CPT Category II codes are not yet available) for reporting quality data. The quality codes must be reported on the same claims as the payment codes.
The 1.5% bonus payment remains the same for 2008 but there is no national or individual "cap" that would reduce an individual's earned incentive below the 1.5% of their allowable charges for the reporting period.
The PQRI Tool Kit has been updated to include a downloadable file containing Data Collection Worksheets for all 119 2008 PQRI quality measures. To access this file, please go to http://www.cms.hhs.gov/PQRI, and select the PQRI Tool Kit tab on the left side of the page. Then, scroll down to the Downloads section and select "2008 PQRI Data Collection Worksheets".
The Centers for Medicare and Medicaid Services (CMS) is now accepting quality measure suggestions for consideration for possible inclusion in the proposed set of quality measures to be published in the 2009 Medicare Physician Fee Schedule (MPFS) Proposed Rule for the PQRI.
To learn more information about this opportunity to suggest measures for consideration for inclusion in 2009, please go to http://www.cms.hhs.gov/PQRI, and select the Measures/Codes tab on the left side of the page. Next, scroll down to the Downloads section and select "Notice of 2009 Measure Suggestions."
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Each year, the list of Top 10 claims billing errors includes the error of billing a patient encounter as a consult rather than an office visit. CMS CERT reports indicate that most errors resulted from documentation supporting a lower level of service than the submitted code. In order to distinguish between the two for coding purposes, you can use the "3 R" method to indicate a consultation. You should ask yourself these questions:
1. Is this a request or an opinion?
2. Is this a rendering of an opinion?
3. Is there a written report to send back to the requesting physician?
These questions should help ensure that you are billing correctly for a visit or consult in order to receive appropriate reimbursement.
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The Bureau for Medical Services would like to inform providers of the recently approved changes to the West Virginia Preferred Drug List. For a complete list of changes please refer to the posted PDL at www.wvdhhr.org/bms. Some of the major changes follow below.
As of 04/01/2008, the following medications will be preferred and will be available without prior authorization:
Erythromycin/benzoyl peroxide Mupirocin Ultrase
Fentanyl patches Caduet Veramyst
Exforge Altabax Pravastatin
Cetirizine OTC Zemplar Vyvanse
Sanctura XR Aldara
As of 04/01/2008, the following medications will be non-preferred and will require prior authorization:
Benzaclin Gel Duragesic patches Bactroban
Cleocin-T Ramipril Rocaltrol
Lotrel (brand) Tarka Sensipar
Equetro Xyzal Pancrease
Toprol XL (brand) Creon Ditropan XL (brand)
Altoprev Vytorin Condylox
Duragesic Update: The Bureau is aware that pharmacy providers may have an abundance of brand name Duragesic patches in stock. While the generic patches will be the preferred product as of 04/01/08 if a provider still has significant stock on hand please call the Pharmacy helpdesk and an override may be granted to allow you to finish current stock of the non-preferred Duragesic. Please note this will be limited and not meant to circumvent the PA requirements.
Vytorin Update: Members who are currently on therapy of Vytorin 10/80 will be allowed to continue therapy indefinitely; members who are currently on therapy of all other strengths of Vytorin will need a PA after 6/30/2008. Providers are encouraged to either switch these patients to other preferred agents or request prior authorization before 6/30/2008.
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Southern WV Community and Technical College will be offering a 3 credit hour Medical Coding and Billing Class (OA 230) beginning March 7, 2008. Classes will be offered on Fridays from 6-8.30 P.M. and on Saturdays from 9-11.30 A. M. at the Logan Campus. This is an 8 week course.
For more information, contact Rhonda Collins at 304-236-7609.
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The WVSMA is saddened by the death of Frank Tolliver, the father of Amy Tolliver, Government Affairs Specialist. Mr. Tolliver passed away on Friday, March 7, 2008. A memorial service will be held on Sunday, March 16, 2008.
All of us at WVSMA express our deepest sympathy to Amy and the Tolliver and Lefler family. A copy of the obituary is given below.
FRANK SYMBOL TOLLIVER
Frank Symbol Tolliver, 68, of Charleston passed away among family at home on March 7, 2008 after a heroic battle with cancer.
Born and raised in Mullens, West Virginia, Frank was a graduate of Marshall University where he earned both a Bachelor of Arts and a Master of Arts in Psychology. While at Marshall, he served as president of Zeta Zeta Zeta Chapter of Lambda Chi Alpha Fraternity. Frank went on to doctoral work in psychology at the University of Oklahoma where he met his future wife of 43 years, Nancy Skram Tolliver. Returning to West Virginia in 1965, he worked for the State Division of Vocational Rehabilitation for 34 years, retiring as Associate Director of Vocational Rehabilitation in 1999. While at the Agency Frank served as Chief of Management Information and was instrumental in fostering the integration of technology into services provided to the State's physically and mentally challenged.
Frank was known by friends and family as a modern-day Renaissance Man. He had an unquenchable thirst for learning and acquiring new skills and his eclectic pursuits ran the gamut from beekeeping and hunting to bricklaying and gentleman farming. He was an accomplished woodworker, making furniture and grandfather clocks. A lover of bluegrass music, he made his own guitar and two mandolins which he then taught himself to play.
Frank had a passionate love of nature and most enjoyed hiking with his dogs on the "Darwin Paths" he developed on his Jackson County farm, identifying the trees and mushroom species along the way. With help from his close friends and family, Frank also renovated the old farm house, and constructed a workshop, and a barn. He was an avid reader, a great debater of politics and a storyteller. Above all, Frank was the major emotional and intellectual supporter of his wife and daughters. The friends, family and beloved dogs, fortunate enough to have shared in portions of his winding lifelong journey, were truly enriched by the experience.
Frank was preceded in death by his mother, Elsie Hall Lefler, his loving stepfather Ernest Lefler, his biological father, Frank Symbol Tolliver, Sr., all of Mullens, and a beloved aunt and uncle, former State Senator Dr. Ward Wylie and Anilee "Momma Rosie" Hall Wylie, who helped raise him in his early years.
He is survived by his wife, Nancy; daughters, Leah Tolliver and husband David Rogers of Huntington; Tasha Tolliver and husband Raymond McKinney, III of Richmond, VA; Amy Tolliver and husband, Scott Duffer of Charleston; five grandchildren, Nicholas Ryan Rogers, Olivia Grace Rogers, Isabel Symbol McKinney, Ava Laine McKinney, and Emma Nicole Duffer; brother Ward Lefler of Gap Mills; nephew, Derrick Lefler of Princeton; a close brother-in-law, Paul Skram of Charleston and wife Nancy Tyler; cousins, Betty Jack Farmer of Salt Sulphur Springs: Robert Wylie of Durham, NC; Tom Hall of Kansas City, Kansas; Bob Cherry of Biloxi, Ms; and Bill Cherry of Warner-Robins, Georgia, and many dear and special friends.
A memorial celebration of Frank's life will be held at the University of Charleston at 3 PM on Sunday, March 16th in the Erma Byrd Room of Riggleman Hall. A reception will follow in the Rotunda. Frank's ashes will be laid to rest at a later date on his farm in Jackson County where he most enjoyed life.
In lieu of flowers donations may be sent to HospiceCare, 1143 Dunbar Avenue, Dunbar, WV 25064, the National Arbor Day Foundation, 100 Arbor Avenue, Nebraska City NE 68410, or the charity of your choice.
Barlow-Bonsall Funeral Home, Charleston, is in charge of the arrangements.
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March 12, 2008
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