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October 2011

Deadlines Approaching November 1, 2011, is the deadline to request a hardship exemption for the 2012 eRx payment adjustment. The MLN Article SE1107 provides information on who is eligible for the 2012 eRx payment adjustment. This Quick Reference Guide helps you understand the changes made to the 2011 eRx Incentive Program. To request an exemption, eligible professionals should submit hardship exemption requests through the Quality Communications Support Page and group practices participating under the GPRO option must submit hardship exemption requests via a letter to CMS. Please remember that CMS will review these requests on a case-by-case basis. All decisions on significant hardship exemption requests will be final. For additional information and resources, please visit on the CMS website.

Updated Registration and Payment Numbers As of August 31, 2011, more than 90,000 providers have registered for the EHR Incentive Programs, and more than $652 million has been received in incentive payments for both the Medicare and Medicaid programs. If you have not already done so, take a look at CMS' Educational Materials page on the EHR website to find helpful information about eligibility, registration, meaningful use, and attestation.

Jan 1, 2012, is the deadline for suppliers who furnish the technical component of Advanced Diagnostic Imaging (ADI) to be accredited in order to bill Medicare for these services. ADI procedures include MRI, CT, nuclear medicine imaging, and positron emission tomography; xray, ultrasound, fluoroscopy, and Hospital Outpatient procedures are excluded. Information about accreditation, a list of accrediting organizations & details of the accreditation process are on this link. Important reminders about ADI accreditation requirements (MLN SE1122) are also available.


Practice Management & Coding Educational Opportunities for 2011 Al l C o ur s e s In 3 months, you will need to submit your claims not only to Medicare, but to ALL your payers using Version 5010A1. ARE YOU

Fundamentals and Advanced Endocrine Coding Course December 2-3, 2011 Phoenix, AZ Phoenix Marriott Mesa

The Fundamentals of Endocrine Coding provides attendees with foundational coding, billing, and documentation knowledge required to stay compliant and obtain maximum reimbursement. Fundamentals Course Agenda and Learning Objectives Presenter: Vanessa Lankford, CPC, CMOM, AACE-CEC Course Duration: 8:00am – 4:30pm

READY? ARE YOU TESTING? IS YOUR VENDOR AND/OR CLEARINGHOUSE TESTING? If you (and your vendor/clearinghouse) are not prepared as of January 1, 2012, you will not get paid! CMS has stated that there will be no extension of the January 1, 2012 deadline. The Medical Group Management Association released results of a recent survey which showed that of 356 practices surveyed, 45.2% had not even started preparing for Version 5010A1 implementation. Is your vendor or clearinghouse HIPAA 5010 compliant with your MAC (Medicare Administrative Contractors)? Lists of HIPAA 5010 compliant vendors and clearinghouses were found on the following MAC’s websites. This list is informational only. The AACE does not endorse any vendors, billing companies, or clearinghouses. This information is subject to change. First Coast Service Options

Trailblazer WPS NGS

Palmetto-Jurisdiction 1 Palmetto Jurisdiction 11 Highmark NHIC Jurisdiction 14 CGS – Idaho Kentucky Ohio

The Advanced Course provides the physician and staff with additional knowledge and skill in understanding the business side of the office. Advanced Course Agenda and Learning Objectives AACE-CEC General Information Presenter: Anita Henderson-Sumpter, MHA, MBA, CPC Course Duration: 8:00am - 4:00pm AACE-CEC Exam: 4:00pm - 6:00pm

At the end of the course, attendees will have the opportunity to take the AACEsponsored Certified Endocrine Coder (AACE-CEC) exam.


CMS offers free billing software that is Version 5010 compliant. Please contact your MAC, FI or Carrier to obtain the latest Version of PC-Ace Pro32.

What is PC-Ace Pro32? PC-Ace Pro32 is a complete, self-contained electronic processing system for health care claims submission and management. It does not integrate into office systems, such as accounts receivable, inventory or billing, but provides the ability to enter patient information, claim information, procedure file information and create a summary report of the claims you submit electronically. Additional information can be found here. CMS also provides the Medicare Remit Easy Print (MREP) software to view and print compliant HIPAA 5010 - 835 remittance advices. Please visit this link to view the software.

All courses are subject to change.

For more information, please visit ses-and-webinars or contact

HIPAA Version 5010 Vendor Assessment worksheet Versions 5010 & D.0 Implementation Information Educational Resources CMS created an interactive timeline widget 2

Medicare Fee-For-Service (FFS) Claims Processing Guidance for Implementing International Classification of Diseases, 10th Edition (ICD-10) Provider Types Implementation Date: January 1, 2012 Effective Date: October 1, 2012

Medicare and Other Federal Updates Individual Measures and Measures Groups for Consideration in the Physician Quality Reporting System CMS is now accepting quality

2011- 2012 Immunizers’ Question & Answer Guide to Medicare Part B & Medicaid Coverage of Seasonal Influenza and Pneumococcal Vaccinations

The Medicare Part B payment allowance limits for seasonal influenza and pneumococcal vaccines are 95% of the Average Wholesale Price (AWP) as reflected in the published compendia except where the vaccine is furnished in a hospital outpatient department. When the vaccine is furnished in the hospital outpatient department, payment for the vaccine is based on reasonable cost.

FREE Influenza Vaccine Roster for Mass Immunizers from Trailblazer Health Enterprises, a Medicare Administrative Carrier

Free poster for your office

measure suggestions to be considered for use in Physician Quality Reporting System future rule-making years. To learn more visit this link

Final Rule Released for the Medicaid Recovery Audit Program On Wednesday, September 14, 2011, the Department of Health and Human Services (HHS) released its final rule for the Medicaid Recovery Audit Program. The program will help states identify and recover improper Medicaid payments. It will be largely self-funded, paying independent auditors a contingency fee out of any improper payments they recover that took place in the previous three years.

Recent CERT analysis reveals an increase in errors for diagnostic laboratory services. Errors are attributed to the absence of documentation supporting the physician orders or the physician intent to have the diagnostic laboratory tests performed. Submission of appropriate documentation in a timely manner will decrease the number of errors and claims denied by the CERT contractor. Source: 42 CFR 410.32 (Code of Federal Register), Internet Only Manual (IOM) Medicare Benefit Policy Manual, Publication 100-03, Chapter 15, Section 80.6.1

The use of the term, "standing orders," in Medicare is problematic due to its diverse meanings and usages, not all of which are covered by Medicare. "Standing orders" may be understood to describe both recurring orders specific to the care of an individual patient and as routine orders for services delivered to a population of patients. Standing orders may be used for non-laboratory services if they meet the definition of recurring orders, not routine orders. Standing orders may be used for laboratory tests ONLY if several conditions are met.

Diagram of how Medicare appeals are handled

Medicare Pilot Project for Electronic Submission of Medical Documentation (esMD): The esMD pilot began in September 2011. 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. A secondary goal of esMD is to reduce costs and time at review contractors. A list of review contractors that will accept esMD transactions can be found at on the Internet. 3

Have You Been Incorrectly Qualified as a PCIP Eligible Practitioner? If you feel that you have been incorrectly qualified as a Primary Care Incentive Payment Program (PCIP) eligible practitioner, you many contact your Medicare claims processing contractor and request a review of your prior claims history that resulted in an eligibility determination. If it is determined that an error was made in your claims history, your contractor may accept the return of your PCIP payment. Refer to MLN Matters article MM7060 at for a list of eligibility requirements.

FREE Web Based Education Typically, insurance billing staff and office management attend Medicare training classes and the front office staff has limited access to specific training tailored just for them. This class is designed to inform front office staff of general Medicare program guidelines as well as basic patient screening information. This training is designed to help front office staff with: o Overview of the Medicare program o Privacy Act o Patient screening o Overview of Medicare Secondary Payer (MSP) provisions o Overview of Medicare Advantage plan guidelines o Overview of supplemental insurance o Overview of: o Interactive Voice Response (IVR) o Professional Telecommunication Network (PPTN)

Source: Frontier Focus Newsletter, Division for Medicare Health Plans Operations, CMS Region VIII, Denver, CO, dated September 27, 2011

Understanding Medicare means understanding the meaning of many unfamiliar terms. This list provides viewers with definitions of words and acronyms that are discussed in Medicare Interactive Counselor, or are important to give you a better understanding of how Medicare works.

As a result of the Affordable Care Act, providers

will need to enroll in the Medicare Program for the sole purpose of ordering or referring services to Medicare beneficiaries. This fact sheet provides education on the enrollment requirements for eligible ordering/referring providers.

This educational tool is designed to provide education on the definitions and responsibilities of entities that are involved in various aspects of claims adjudication activities. It includes a chart that outlines each entity by type, definitions, responsibilities, and reasons for contacting providers, especially FeeFor-Service (FFS) providers. Contractor Entities at a Glance: Who May Contact You About Specific Centers for Medicare & Medicaid Services (CMS) Activities CMS Quarterly Provider Update October - December 2011 Comparative Billing Reports (CBRs)- Did You Receive One? At first glance, the reports appear that endocrinologists are considered to be outliers for ordering diabetic testing supplies. Dr. Howard Lando (Vice-Chair of Advocacy), Dr. Eric Orzeck (Coding Chair) and AACE staff participated on a conference call with Safeguard Services, who is the contractor CMS hired to compile this data. Safeguard Services elaborated on the purpose of these reports which is to educate ordering physicians on the guidelines for diabetic testing supplies. As you know, there is ongoing fraud with diabetic testing supplies and CMS wants to ensure that these supplies are medically necessary and ordered based on the physician’s request. If you have any questions regarding your report, you may contact Safeguard Services at 1-530-896-7080 or the Socioeconomics & Member Advocacy Department at 1-800-393-2223. 4

Jurisdiction 11 Part B Message from Dr. James Lee, Connolly, RAC Medical Director: Modifier Usage

National Provider Call: Revalidation of Medicare Provider Enrollment – Thursday, October 27, 2011; 12:30-2pm ET CMS will hold this call to discuss the revalidation of Medicare provider enrollment information. Most providers and suppliers who are enrolled in the Medicare program will have to revalidate their enrollment, which will be reviewed under the new risk screening criteria required by the Affordable Care Act Section 6401(a). Learn what you can expect and how to prepare for this process. Target Audience: All providers and suppliers enrolled with Medicare prior to March 25, 2011, and who expect to receive payment from Medicare for services provided. Agenda will include: § What is Revalidation? § ACA Screening Requirements § Electronic Funds Transfer § Streamlining the Process

In accordance with Palmetto GBA’s guidance in reference to CPT Modifier 25 and Modifier 57, the Evaluation and Management (E/M) codes (for new patients only) 92002, 92004, 99201-99205, 99281-99285, 99321-99323, and 9934199345 may be submitted without CPT modifiers 25 or 57 even where the service billed is significant and separately identifiable from the usual work associated with the minor or major surgery. These E/M codes have been removed from the audit concept C003852010 and corrective action has been initiated. Connolly has put a hold on processing claims for the aforementioned concept number regarding CPT modifier 25 and awaits CMS’ guidance concerning the issue.

Question: Is it permissible to charge Medicare beneficiaries late fees for failing to pay deductible and coinsurance amounts?

Answer: It is a violation of the assignment rules for a physician or supplier to charge a beneficiary an amount in addition to the deductible and/or copayment amounts. Similarly, non-participating physicians/suppliers who do not take assignment may charge no more than the limiting charge for the covered service. Medicare views the cost of collection of deductibles and coinsurance as part of the routine practice expense of doing business. Therefore, if a physician or supplier was to charge interest or late fees to beneficiaries for the collection of deductible and/or coinsurance amounts, that would be a violation of the assignment rules or the limiting charge provisions. See 42 CFR 424.55 for details regarding assignment and 42 CFR 414.48 for details regarding the limiting charge. CMS Central Office

Question: Who is considered part of the physician group? Answer: Physician specialty means the self-designated primary specialty by which the physician bills Medicare and is known to the contractor that adjudicates the claims. Physicians in the same group practice who have different medical specialties may bill and be paid without regard to their membership in the same group. (Refer to the Medicare Claims Processing Manual, Pub. 100-04, Chapter 12, §30.6.)

§ Phased Revalidation § Tips on Revalidation § Question and Answer Session Registration Information: Will be made available soon on the CMS website and announced in future communications. For more information about provider enrollment revalidation click here.



Vitamin D Assay Testing LCD - Effective November 14, 2011 for Noridian Administrative Services, LLC

Coding TRAC Tips on reimbursement and coding o

Incorrect taxonomy codes may cause reimbursement denials. Health care providers select the taxonomy code(s) that most closely represents their education, license, or certification. The Healthcare Provider Taxonomy code set is available at no charge from the Washington Publishing Company’s website.


"O" Versus "0": Did you know that the letter "O" and the number "0" are NOT interchangeable when authenticating yourself with the CMS call center staff? If your PTAN or NPI contains the number "0," please say "zero" instead of "oh" when providing your information to our customer service representatives. This will help our staff members locate your information quickly and accurately, and it will allow us to disclose protected health information or personally identifiable information to you when appropriate.


This article from Noridian Administrative Services LLC, a Medicare Administrative Contractor, contains instructions for coding medical necessity in accordance with both the National Coverage Determinations (NCD) and CMS instructions on bone mass measurements (BMM), which includes the 2012 ICD-9-CM code updates.


The top five claim submission errors that lead to denials listed on CGS’, a Medicare Administrative Contractor, website

We want to hear from you! Tell us what you think of Endonomics! Please take a few minutes to take this 4-question survey. Your feedback is very important to us as we strive to assist you with a profitable and compliant business office. o Is Endonomics valuable and useful for your office? o Are you or your physician a member of AACE? o What other topics would you like to see offered in Endonomics? o Other comments…

are consistently among the most common of all claim submission errors.

AACE's Socioeconomic and Member Advocacy Department's goal is to reach out into the endocrinology business world and become the one stop shop, not only for endocrinology clinicians, but their support staff as well. Currently, Endonomics is a free newsletter for both members and non members. Interested parties should send an e-mail to with their name, phone and fax numbers, location and preferred e-mail address to be added to our Practice Support Network database.

All medical coding must be supported with documentation and medical necessity. **While this document represents our best efforts to provide accurate information and useful advice, we cannot guarantee that third-party payers will recognize and accept the coding and documentation recommendations. As CPT®, ICD-9-CM and HCPCS codes change annually, you should reference the current CPT®, ICD-9-CM and HCPCS manuals and follow the "Documentation Guidelines for Evaluation and Management Services" for the most detailed and up-to-date information. This information is taken from publicly available sources. The American Association of Clinical Endocrinologists cannot guarantee reimbursement for services as an outcome of the information and/or data used and disclaims any responsibility for denial of reimbursement. This information is intended for informational purposes only and should not be deemed as legal advice, which should be obtained from competent local counsel. Current Procedural Terminology (CPT©) is copyright and trademark of the 2010 American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT©. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.


Endonomics October 2011  

Useful tips for improving practice management in an endocrinologist office setting.