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WCH TIMES ISSUE 20 Fall 2012

Welcome to our Fall Edition! ICD 10 DEADLINEOctober 1, 2014


Join Us for Credentialing Live Webinar

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WCH Service Bureau is a proud member of the following professional organizations:

INSIDE THIS ISSUE: 4 WCH TIMELINE 6 WCH Referral Program for our clients 7 WCH New virtual website Assistant!

21 Avoid claim denials: bill with codes listed on your fee schedule 22 AMA set to Urge Medicaid Eligibility expansion

7 Help for Hurricane Sandy disaster 8 Changes in Mental Health For 2013 prepared per request of our clients CREDENTIALING NEWS 10 Independent Diagnostic Testing Facility ("IDTF") enrollment

22 CMS details Medicaid primary-care payments boost 23 Primary Care Payment and vaccine administration charge increase 23 Health Care Law delivers higher payments to primary care physicians

11 Credentialing Live Webinar HEALTHCARE UPDATES 12 CPT Coding Updates for 2013 14 OIG'S 2013 work plan what should you expect next year

24 Enhanced autism mandate effective November 2012 24 Obama Administration moves forward to Implement Health Care Law 25 Emblem Health update

15 Reminder for Behavioral Health providers 15 Changes in Sleep Management Precertification 16 Higher use of Advanced Imaging Services by providers who self-refer costing Medicare millions

25 United Health Care (UHC) DME Modifier Requirement in 2013 26 HIP Service area expansion affects GHI HMO providers 26 Neighborhood Health Plan Updates

17 Stark Law (physician self-referral)

26 Behavioral Health Screening

18 Advanced Beneficiary Notice


19 How might Medicare penalties affect you? 20 Geographic payment adjustments, Medicare's disputed borders


WCH PUBLICATION RECEIVED CEU CREDITS WCH Bulletin and WCH Times have been each approved for 1 CEU credit by AMBA American Medical Billing Association.

Clients will find Registration form on WCH website to receive CEU credit. On your online profile you can review your CEU credits and maintaing full credit list.

From January 1, 2013 all WCH publications will be under package subscription. WCH is proud to offer numerous opportunities for professional growth and certification/licence maintenance. We offer a fast and convenient way to earn CEU credit. Each publication gives you 1 CEU credit.

CHANGES IN THE BILLING DEPARTMENT WCH is continuing to grow and expand our departments! The billing department has reached over fifty employees. Our department updated staff is below.

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Oksana Pokoyeva, CPC, CPMA, Billing Department Manager

Elizaveta Bannova, CMRS, CFPC, CPC, Vice Manager

Victoria Uzakova, Supervisor

Zukhra Kasimova, CPC, Supervisor

SOCIAL MEDIA DEPARTMENT Social Media Department promotes WCH services through different channels of marketing: We Invite You To Join Us! Please Visit

Department pushes the WCH into new social media Valeriya Aksyonova, Designer spaces, drives innovation and online communication Olesya Petrenko, Marketing Manager programming in this arena, provides platform for real-time conversation, collaboration and idea sharing. Plus we can do it all for you! If you want to promote your services, please contact us:

WCH PANTHERS-RACE FOR CURE 2012 On September 9, 2012, WCH has taken part in 2012 Komen New York City Race for the Cure in Central Park. We were honored and privileged to take part of such an extraordinary event that not only benefited the foundation by helping them reach the goal of $6 million, but also to promote awareness of local breast cancer screening, education and outreach programs.

REMINDER, WCH IS A DIRECT SUBMITTER WITH NEW JERSEY MEDICAID! WCH is 5010 compliant with NJ Medicaid Program and we are approved as direct vendor to submit claims. We can assure you that YOUR CLAIMS ARE IN GOOD HANDS.

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WCH Referral Program for our clients

Refer WCH Billing Service to Your Colleagues and Friends! We are grateful for referrals that come our way and pleased to offer a Referral Reward Program. WCH will provide you with 2 complimentary insurances for credentialing, the deal is worth $800, for every client that will sign with us. Only happy clients refer others, and we want to make sure we exceed the expectations of every client who passes through our doors. WCH understands that we can only grow if we provide quality service and achieve maximum reimbursement for our clients. If you know anyone experiencing difficulty with their current billing service, or a new friend that needs to start the billing process , WCH is here to help!

For any questions please contact Olga Khabinskay General Manager 888-924-3973 (x 1201), 718-934-6714 skype: olgakwchsb

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WCH new virtual website assistant! As you are remember few months ago we announced winner of the WCH Contest. The winner is Ilya Mirolyubov and his virtual website assistant octopus. In the nearest future our clients and visitors will see on WCH website the new virtual website assistant. Virtual assistant who is main functional will have quicker and easy contact with technical support, general manager, account representatives as many others planed functions.

Need help? Click on me for any questions

HELP FOR HURRICANE SANDY DISASTER The Internal Revenue Service (IRS) announces qualified disaster treatment of payments to victims of Hurricane Sandy We thought you could find this useful. If you know anybody who could also benefit from this tax break - forward it to them. The Internal Revenue Service alerted employers and other taxpayers that because Hurricane Sandy is designated as a qualified disaster for federal tax purposes, qualified disaster relief payments made to individuals by their employer or any person can be

excluded from those individuals' taxable income. Qualified disaster relief payments include amounts to cover necessary personal, family, living or funeral expenses that were not covered by insurance. They also include expenses to repair or rehabilitate personal residences or repair or replace the contents to the extent that they were not covered by insurance. Again, these payments would not be included in the individual recipient's gross income. Source:

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CHANGES IN MENTAL HEALTH FOR 2013 - PREPARED PER REQUEST OF OUR CLIENTS Psychiatry: Significant changes to codes and guidelines New codes: џ Interactive complexity џ Psychiatric diagnostic evaluation џ Psychotherapy џ Psychotherapy for crisis џ Pharmacologic management

Interactive Complexity - Add-on code (90785) used to report communication factors that complicate psychiatric services - Typical factors џ Third parties involved with care (guardians, caregivers) џ Require others to be involved with the care (interpreters) џ Require third parties (welfare agencies, schools)

Interactive Complexity cont... - Can be used with the following codes: џ Diagnostic psychiatric evaluation (90791,90792) џ Psychotherapy (90832,90834,90837) џ Psychotherapy with E/M (90833,90836,90838,99201 -99255, 9930499337,99341 -99350) џ Group psychotherapy (90853)

Interactive Complexity, cont... - Do not report with: џ Psychotherapy for crisis (90839,90840) џ E/M performed without psychotherapy WCH Times | 8

Psychiatric Diagnostic Evaluation (90791, 90792) 90801,90802 deleted Biophysical assessment including history, mental status and recommendations Do not report on the same date as E/M - If medical service is performed on same DOS as psychiatric diagnostic evaluation, report 90792 џ For interactive complexity, report 90785 with 90791 or 90792 џ Do not report 90791 and 90792 on the same DOS џ џ џ џ џ

Should you have any questions about the changes, please do not hesitate to contact your account representative in the billing department. WCH will be working to update superbills for our clients and is in process of education our staff about the changes in the billing and collection process. CALL WCH 888-WCHEXPERTS Source: American Psychiatry Association

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CREDENTIALING NEWS We have been researching this topic for many months and finally received an official answer from New York State Department of Health concerning proper arrangement between supervising physician and IDTF.

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186 new codes 119 deleted codes 263 revised codes 18 revised CPT® modifiers Guideline changes

Pediatric Critical Care Transport џ New codes report services provided by the control physician during an interfacility transport - 99485 and 99486

Complex Chronic Care Coordination Services џ For clinical staff time directed by a physician or other qualified health care provider џ Reported for coordination of services (medical and psychosocial) џ Time based џ - Reported per calendar month Based on whether patient has face-to-face encounter during the month

Clinical indications that qualify: - One or more chronic illnesses expected to last at least 12 months - Acute exacerbation or decompensation - Functional decline - Medical Decision Making must be moderate or high

Psychotherapy (90832-90838) џ 90804-90809, 90810-90815, 90816-90822 and 90823-90829 deleted џ New codes are based on time џ Add-on codes used when psychotherapy is performed on the same DOS as E/M џ Do not include time performing the E/M service as psychotherapy time џ For interactive psychotherapy, report 90785 with the psychotherapy code

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Time (min)


Psych and E/M

Psych and Interactive Psych

Psych, Interactive Psych and E/M













E/M, 90838



џ џ џ џ џ

Psychotherapy in Crisis (90839, 90840) Urgent assessment of a patient with a life threatening or complex condition Reported based on time - If performed 30 minutes or less, report with 90832 or 90833 Do not report with psychiatric diagnostic evaluation (90791, 90792), psychotherapy codes (90832-90838) or other psychiatric services (90785-90899)

Pharmacologic management (90863) џ 90862 was deleted џ New code is an add-on code that can only be reported with psychotherapy codes џ Do not use time spent performing pharmacologic management to determine psychotherapy codes џ If the provider is permitted to bill with E/M codes (eg, psychiatrist), report the service as an E/M џ Do not report 90863 with an E/M code

Documentation must include: - Condition of the patient - Total time spent performing coordination services for complex chronic care - Based on clinical staff time џ If physician performs coordination services, the time is added to the clinical staff time to support the code

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Complex Chronic Care Coordination Services 99488 (first hour) 99489 (each additional 30 minutes) 99487 (first hour)


Face-to-face visit within 7 days

Face-to-face visit within in 8 to 14 days







Source: American Psychiatry Association

OIG'S 2013 WORK PLAN WHAT SHOULD YOU EXPECT NEXT YEAR 2013 Work Plan by the Numbers: OIG's Results: Reporting on 2011 data, OIG projected recoveries of $5.2 billion ($4.6 billion in investigative work and $627.8 million in audit work). џ Identified $19.8 billion in possible savings

based on OIG's recommendations for legislative, regulatory, or administrative changes. џ Excluded 2,662 individuals and entities; participated in 723 criminal actions and 382 civil actions. Providers Under Review: џ Hospitals џ Nursing Homes & Skilled Nursing Facilities

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џ џ џ џ џ

(SNFs) Home Health Agencies (HHAs) Hospice (Medicare & Medicaid) Medical Equipment and Supplies Home and Community-Based Services (HCBS) Physicians

Source: OIG

eligibility and/or obtain treatment authorization for Universal Health Care Medicare members by calling 1-800-327-7959.

REMINDER FOR BEHAVIORAL HEALTH PROVIDERS Magellan Behavioral Health (Magellan) announced that Universal Health Care has selected Magellan as their behavioral health care vendor. As a provider for Magellan, you may have members in treatment whose care is managed by Universal Health Care. Authorization and Eligibility Verification Effective November 1,2012, verify benefit

Claims Processing Effective November 1, 2012, claims for authorized covered services rendered to Universal Health Care Medicare members must be submitted to the following address: Magellan Behavioral Health PO Box 1928 Maryland Heights, MO 63043 If you have any questions regarding this information, please contact 1-800-788-4005 Source: Magellan Behavioral Health and Universal Health Care Medicare

and oral devices, appliances and related supplies)

CHANGES IN SLEEP MANAGEMENT PRECERTIFICATION As we previously communicated, effective November 1, 2012, Anthem Blue Cross will require precertification for the following elective sleep diagnostic and treatment services: џ Home sleep test (HST) џ In-lab sleep study (PSG) џ Titration study џ Initial treatment order (APAP, CPAP, BPAP and oral devices, appliances and related supplies) џ Ongoing treatment order (APAP, CPAP, BPAP

Effective November 1, 2012, the prior authorization requirement applies to Anthem Blue Cross members who participate in Anthem Blue Cross Local and individual health plans, including HMO members who are not enrolled with a PMG/IPA as well as HMO members enrolled in the following PMG/IPAs: Scripps Clinic/Scripps Coastal Medical Center, Scripps Foundation and The Industry Health Network. Effective January 1, 2013, it also will apply to members covered by Medicare Advantage. The requirement does not apply to the following members: WCH Times | 15

џ Those in the Federal Employee Program

(FEP) џ Those for whom Anthem Blue Cross is secondary coverage, including those whose primary insurance carrier is Medicare џ HMO members, with the exception of those noted above. Precertification requests for sleep testing and therapy services will be handled by AIM Specialty HealthSM (AIM), an affiliate of Anthem Blue Cross. Requests will be reviewed against AIM Obstructive Sleep Apnea Diagnostic & Treatment Clinical Guidelines. AIM will consider the medical necessity of

HIGHER USE OF ADVANCED IMAGING SERVICES BY PROVIDERS WHO SELF-REFER COSTING MEDICARE MILLIONS GAO's analysis showed that providers' referrals of MRI and CT services substantially increased the year after they began to self-refer--that is, they purchased or leased imaging equipment, or joined a group practice that already selfreferred. Providers that began self-referring in 2009--referred to as switchers--increased MRI and CT referrals on average by about 67 percent in 2010 compared to 2008. In the case of MRIs, the average number of referrals switchers made increased from 25.1 in 2008 to 42.0 in 2010. In WCH Times | 16

sleep testing and therapy services, including the need for use of a facility vs. doing the test in the home. For therapy services, members must meet usage criteria for the continued rental of equipment and replacement of supplies For Sleep testing and therapy service only, both ordering physicians (those referring the member for sleep testing) and servicing providers (free-standing or hospital labs that perform sleep testing) may submit requests to AIM. Source: Anthem Blue Cross

contrast, the average number of referrals made by providers who remained self-referrers or nonself-referrers declined during this period. This comparison suggests that the increase in the average number of referrals for switchers was not due to a general increase in the use of imaging services among all providers. GAO's examination of all providers that referred an MRI or CT service in 2010 showed that self-referring providers referred about two times as many of these services as providers who did not selfrefer. Differences persisted after accounting for practice size, specialty, geography, or patient characteristics. These two analyses suggest that financial incentives for self-referring providers were

likely a major factor driving the increase in referrals. What GAO Recommends GAO recommends that CMS improve its ability to identify self-referral of advanced imaging services and address increases in these services. The Department of Health and

STARK LAW (PHYSICIAN SELFREFERRAL) Stark Law “prohibits physicians from making referrals for designated health services (DHS) payable by Medicare to an entity with which he or she (or an immediate family member) has a financial relationship (ownership, investment, or compensation), unless an exception applies,” according to the Centers for Medicare & Medicaid Services (CMS). Specifically, covered DHS include: џ Clinical laboratory services џ Physical therapy services џ Occupational therapy services џ Outpatient speech-language pathology services џ Radiology and certain other imaging services џ Radiation therapy services and supplies џ Durable medical equipment (DME) and supplies џ Parenteral and enteral nutrients, equipment, and supplies џ Prosthetics, orthotics, and prosthetic devices and supplies џ Home health services џ Outpatient prescription drugs џ Inpatient and outpatient hospital services

Human Services, which oversees CMS, stated it would consider one recommendation, but did not concur with the others. GAO maintains CMS should monitor these self-referred services and ensure they are appropriate. Source:

Penalties: Penalties for violating the Stark Law include denial of payment, refund of payment, imposition of a $15,000 per service civil monetary penalty, and imposition of a $100,000 civil monetary penalty for each arrangement considered to be a circumvention scheme. Be Compliant: To help you stay in compliance with the Stark Law: 1. Offer all patients a written list of choices for obtaining the care your physicians are recommending. 2. Disclose any financial relationship with any entity that is on the list offered to patients. Source:

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ADVANCED BENEFICIARY NOTICE The Centers for Medicare & Medicaid Services (CMS) recently released a new Advanced Beneficiary Notice of Noncoverage (ABN), making it a perfect time to refresh your understanding of this form and make sure you are using it appropriately. ABN Basics The ABN is a standard form that a medical practice can use to inform a patient that Medicare may deny coverage for a recommended or desired item or service. It explains why Medicare may deny the item or service, and provides a cost estimate for it. An ABN also notifies the patient of his responsibility to pay for the noncovered item or service, if he chooses to receive it. In many cases, a provider cannot seek payment from the patient for unpaid Medicare services if an ABN was not properly issued. CMS periodically revises the ABN. The most recent version, Form CMS-R-131 (release date March 2011), is mandatory as of Jan. 1, 2012. Previous versions of the ABN (release date March 2008) are no longer being accepted. The “Revised ABN CMS-R-131 Form and Instructions” may be downloaded from the CMS website. ABNs must be reproduced on a single page (either letter or legal size). To be safe, reproduce the ABN “as is” from the CMS website; except where specifically allowed by the form instructions, “to integrate the ABN into other automated business processes,” you may not customize the ABN. How NOT to Use an ABN Do not use an ABN to bill a patient for additional fees beyond what Medicare reimburses for a given procedure or service. The ABN does not allow the provider to shift WCH Times | 18

liability to the beneficiary when Medicare payment for a particular procedure or service is bundled into payment for other covered procedures or services. An ABN should never be applied as a Band-Aid cure to gain payments in spite of sloppy coding, or as a way to “game” Medicare beneficiaries. ABNs Are NOT Required in an Emergency ABNs are never required in emergency or urgent care situations. CMS policy prohibits giving an ABN to a patient who is “under duress,” including patients who need emergency department services before stabilization. Source:

HOW MIGHT MEDICARE PENALTIES AFFECT YOU? 2013 will be a crucial year for physicians to avoid possible pay reductions under quality reporting and health information technology programs. Successfully reporting quality measures and achieving meaningful use of an EHR in 2013 will prevent a doctor's Medicare rates from being reduced by 3.5% in 2015 for noncompliance. For some physicians, preventing the electronic prescribing noncompliance penalty will mean using claims to report that they utilized the technology during at least 10 patient encounters between January 1, 2013, and June 30, 2013. Others who earned eprescribing bonuses in 2012 will be exempt from the 2% penalty in 2014. CMS requires doctors who e-prescribe for patients to attach the code G8553 to the applicable claims for their Medicare services. The code signals that the physician used a health information technology system to send an electronic order for medication to a pharmacy. Members of a physician group practice can work together to nullify the penalty, according to newer options added by CMS. For instance, groups of two to 24 eligible professionals can report the e-prescribing measure at least 75 times over the six-month 2013 reporting period to stop the penalty. CMS will pay an estimated $27 billion in EHR incentive payments through 2016, and each physician can earn up to $44,000 from Medicare or $63,750 from Medicaid by adopting and using the technology. Others who do not participate will see their Medicare pay reduced over the years, but Medicaid

rates would not be decreased. Physicians who first reported achieving meaningful use in 2011 won't need to move onto the next stage until 2014. The 2014 calendar year also marks the last opportunity for eligible physicians and other health professionals to stop a 2015 Medicare EHR noncompliance penalty of 1% in 2015. An eligible professional must adopt and demonstrate meaningful use of an EHR system by October 1, 2014. The penalty is set to grow to 3% by 2017 for physicians who continue not to participate. Eligible professionals who do not successfully participate in the physician quality reporting system in 2013 will see their Medicare pay reduced by 1.5% in 2015. Physicians have a couple of options to report to the Medicare agency from among the 200 PQRS measures. Reporting measures group(s) through the registry option is presented as the easiest method for a physician to prevent a penalty and earn a bonus. CMS will provide a list of active registries in early 2013 — most of which will have been part of the program in 2012. Reporting individual measures or measures groups using Medicare claims or an EHR also WCH Times | 19

are options for physician practices. Physicians will receive a bonus equal to 0.5% of their 2013 Medicare pay if they participate in PQRS. The incentive will rise an additional 0.5% for physicians participating in a maintenance-ofcertification program.

quality and lower cost than other large-group physicians who are subject to the modifier adjustment. Like the 2015 PQRS penalty, the 1% reduction will be based on 2013 PQRS data.

Failure to report PQRS measures successfully in 2013 will lead to a Medicare penalty of 1.5% on 2015 rates. The reduction will be 2% in 2016 and each subsequent year. For now, CMS is planning to use a PQRS reporting period well before the authorized penalty year to determine who will see their Medicare pay reduced.

CMS is limiting the modifier's scope to physicians practicing in groups of 100 or more eligible professionals, but agency officials have warned that this is only temporary. The modifier adjustment eventually will affect all physicians, CMS said in its 2013 Medicare final physician fee schedule.

For larger practices, failing to report PQRS measures also will lead to a 1% penalty in 2015 under Medicare's value-based payment modifier program, which is designed to pay more to practices that provide care at a higher

GEOGRAPHIC PAYMENT ADJUSTMENTS: MEDICARE'S DISPUTED BORDERS The map Medicare uses to set physician pay rates based on location could become more nuanced if Congress adopts recommendations for revised localized payments. Physicians practicing in all parts of the country long have agreed that Medicare payments have been too low for too long, but a growing chorus of health policy officials say these WCH Times | 20

Tool that can give you an idea of whether you can expect payment bonuses or penalties in future years us.htm Source:

doctors' rates also are inaccurate when compared with one another. Medicare uses geographic adjustments to pay more in areas deemed to have higher costs of providing care to seniors. The Centers for Medicare & Medicaid Services employs a patchwork of 89 pay locales to set rates in a budget-neutral environment. As a result, a doctor treating a Medicare patient in midtown Manhattan receives more than a doctor providing the same service in rural West Virginia.

Medicare uses a complex system when adjusting payments to reflect the costs of practicing medicine across the country. Such expenses as rent, staff salaries and the cost of living in an area are designed to be reflected in pay rates. CMS is required to account for such price differences using indexes that adjust the portions of doctors' fees attributed to practice expenses, medical liability costs and the amount of physician work required to provide care. Each locale has geographic practice cost indexes, or GPCIs, that are multiplied by the relative values corresponding to each of these factors, which then impacts the final amount that Medicare pays a doctor for a given service in a particular area.

AVOID CLAIM DENIALS: BILL WITH CODES LISTED ON YOUR FEE SCHEDULE Summary of change: Effective January 1, 2013, Medicaid Managed Care (MMC) and Child Health Plus (CHP) claims received by HealthPlus, an Amerigroup Company, containing procedure codes not priced by the fee schedule or not a payable code under New York Medicaid as listed in your provider agreement, may be denied or pended for further review. What this means to you: To get paid timely and accurately, please be sure to bill with the most current, applicable procedure codes listed on your fee schedule and ensure the code is payable under New York Medicaid.

How Medicare GPCIs affect physician pay Medicare geographic practice cost indexes are among several factors affecting the final fee that a doctor in a particular area receives for a service. Each locality has GPCIs that are applied to the relative value units (RVU) for a given service based on physician work requirements (Work), practice expenses (PE) and professional liability insurance costs (MP). The resulting figure is multiplied by a conversion factor (CF) to determine the dollar amount for a service. Source: Physician fee schedule search, Centers for Medicare & Medicaid Services

What is the impact of this change? To ensure accurate processing of claims going forward, claims billed with procedure codes not listed on the applicable fee schedule(s) will be denied or pended for further information. If your contract uses a CMS-based fee schedule, please be aware some codes listed on CMS are not payable under New York Medicaid. If the code is not recognized or payable under New York Medicaid, the code will not be reimbursed. Your claim might be denied if you don't bill with the most current, applicable procedure code to reflect the service(s) rendered, per your contract and fee schedules. Claims billed in line with the fee schedule will be processed accordingly. Source: Magellan Behavioral Health and Universal Health Care Medicare

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AMA SET TO URGE MEDICAID ELIGIBILITY EXPANSION The American Medical Association will advocate for increasing Medicaid payments for physicians and—in states where it is invited by the state's medical societies to do so—for expanding Medicaid eligibility under the terms of a new policy approved by the AMA House of Delegates. The resolution calling for the policy noted that, according to the U.S. Supreme Court's ruling on the Patient Protection and Affordable Care Act, the Medicaid expansion called for by the law is optional and that an estimated 15.1 million additional people could become eligible if the option is exercised nationwide.

CMS DETAILS MEDICAID PRIMARYCARE PAYMENTS BOOST The CMS issued a final rule temporarily increasing primary-care physician payments from Medicaid. The rule, which implements a provision of the Patient Protection and Affordable Care Act, details the extent and target of the increase, which takes effect in January and lasts through 2014. The provision is designed to match Medicare rates, but the rule specifically covers only the difference between the Medicare rate and states' Medicaid rates as of July 1, 2009. The additional federal funding may not be enough to increase the rate to Medicare levels because some states have enacted Medicare provider rate cuts since middle -2009. WCH Times | 22

The current federal poverty level for a family of four is an income of $23,018; the AMA will urge the expansion of Medicaid eligibility to those whose income is up to 133% of the federal poverty level. The resolution also noted that caring for the uninsured produces "huge financial burdens" on doctors' offices and hospitals. Source: Moderhealth

The rule specifies that federal funding will be provided to states to increase payments for physicians practicing in family medicine, general internal medicine, pediatric medicine and related subspecialties. It also clarifies, that primary-care services provided by practitioners working under the personal supervision of any qualifying physician can qualify for the higher payment rate. The CMS, in the rule, gives states several options for implementing the rate increase in fee-for-service and managed-care settings. For example, states either can pay in accordance with all Medicare locality adjustments within the state or develop a rate for each code based on the mean Medicare rate for all counties in the state. Source:

PRIMARY CARE PAYMENT AND VACCINE ADMINISTRATION CHARGE INCREASE CMS put on display in the Federal Register the final rule implementing Payments for Services Furnished by Certain Primary Care Physicians and Charges for Vaccine Administration under the Vaccines for Children Program as authorized by sections 1902(a)(13), 1902(jj), 1905(dd) and 1932(f) of the Social Security Act. The rule provides that states reimburse certain primary care physicians in calendar years (CYs) 2013 and 2014 at rates not less than the Medicare rates in effect in those calendar years. This minimum payment level applies to specific

HEALTH CARE LAW DELIVERS HIGHER PAYMENTS TO PRIMARY CARE PHYSICIANS Health and Human Services (HHS) announced the final rule implementing the part of the health care law that delivers higher payments to primary care physicians serving Medicaid beneficiaries. The new rule raises rates to ensure doctors are paid the same for treating Medicare and Medicaid patients and does not raise costs for states. The final rule implements the Affordable Care Act's requirement that Medicaid pay physicians practicing in family medicine, general internal medicine, pediatric medicine, and related subspecialists at Medicare levels in Calendar Years 2013 and 2014.

primary care services reimbursed fee for service and through managed care. It provides 100 percent federal matching funds for the difference in payment between the applicable Medicare payment in those years and the Medicaid rate in effect as of July 1, 2009. This final rule also updates the interim regional maximum fees that providers may charge for the administration of pediatric vaccines to federally vaccine-eligible children under the Vaccines for Children (VFC) program. Source:

In addition to payment improvements, the health care law includes numerous initiatives designed to bolster primary care and strengthen the primary care workforce, including an expansion of medical residency positions for primary care physicians, new investments in physician assistant and nurse practitioner training, and an unprecedented expansion of the National Health Service Corps, which provides scholarships and loan repayments to primary care providers who practice in underserved areas. Source:

This payment increase goes into effect in January of 2013. WCH Times | 23

ENHANCED AUTISM MANDATE EFFECTIVE NOVEMBER 2012 New York State has enacted a mandated benefit for screening, diagnosis and treatment of autism spectrum disorder (ASD). ASD refers to any pervasive developmental disorder as defined in the most recent edition of the DSM, including: џ Asperger's syndrome џ Autistic disorder џ Childhood disintegrative disorder џ Pervasive developmental disorder (not otherwise specified) (PDD-NOS) џ Rett's disorder

OBAMA ADMINISTRATION MOVES FORWARD TO IMPLEMENT HEALTH CARE LAW, ban discrimination against people with pre-existing conditions The Obama administration moved forward to implement provisions in the health care law that would make it illegal for insurance companies to discriminate against people with pre-existing conditions. The provisions of the Affordable Care Act also would make it easier for consumers to compare health plans and employers to promote and encourage employee wellness. The Obama administration issued: A proposed rule that, beginning in 2014, prohibits health insurance companies from WCH Times | 24

Diagnosis is defined as assessments, evaluations, or tests to diagnose whether a person has ASD. The new law supplements the existing NYS mandate relating to autism, which prohibits plans from excluding benefits for otherwise covered services because they are provided to diagnose or treat autism. The new law is intended to provide parity for people with autism by requiring equitable coverage of the disorder by insurance companies. Source:

discriminating against individuals because of a pre-existing or chronic condition. Under the rule, insurance companies would be allowed to vary premiums within limits, only based on age, tobacco use, family size, and geography. A proposed rule outlining policies and standards for coverage of essential health benefits, while giving states more flexibility to implement the Affordable Care Act. A proposed rule implementing and expanding employment-based wellness programs to promote health and help control health care spending, while ensuring that individuals are protected from unfair underwriting practices that could otherwise reduce benefits based on health status. Source:

EMBLEM HEALTH UPDATE EmblemHealth has relaxed all of its prior authorization requirements for covered services. All such services performed by participating providers may be performed without prior authorization. EmblemHealth requests that participating providers submit notification of procedures, admissions and provision of Home Care, DME, and other services. The relaxation of prior authorization rules also applies to all services managed by their delegated entities on behalf of EmblemHealth (GHI and HIP). To verify benefits and eligibility, please continue to access their secure provider portal.

and electronic claim submissions which took place both before and after the storm and are processing accordingly. Please note: EmblemHealth's employee voice mail system is not functional at this time. If you experience issues with their phone lines, please log into and proceed directly to the Message Center and send the inquiry instantly via the general information dropdown to communicate with them. Source: EmblemHealth

Claims Operations EmblemHealth claims processing is operational. They have received both paper

UNITED HEALTH CARE (UHC) DME MODIFIER REQUIREMENT IN 2013 Effective January 1, 2013, UHC will require that items eligible for purchase or rental be submitted with the appropriate modifier(s) designating which is being billed. The policy now states that if a modifier is not applied, the charge will be considered a "purchase." IF an item is eligible for either rental or purchase, and you do not submit it with the required modifier, the claim will be denied and returned.

* RR - Rental * KH - Initial claim, purchase or first month rental * KI - Second or third monthly rental * KJ - Capped rental months four to fourteen * KR - Partial month * NU - New Equipment * UE - Used Equipment Source: UHC updates

For those codes on UHC fee schedule that allow both rental and purchase, one of the following modifiers must be reported: WCH Times | 25

HIP SERVICE AREA EXPANSION AFFECTS GHI HMO PROVIDERS Pending approval from the NYS Departments of Health and Financial Services (DOH and DOFS, respectively), EmblemHealth anticipates merging its company GHI HMO Select, Inc. (GHI HMO) into HIP Health Plan of New York (HIP) on or around November 1, 2012. In accordance with DOH requirements, notices have been sent to GHI HMO contracted providers in July and again in August, 30 days apart. A final notice will be sent once the merger is approved. Most providers in the GHI

NEIGHBORHOOD HEALTH PLAN UPDATES Effective December 1, 2012, the following services will no longer require prior authorization: Outpatient and home Occupational Therapy (OT)


HMO network who are not already in the HIP network will be invited to participate in certain HIP commercial HMO benefit plans: HIPaccess I, HIP Prime HMO, HIP POS, Direct Pay HMO, Direct Pay POS and Healthy NY. Source:

Outpatient and home Physical Therapy (PT) Outpatient and home Speech Therapy (ST) Most Surgical Day Care (SDC) Please Note: HVMA members seeking PT/OT/ST services will continue to require authorization. Source:

Neighborhood Health Plan (NHP) requires that Primary Care Providers (PCPs) offer periodic and medically necessary inter-periodic screens to members under the age of 21 in accordance with the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) and Preventive Pediatric Healthcare Screening and Diagnosis (PPHSD) Periodicity Schedules. This requirement applies to MassHealth members only.

To be eligible for reimbursement, Primary Care Providers (MDs and NPs) must use specific, clinically appropriate behavioral health screening tools accommodating different age ranges while allowing some flexibility for provider preference and clinical judgment. Additionally, procedure code 96110 must be billed with the appropriate U modifiers (U1 U8) indicating the type of provider who conducted the screening and whether a behavioral health need was identified.

NHP reimburses one (1) screening per member per day, regardless of the number of screening tools administered for a member on a single day.

Claims submitted without the corresponding U modifier are subject to deny.

WCH Times | 26


NEWS BY SPECIALTY Cardiology 1)TEE studies are billed with CPT codes 93312 through 93318. The most common codes billed by a hospital department are codes 93312 and 93318. Medicare has also issued two HCPCS codes that would be reported if the TEE is performed with contrast for Medicare patients: C8926 and C8927. 2) The most common way that facilities charge out for cardiac catheterization procedures is by procedure. In general, surgery departments bill by time-based because the surgical procedure usually only requires one CPT code and one revenue code (RC) to bill. Even if more than one surgical code is required, they almost always end up with RC 360. For example: A laproscopically performed appendectomy requires CPT code 44970 and RC 360. In a cardiac cath, several CPT codes may be required along with different revenue codes. For example: If ultrasound guidance is used to gain access into the body, CPT code 76937 (RC 402) is assigned, and the cardiac cath (LHC) would be CPT code 93458 (RC 480). If a radiology procedure is performed in addition to the cardiac cath, different CPT and revenue codes are assigned. For example: Lower extremity angiography would be CPT code 75716 (RC 320). Based on the aforementioned, it is understandable why surgery departments bill time-based where one element of time (two hours) is attached to RC 360 and assigned a CPT code by the health information management (HIM) department. However, when there is the possibility of numerous CPT and revenue codes, most departments bill by individual procedure.

Radiology All CTA exams, including 71275, require 3D post-processing. Coronal and sagittal reconstructions, even if sent with the axial images, do not constitute 3D. As noted in the fall 2008 issue of Clinical Examples in Radiology, CTA is a distinct type of service that includes post-processing for angiographic reconstructions. In order to report these, the physician needs to use different techniques that can all broadly be classified as 3D techniques. These include maximum intensity pixel (MIP) reconstruction, volumerendered images, or other 3D techniques. The Centers for Medicare & Medicaid Services finalized the policy to apply the MPPR to the PC and TC of the second and subsequent advanced imaging procedures furnished to the same beneficiary in the same session by a single physician or by multiple physicians in the same group practice. However, due to operational limitations, it did not actually apply the MPPR to services performed by multiple physicians in the same group practice (same national provider identifier [NPI]). However, this will change on and after January 1, 2013, and the MPPR will apply to multiple physicians in same group practice. Source of information: panaceahealthsolutions

WCH Times | 27

STATES UPDATES PROVIDERS PUSH BACK ON MEDICAID INQUIRIES The Texas Health and Human Services Commission's Office of Inspector General is trying to reclaim hundreds of millions in misspent Medicaid money. But after months of investigations, more medical providers are saying publicly that they have been wrongly targeted. They say a controversial federal rule that allows the inspector general to stanch the flow of Medicaid payments as it pursues fraud investigations is crippling businesses, denying providers due process and harming patients by jeopardizing the state's limited network of Medicaid providers.

HEALTH FIRST TO ACQUIRE FLORIDA DOCTORS PRACTICE Health First, an integrated Rockledge, Florida health system, plans to acquire Melbourne Internal Medicine Associates, a multispecialty physician practice. Financial terms of the deal were not disclosed. Health First said that it plans to combine the new practice with its existing physician group and rename the entity Health First Medical Group. It will have a total of 250 physicians who will work in a number of locations.

ILLINOIS DOCTORS PAY LESS TO RENEW THEIR LICENSES Illinois doctors pay less to renew their licenses than many other professions, according to a department presentation shared WCH Times | 28

with lawmakers. Lawyers pay an annualized fee of $342 to renew a license in Illinois. Acupuncturists pay $250. Optometrists pay $200.

CHANGES TO NEW YORK MEDICAID BENEFITS Summary of change: The state of New York has made changes to the Medicaid contract affecting coverage of certain procedures. These changes are applicable to all Medicaid Managed Care and Family Health Plus (FHP) enrollees. The effective dates for these changes occur between June 1, 2012, and November 1, 2012. Back Pain Treatment Effective June 1, 2012. What's changing? Coverage is eliminated for the following treatments: џ Prolotherapy џ Systemic corticosteroids џ Therapeutic facet joint steroid injections in the lumbar and sacral regions with or without CT or fluoroscopic image guidance џ Injections of steroids into intervertebral discs џ Continuous or intermittent traction Why the change? The above treatments are considered ineffective or experimental and investigational. Pharmaceuticals (prescription and nonprescription) to reduce pain and practitioner-ordered physical therapy for treatment of back pain are still covered.

Source: Modernhealth news

QUESTIONS AND ANSWERS F.A.Q Question: t What type of documentation does Medicare require for recording the annual wellness visit (AWV)?

Answer: t You'll want to document the AWV the same way you document all other services that your practice performs — thoroughly and carefully. According to a directive on the Web site of Trailblazer Health Enterprises, “Physicians, qualified non-physician practitioners, and medical professionals are required to use the 1995 or 1997 E/M documentation guidelines to document the medical records with the appropriate clinical information. All referrals and a written medical plan must be included in the documentation.”

Question: t How does WCH assure the security and availability of the software and the practice's data?

Answer: t Security is an important factor to us; your practice's information will always be backed up and assured security. During the course of every day, including weekends and holidays, the computer sever automatically generates the back-up file every four (4) hours. At the end of each day, the last back up file is automatically written to a data CD. In addition there to, at the end of each week, the last back-up file is automatically written to a CD. Therefore, there are a total of eight (8) CDs at the end of each week that is stored on external drive safely, in a fire-proof facility. WCH provides technical support Sunday-Friday through phone, e-mail, or in person. Your data and access is reliable at any time. Data in our PMBOS program is confidently stored and is only given access to parties which are authorized by the client and WCH Service Bureau. All information and paperwork you provide to our company will only be used for work purposes only. We will not share your information with outside parties. Our staff signs a confidentially agreement to assure that your information will not be accessed outside of WCH Service Bureau. Olga Khabinskay, General Manager WCH Times | 29

FEEDBACK Please send us your feedback today. Let us know what you want to see in upcoming issues or changes to the format that you would like to see. Give us your feedback and receive free glass name plate. __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ Name_________________________________ E-Mail_________________________________

Thank you for your support!

WCH Newsletter Fall 2012  

WCH Newsletter Fall 2012

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