The Centers for Medicare & Medicaid Services (CMS) recently announced that the Office of E-Health Standards and Services (OESS) will not initiate enforcement action with the HIPAA 5010 transaction set until March 31, 2012.   This does not delay the compliance date; only the enforcement date.  CMS’ Office of E-Health Standards and Services is the U.S. Department of Health and Human Services’ component that enforces compliance with HIPAA transaction and code set standards.
 
The actual implementation date of HIPAA 5010 did not change.   Physicians and other providers must still comply with the 5010 transaction standards by January 1, 2012. Small health plans have until January 1, 2013.  The Office of E-Health Standards and Services has decided it will not take any enforcement actions until March 31, 2012.

Also, the 90-day delay will not affect the implementation date for the ICD-10-CM/PCS coding systems, CMS said.  The compliance date for ICD-10 still remains October 1, 2013. 

The decision to delay enforcement was made because most covered entities do not think they will be ready to comply by January 1, 2012.

During the 90 day period of delay (January 1 through March 31, 2012), compliance complaints will be accepted and if they are investigated, covered entities will have to provide evidence that they are complying or are making a good faith effort to comply with the new HIPAA standards during the 90-day period . 

All HIPAA-covered entities and their business associates are required to switch to HIPAA 5010 in preparation for the conversion to ICD-10-CM/PCS. Failure to comply with the HIPAA 5010 requirement means covered entities might not be paid for their services.

The WVSMA continues to recommend that physicians get a statement of readiness in writing from your vendor and clearinghouse.   Don’t wait until your payments stop before upgrading to 5010! 

As a reminder, one of the main changes with the federally mandated HIPAA 5010 upgrade is that a PO Box can no longer be submitted in the “Billing Provider” field.  The “Billing Provider Address” must be a street address. Continuing to report a P.O. Box in the billing provider address field will cause your claims to reject.

A PO Box or lock box address should only be entered in the “Pay to Provider” address field.
 
You may need to work with your practice management system vendor, billing service, or clearinghouse to have this address change made for your claims.  Talk to them today to find out if a change is needed and when it will be done.  This work needs to be done prior to Jan. 1, 2012,  to prevent claims rejections and interruptions in your cash flow.

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There are many questions about the 2012 CPT code changes.   The WVSMA and Practice Management Institute (PMI) are partnering to ensure that you are fully aware of all the coding changes so that you may code and bill correctly in order to receive the maximum amount of reimbursement for your services.

The first of several 2012 CPT Update Courses will be held on Friday, December 16, 2011, in Charleston.  For your convenience, a morning and afternoon session will be offered.  Rhonda Granja, the instructor for the recent Certified Medical Coder class, will be the instructor.   Rhonda’s knowledge and enthusiasm will captivate you as you learn about the new proposed modifiers, incentive programs, coding edits, CPTs for your specialties, and much more.  In addition, the class will discuss the status of the proposed 27.4% reduction in the Medicare Physician Fee Schedule and Update to the Sustained Growth Rate (SGR).  You won’t want to miss this exciting course!

Many of you have had questions since we announced the upcoming 2012 Coding and Medicare Update Course.  Here are answers to some of the questions that the WVSMA has received.

Question: “Do I need to attend both the morning and the afternoon session?” 
Answer:  The session will cover the same material so you may choose whichever session you wish to attend.  Be aware, though, that classes fill up quickly, so register early!

Question: “Will this class deal with all specialties?”  
Answer:   Yes, the 2012 Medicare and Coding Update will cover EVERY coding change for the New Year.   Every specialty will be included if there is a change.  The course will be all encompassing with respect to the three key areas of reimbursement-CPT, ICD-9, and Medicare.

Question: “Will I be able to receive AAPC CEUs for this class”?
Answer:   PMI is preparing the course manual and it will include the most up to date and accurate information available.  The Institute will then submit the course material to AAPC for CEUs.  In the past, PMI classes have been approved for AAPC credit based on the total number of instructional hours, and we feel confident that this class will be the same.   Attendees who hold PMI credentials will receive 3 CEUs.

Question: “What do I need to bring to the class?”
Answer:  A course manual will be provided for each participant.  

Question: “Who can come to the 2012 Coding Update class?”
Answer:  The course is appropriate for coders, billing staff, physicians, office managers and compliance officers.

Question: “How do I register for the 2012 Coding Update class?”
Answer:  To register, you may our website, www.wvsma.com to download a registration form.

Question:  “Are there any discounts available?”
Answer:    PMI Certified Professionals, as well as WVSMA members, receive a 10% discount.

Question:   “Will there be classes in other locations throughout the state?”
Answer:     Classes are scheduled in Morgantown (January 10, 2012), Beckley (January 11, 2012), and Huntington (January 12, 2012).  Watch for more details!

Question: “Who can I talk to about other questions?”
Answer:  Karie Sharp (304-925-0342, ext 12) or via email (karie@wvsma.com).  

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(Information provided by CMS)

Efforts Will Build on 2011 Decreases in Medicare, Medicaid Improper Payments
 
In 2010, the President announced three goals for cutting improper payments by 2012: reducing overall payment errors by $50 billion, cutting the Medicare fee-for-service error rate in half, and recovering $2 billion in improper payments. 
 
To help achieve these goals, the Centers for Medicare & Medicaid Services (CMS) has announced it will launch demonstration programs beginning in January 2012 targeting some of the most common factors that lead to improper payments.
 
Cost Saving Projects will Help Protect Medicare and Medicaid
 
Beginning on January 1, 2012, CMS will conduct demonstration projects that will strengthen Medicare by aiming at eliminating fraud, waste, and abuse.   Reductions in improper payments will help ensure the sound future of the Medicare Trust Fund and protect Medicare beneficiaries who depend upon it.
 
Recovery Audit Prepayment Review: The Recovery Audit Prepayment Review demonstration will allow Medicare Recovery Auditors (RACs) to review claims before they are paid to ensure that the provider complied with all Medicare payment rules.  The RACs will conduct prepayment reviews on certain types of claims that historically result in high rates of improper payments.   These reviews will focus on   seven states with high populations of fraud- and error-prone providers (FL, CA, MI, TX, NY, LA, IL) and four states with high claims volumes of short inpatient hospital stays (PA, OH, NC, MO) for a total of 11 states. This demonstration will also help lower the error rate by preventing improper payments rather than the traditional “pay and chase” methods of looking for improper payments after they have been made.
 
Prior Authorization for Certain Medical Equipment: The second demonstration announced today will require Prior Authorization for certain medical equipment for all people with Medicare who reside in seven states with high populations of fraud- and error-prone providers (CA, FL, IL, MI, NY, NC and TX).  This is an important step toward paying appropriately for certain medical equipment that has a high error rate.  This demonstration will help ensure that a beneficiary’s medical condition warrants their medical equipment under existing coverage guidelines. Moreover, the program will assist in preserving a Medicare beneficiary’s right to receive quality products from accredited suppliers.
 
The Prior Authorization demonstration will be implemented in two phases. During the first phase (the first three to nine months), the Medicare Administrative Contractors will conduct    prepayment reviews on certain medical equipment claims. The second phase, for the remainder of this three-year demonstration, will implement prior authorization, a tool utilized by private-sector health care payers to prevent improper payments and deter the fraudulent provision of items or services. 
 
Part A to Part B Rebilling: The third initiative will allow hospitals to rebill for 90 percent of the Part B payment when a Medicare contractor denies a Part A inpatient short stay claim as not reasonable and necessary due to the hospital billing for the wrong setting.  Currently, when outpatient services are billed as inpatient services, the entire claim is denied in full.
 
This demonstration will be limited to a representative sample of 380 hospitals nationwide that volunteer to be part of the program. This demonstration will allow hospitals to resubmit claims for 90 percent of the allowable Part B payment when a Medicare Administrative Contractor, Recovery Auditor, or the Comprehensive Error Rate Testing Contractor finds that a Medicare patient met the requirements for Part B services but did not meet the requirements for a Part A inpatient stay.  In addition, this demonstration is expected to lower the appeals rate which will protect the trust fund and reduce hospital burden.   Beneficiaries will be held harmless with respect to changes in hospital coinsurance liability.
 
This past May, HHS announced a pilot project under the Partnership Fund for Program Integrity Innovation to test an automated tool to screen providers for the risk of fraud.  Currently, HHS and States lack standardized Medicaid provider data, which hampers detection of potential fraud.  If successful, this tool will not only help prevent improper payments by weeding out fraudulent providers, but it will help States focus their resources where fraud is most likely to occur.
 
New Projects Build on 2011 Savings
 
The 2012 projects announced today will build on accomplishments in 2011 to reduce Medicare and Medicaid improper payment rates.
 
For example, the Medicare fee-for-service improper payment rate dropped to 8.6 percent, or $28.8 billion in estimated improper claims payments.  This rate was calculated using a refined methodology, after consulting with the Office of the Inspector General, that reflects the impact of late documentation and the results of appeal activities that typically occur after the cut-off date.   For consistency and comparison purposes, CMS adjusted the 2010 error rate to 9.1 percent or $29.7 billion. When comparing the adjusted rates, the 8.6 percent error rate for 2011 represents a 0.5 percentage point reduction in the improper payment rate from 2010.  [1]
 
In addition, for 2011:
 
The Medicare Advantage (Part C) improper payment rate, based on the 2009 payment year, is 11.0 percent, or $12.4 billion, a reduction from last year’s rate of 14.1 percent, or $13.6 billion.  The Part C improper payment rate dropped 3.1 percentage points (or 21 percent) from 2010, a result of the Administration’s aggressive corrective actions, including ongoing audits - with an emphasis on contract-level risk adjustment data validation audits - designed to recover overpayments to Part C plans.
 
The Medicaid improper payment rate is 8.1 percent, or $21.9 billion in estimated improper payments.  This rate reflects a three-year average of the 2009, 2010, and 2011 cycle rates.  The Medicaid improper payment rate declined by 1.3 percentage points, reflecting ongoing efforts by the States and the Department of Health and Human Services (HHS) to educate providers on the root causes of improper payments.
 
CMS is also reporting for the first time a composite improper payment rate for the Medicare Part D prescription drug program.  Based on payment year 2009, the improper payment rate is 3.2 percent, or $1.7 billion.  The Part D payment improper payment rate combines five component payment error measures: Medicare Advantage prescription drug payment system error; payment error related to low income subsidy status; payment error related to incorrect Medicaid status; payment error related to prescription drug event data validation; and payment error related to direct and indirect remuneration.
 
The improper payment rate for the Children’s Health Insurance Program (CHIP) will not be published until 2012.  CMS was prohibited from calculating or publishing a rate until six months after the August 2010 Payment Error Rate Measurement (PERM) program rules went into effect.  Due to the timing , HHS began measuring CHIP improper payments under the new program rules in 2011, and will publish the results in 2012.  
 
While improper payment rates are not necessarily an indicator of fraud in Medicare, Medicaid or CHIP, they do provide HHS, CMS and States with a more complete assessment of   factors leading to error rates and new ways to help prevent them.
 
CMS is continuing to invest time and resources to work with providers across the country and eliminate errors through increased and improved training, education, and outreach.
 
For more information, please visit CMS Fact Sheets (11/15/11): https://www.cms.gov/apps/media/fact_sheets.asp
 

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(information supplied by Palmetto GBA)

When documentation is worded exactly like or similar to previous entries, the documentation is referred to as cloned documentation.
Documentation exactly the same from patient to patient is considered cloned and often occurs when services have a specific set of limited or select criteria. Cloned documentation lacks the patient specific information necessary to support services rendered to each individual patient.

Whether the cloned documentation is handwritten, the result of pre-printed template, or use or Electronic Health Records, cloning of documentation will be considered misrepresentation of the medical necessity requirement for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.

It would not be expected that every patient had the same exact problem, symptoms, and required the exact same treatment. Cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information for each unique patient.

Documentation exactly the same from patient to patient is considered cloned and often occurs when services have a specific set of limited or select criteria. Cloned documentation lacks the patient specific information necessary to support services rendered to each individual patient. 

The WVSMA is aware that physicians and codes alike have many questions about the cloned documentation.   We are currently working with Palmetto GBA on this topic.  
 

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Quarterly Update to Correct Coding Initiative (CCI) Edits, Version 18.0, Effective January 1, 2012

Change Request (CR) 7616 which provides a reminder for physicians and billing staff to take note of the quarterly updates to Correct Coding Initiative (CCI) edits. The last quarterly release of the edit module was issued in October, 2011.  You may view the article on the Palmetto GBA website (www.palmettogba.com.  

New EDI Enrollment Setup and Transaction Options

Effective December 1, 2011, Medicare Fee-for-Service (FFS) contractors will no longer process EDI enrollment requests for submitters who have not converted to v5010. All new providers requesting to submit files or receive
835 Health Care Payment Advices through an existing submitter ID will be required to enroll / link using HIPAA v5010-compliant transactions only.

Influenza Vaccine Payment Allowances: Annual Update for 2011-2012 Season

The Centers for Medicare & Medicaid Services (CMS) issued Change Request
(CR) 7575 in order to update payment allowances, effective September 1, 2011, for influenza vaccines when payment is based on 95 percent of the Average Wholesale Price (AWP). Physicians may want to be sure your billing staffs are aware of this update.

New EDI Enrollment Setup and Transaction Options

Effective November 1, 2011, Medicare fee-for-service (FFS) contractors will no longer process EDI enrollment requests for submitters who have not converted to v5010. All providers requesting to submit files or receive 835 Health Care Payment Advices through an existing submitter ID will be required to enroll / link using HIPAA v5010-compliant transactions only.

Further Details on the Revalidation of Provider Enrollment Information

All providers and suppliers enrolled with Medicare prior to March 25, 2011, must revalidate their enrollment information. Newly enrolled providers and suppliers that submitted their enrollment applications to CMS on or after March 25, 2011, are not impacted. There is no need to contact Palmetto GBA at this time.  When it is time to revalidate, you will receive a revalidation notification from Palmetto GBA.

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(information supplied by the American Medical Association)

Stop the Implementation of ICD-10

The AMA House of Delegates voted today to work vigorously to stop implementation of ICD-10 (The International Classification of Diseases and Related Health Problems, 10th Revision), a new code set for medical diagnoses. ICD-10 has about 69,000 codes and will replace the 14,000 ICD-9 diagnosis codes currently in use.

“The implementation of ICD-10 will create significant burdens on the practice of medicine with no direct benefit to individual patients’ care,” said Peter W. Carmel, M.D., AMA president. At a time when we are working to get the best value possible for our health care dollar, this massive and expensive undertaking will add administrative expense and create unnecessary workflow disruptions. The timing could not be worse as many physicians are working to implement electronic health records into their practices. We will continue working to help physicians keep their focus where it should be – on their patients.”

A 2008 study found that a small three-physician practice would need to spend $83,290 to implement ICD-10, and a 10-physician practice would spend $285,195 to make the coding change.

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(Medicare information for patients provided by the U.S. Department of Health & Human 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.

Open Enrollment started earlier this year - on October 15th - and lasts longer (7 full weeks) to give patients enough time to review and make changes to their coverage. 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.

You can remind your patients 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.  You may also want to remind patients that they may call 1-800-MEDICARE (1-800-633-4227) 24-hours a day/7 days a week to find out more about  coverage options.

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• • CMS Changes Enforcement Date for HIPAA 5010 Standards
• • Be Prepared for the 2012 Coding and Medicare Changes!
• • CMS Demonstration Programs for 2012
• • Medical Record Cloning
• • Palmetto GBA News
• • American Medical Association News
• • Medicare Open Enrollment is October 15- December 7
• • Happy Thanksgiving!