4 Breast Cancer Awareness
ICD-10 UPDATE on page 6
on page 3
Credentialing TIPS on page 11
EMR Registered for Certification on page 7
WCH invites you for an educational conference
How to Overcome the Occurring Healthcare Industry Challenges
Featured Speakers: Olga Khabinskay, COO, WCH Service Bureau Inc. Solving todays challenges between doctors and insurances.
Kenneth Music, Vice President, Bank of America Practice Solutions
When October 29th, 2013 at 6:30-9:30PM
Medical Practice ďŹ nancing solutions.
Where Mathew J. Levy, Principal/Partner, Kern Augustine Conroy & Schoppmann, P.C. A legal view on physician practice audits from insurance companies. John V. Pellitteri , CPA, Grassi & Co. Merger Mania- is it the right option for your practice?
Peter Bechtel, President of Well Track One Medicare annual visit program compliance and patients health improvement.
Bank of America Tower 1 Bryant Park (W 43st), New York, NY Direction: 42 St - Bryant Pk (B, D, F, M) 5 Av (7, 7X) Times Sq - 42 St (S) Light dinner will be served. There is no cost to attend this event. You may bring guests with you!
Click here to register TODAY! Register on our website www.wchsb.com For information call us at 718-934-6714 Ex. 1202 or 1214 Or e-mail ilanak@wchsb.com
IN THIS ISSUE 3 4 WCH Corner Breast Cancer Awareness Education Month Conference
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WCH Event in the News!
ICD-10 Update
WCH iSmart EMR
8-9
13-18
19-20
WCH ICode
11-12
Tips for Successful, Healthcare Timely Provider News Credentialing
News by Specialty
21 News by State 22-23 Questions & Answers
Follow Us:
Get your CEU credits TODAY For more information please contact Marianna Shapiro at 718-934-6714 ex. 1202 or by e-mail to: mariannash@wchsb.com
WCH Corner
Organizational charities around the globe are coming together this month to increase awareness of the disease and raise funds for research, prevention diagnosis, treatment and cure of breast cancer. Since 2009, WCH team has been an active contributor to the Susan G. Komen foundation for a cause we believe is extraordinary. It is important to us at WCH to help increase awareness of breast cancer screenings and promote education and outreach programs in the fight again breast cancer. Our goal is to make a difference by spreading the word about mammograms and encourage our healthcare community, our clients, staff and partners to get involved. The race is over, but it is not too late to donate to support the NYC race for the Cure on Behalf of WCH panthers. If you wish to support our team, please kindly make your contribution by following this link: www.secure2.convio.net
WCH Newsletter Fall 2013 www.wchsb.com
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WCH and Bank of America are Joining Forces to Educate the Healthcare Community this Fall. WCH and Bank of America are joining forces to educate the healthcare community this fall. We are organizing a free educational and networking event on October 29th, 2013 at 6:30 PM in NYC. Join us to get resources and tools which will help overcome the healthcare industry challenges. The topic of the conference is "How to Overcome the Occurring Healthcare Industry Challenges". The healthcare industry is changing and there are many challenges and issues that arise. Your participation would add value to your practice and will help you to plan a good strategy to withstand and overcome all changes currently happening in Healthcare industry. We took a careful and thoughtful approach, inviting speakers that we feel would enlighten you on the most vulnerable aspects and be able to provide most extensive and comprehensive answers to most of your questions from all aspect of private practice. We are covering a wide range of issues and providing solutions. ABOUT TOPICS AND SPEAKERS џ WCH will present the solutions to solving the complex challenges that occur in today's ever-changing healthcare industry. WCH COO, Olga Khabinskay with 11 years of experience will talk about the controversial topics of medicine and present to you solutions that will help you overcome the occurring challenges. џ Ken Music, Regional manager for Bank of America Practice solutions will discuss loan options available to providers when it comes time to turn dreams into reality. Bank of America will present the many different
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solutions and service such as starting up new practices, selling and purchasing medical practices, business debt consolidation, office expansion, commercial real sate, equipment financing and additional financing options available for healthcare providers. Matthew Levy is a nationally recognized healthcare attorney from Kern Augustine Conroy & Schoppmann PC, a full service healthcare law firm. Matthew Levy will present on the topic of audits from insurance companies and how to effectively handle them. John Pellitteri is a healthcare management consulting leader and the accounting service practice leader and partner at Grassi & Co who will talk about practice consolidation, mergers and effective healthcare accounting practices. Peter Bechtel is the president and founder of Well Track one, a Medicare annual visit program specialist who will be presenting ways effectively conduct annual wellness visits while increasing revenue and improving patient's health.
There is no registration fee, the event is completely free, you can bring guests and we are providing food and beverages. To register please go to www.wchsb.com For more information or questions please contact: Ilana Kozak, General Manager, WCH Service Bureau, E-mail: ilanak@wchsb.com phone: (718) 934-6714 ext. 1214
WCH Event in the News! For the first time ever, WCH Service Bureau's Chief Operation Officer, Olga Khabinskay, made a TV appearance! On Monday October 7th Olga appeared on a TV talk show, OPEN, promoting the upcoming WCH conference in October. Olga was invited as a guest speaker to the BronxNet studio to elaborate about the WCH and Bank of America sponsored event on October 29th, 2013. Dr. Bob Lee, the host on the show OPEN, interview Olga regarding the importance and impact of the conference “How to overcoming the current healthcare industry challenges�. See more on: www.bronxnet.org
WCH Newsletter Fall 2013 www.wchsb.com
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Quick Update on ICD-10 Implementation Plan We are currently in process of the implementation of ICD 10 education for our clients. All WCH billing clients receive updates and materials available through CMS and other sources. We will distribute upcoming webinars, educational conferences and materials to our clients. We promote awareness and share our resources for ICD-10 training with our clients so that everyone has the opportunity to evaluate the different options and measures that need to be taken in order to be ready for the ICD 10. WCH continues to encourage and strongly recommend that our clients begin using our E-superbill feature. Utilizing our free E-supber will allow our client to be ready to begin the testing period and thus be trained and comfortable during and after the transition period. All WCH billing department staff went through training for ICD-10 CM anatomy and physiology terminology. We have completed our internal education about the systems and coding diagnosis. Our AAPC certified professionals will now be preparing for the ICD-10 CM proficiency assessment exam administered by AAPC. The exam will measure the understanding of ICD 10 format and structure, groupings and categories of codes, the ICD-10 official guidelines and coding concepts.
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WCH Newsletter Fall 2013 www.wchsb.com
WCH ismart EMR registered for certification An update about WCH EMR
The WCH IT team continues to work as much as 15 hours a day to complete our Electronic Medical Records System, which will be integrated with our billing system in near future. We bring to you our most recent WCH iSmart EMR update. Since our September publication, we have made significant progress. We are proud to present to you the details: џ WCH has registered for Certification with Drummond Group, ONC Certification Body, contracts for MU certification is signed џ Certification with Dr.First (e-Prescribing Vendor) is in progress. Initial submission was made to Dr.First and feedback was received. The second submission is now under review by Dr.First. џ ONC requires 24 MU Modules for certification to be Certified EHR Technology (CEHRT). We have partially completed 75% and are still working on the remaining modules. The road to certification is lengthy and difficult, however we will get there to provide top quality product to our customers. WCH iSmart EMR, is currently being reviewed to ensure that the necessary technological capability, functionality and security standards are met. WCH iSmart EMR standards are met is scheduled to be completely certified by the end of the season. To inquire about WCH iSmart EMR, please contact Ilya Mirolyubov E-mail: ilyam@wchsb.com Skype: wchsb.ilyam phone: (718) 934-6714 ext. 1111
WCH Newsletter Fall 2013 www.wchsb.com
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Call Kenneth Music at 1.855.318.4146, or e-mail kenneth.music@bankofamerica.com You can also visit us online at www.bankofamerica.com/practicesolutions
Tips for Successful, Timely Provider Credentialing Lessen frustration during the insurance credentialing process. By Olga Khabinskay Payer networks, healthcare organizations, and hospitals require credentialing to accept a provider in a network or to treat patients at a hospital or medical facility. The seemingly straightforward credentialing process is fraught with complications that can frustrate even the most patient practitioner. The good news is there are ways to save time, aggravation, and rejection during the process. But first, it’s important to know the purpose of credentialing. Why Get Credentialed? Credentialing involves obtaining and evaluating documentation regarding a medical provider’s education, training, work history, license, regulatory compliance record, and malpractice history. If a doctor is not “credentialed” by the insurance company, Medicare, or Medicaid plan, he or she can still submit claims, but the doctor may not be paid unless the patient has out-of-network benefits. Begin the Paperwork The process starts with the credentialing form—some 20-40 pages, on average. Most insurers require a license, hospital affiliation, and malpractice insurance. They also may use much of the information that can be compiled in the Council for Affordable Quality Healthcare (CAQH) profile, which is a database on every practitioner. CAQH is a non-profit alliance of health plans and trade associations working to simplify healthcare administration through industry collaboration on public-private initiatives.
A completed CAQH profile puts practitioners a step ahead in the process, particularly in getting on Medicaid insurance panels. Choose Your Location Panels are open or closed to practitioners, depending on where they will practice. When a doctor decides to join a practice, he knows which insurances the practice takes already, but that doesn’t mean the insurers will accept additional practitioners. At the start, this can be an important element in deciding which panels to join. If the office can’t help, a reputable credentialing company can tell you with a phone call whether panels are closed to a specialty. That saves time in applying, only to be rejected weeks or months later. Open Closed Doors Too often, panels are closed, especially in cities where numerous doctors of the same specialty practicing within blocks of one another may request credentialing. But there are ways around these rejections. When doctors close an office or retire, they often forget to inform insurers of their inactive status, which prevents another doctor from taking over that spot in the network. The insurance company isn’t likely to know, and isn’t likely to tell you. This can only be challenged by a phone call to the practice or a site visit to see if it is still in business. Differentiating your practice is key. Describing detailed specifics, such as all certifications, specialized equipment being used in the practice, specific experience, and even awards could set the doctor apart and open up a panel spot. How Many Is Too Many? Can a practice thrive taking on Medicare, Medicaid, and five other insurances? Do they need more? The answer is, “It depends.” It’s incredibly time consuming for someone in an office to submit applications for more than a dozen insurances. WCH Newsletter Fall 2013 www.wchsb.com
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At the start, due to costs, it’s practical to be on five to 10 insurance panels, although there are as many as 60 insurance plans. You may wish to apply to several additional panels, in case the doctor is not immediately accepted to the most-favored plans. Be (or Hire) an Advocate for Your Approval It would be great if sending in the form, waiting a few weeks, and being approved were the reality. The reality is that the credentialing process requires you to shepherd your paperwork through, answer questions and provide additional information, and ensure everything is correct and has been received. Otherwise, you’re likely to be rejected. Here are a few tips on how to prevent this from happening: Communication is key! Establish a friendly rapport with the provider relationship representative at the insurance company who is handling your case. Find out all of his or her contact information at the outset, and communicate in a clear and effective way (as often as once a day) to answer related questions and follow up on processing applications. Ensure accurate information. Remember the three C’s: Correct, Complete, and Concise. All three will result in a smoother processing of your application. Make sure all information is submitted at the same time according to a checklist (which is usually provided with the application). Ensure the documentation is mailed with a tracking number. Verify the information was received. Manage the process. Keep dates on your calendar for tracking and follow up. This will lead to faster processing. Set reminders for yourself to call and verify the status of your application on a regular basis by phone and email. If this all sounds like a lot to manage (and dealing with five to 10 insurance panels can, in itself, become a full time job), that’s why there are services that can help.
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Consider a Service to Lessen Aggravation A reputable credentialing service—which often also offers medical billing and insurance auditing services, etc.—can shave weeks off an approval by making sure the form is filled out correctly the first time, keeping it on track, and providing requested information. A credentialing service’s established insurance company contacts, and their ability to determine the appropriate insurances ahead of time, will save a lot of aggravation and rejection. Most credentialing companies will charge approximately $400-$600 per insurance application. That may sound like a lot, but it’s a wise investment that enables practitioners to start billing and making money sooner. With earlier acceptance to an insurance panel, the reimbursement from only three patients will cover the cost. Balance the cost of weeks of approval delays verses how many patients can be seen and billed and that amount suddenly seems negligible. Olga Khabinskay is chief operating officer of WCH Service Bureau (www.wchsb.com), a global provider of healthcare practice services offering an array of billing and healthcare management services for large and small medical groups and practitioners. WCH provides medical billing, credentialing, coding, chart auditing, and customized medical software solutions, as well as receptionist services and Continuing Education Unit (CEU) credits. She is a member of the Jamaica, N.Y., local chapter. Source: www.news.aapc.com
Healthcare News State Law
Late breaking news on medical-legal developments affecting physicians and health care providers. September 23rd Marks Start of New HIPAA: As noted numerous times in prior Statlaws and other KACS publications, September 23, 2013, marks the enforcement date for HIPAA Privacy, Security and Data Breach Notification regulations, as amended by the HITECH Omnibus Rule. Among other things, revised Notices of Privacy Practices must be distributed as of that date, along with implementation of new patient rights and new covered entity obligations. More information can be found at www.drlaw.com and at: http://www.hhs.gov/ocr/privacy/hipaa/admini strative/index.html. FDA Issues New Opioid Labeling Guidelines: The Food and Drug Administration (FDA) has approved new labeling guidelines for extended-release and long-acting opioid pain relievers, such as Oxycontin, in an attempt to curb what it calls an epidemic of prescription painkiller abuse in the country. The Centers for Disease Control and Prevention notes that nearly three out of four prescription drug overdoses are caused by prescription painkillers. According to the FDA, the new labeling requirements and other actions are intended to help prescribers and patients make better decisions about who can benefit from the use of these medications and to reduce problems associated with their use. See the new labeling guidelines and other safety measures at http://www.fda.gov/Drugs/DrugSafety/Informa tionbyDrugClass/ucm363722.htm.
Dual Eligibles Program Launched: On August 26, 2013, the CMS announced that the State of New York will partner with CMS to test a new model for providing MedicareMedicaid enrollees with the stated intent of providing a more coordinated, person-centered care experience. Under the demonstration, known as “Fully Integrated Duals Advantage” (FIDA), New York and CMS will contract with Medicare-Medicaid Plans to coordinate the delivery of covered Medicare and Medicaid services for participating Medicare-Medicaid enrollees. New York and CMS will contract with health plans known as “FIDA Plans” that will oversee the delivery of covered Medicare and Medicaid services for Medicare-Medicaid enrollees in New York City, Long Island, and Westchester County. New York is the seventh state to establish a Memorandum of Understanding with CMS to participate in the Initiative. Additional information on the ongoing development and implementation of the New York demonstration is available at: http://www.health.ny.gov/health_care/medicai d/redesign/mrt_101.htm. Physicians considering participation in a FIDA Plan should contact KACS for assistance. If you have any questions, please contact Mathew Levy, Esq., at 516 -294-5432. Mathew J. Levy Partner Kern Augustine Conroy & Schoppmann, P.C. Source: www.drlaw.com
Office E/M + Inpatient Admission = One Code Occasionally, a physician may see a patient in the office and send that patient immediately to the hospital for admission. In such a case, you may consider the history and physical (H&P) taken in the office when determining the inpatient admission level (e.g., 99223 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity.). Although the H&P do not have to be dictated at the hospital, if any additional workup is performed at the hospital, you may consider that work—in addition to the H&P performed in the office—when assigning a service level. What you should not do is report an office visit (e.g., 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity.) in addition to the inpatient admission. Instead, choose a single code (the admission) that best describes all of the evaluation and management (E/M) work provided to the patient on that day. Source: www.news.aapc.com
CMS Allows '97 Extended HPI with '95 Guidelines Effective Sept. 10, the Centers for Medicare & Medicaid Services (CMS) has revised its Evaluation and Management (E/M) Documentation Guidelines (DG), to allow physicians to use the 1997 DG for an extended history of present illness (HPI) with the other elements of the 1995 DG to document an E/M service. As a result, “the status of three or more chronic conditions” qualifies as an Extended HPI for either set of DGs. The revised guideline is presented as a Question and Answer on the CMS website: FAQ on 1995 & 1997 Documentation Guidelines for Evaluation & Management Services. Question: Can a provider use both the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services to document their choice of evaluation and management HCPCS code? Answer: For billing Medicare, a provider may choose either version of the documentation guidelines, not a combination of the two, to document a patient encounter. However, beginning for services performed on or after September 10, 2013 physicians may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document an evaluation and management service Source: www.news.aapc.com
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WCH Newsletter Fall 2013 www.wchsb.com
Coverage for Physician Assistant Services EmblemHealth Coverage for Physician Assistant Services The professional services of a physician assistant (PA) may be covered in network if he or she is contracted, meets the qualifications listed below and is legally authorized to provide services in the state where the services are performed. Payments are allowed for assistant at surgery services and services provided in all areas and settings permitted under applicable state licensure laws, but only if no facility or other provider is paid with respect to the provision of such professional services. Qualifications for Pas APA must meet the following qualifications: џGraduated from a PA educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant (or its predecessor agencies, the Commission on Accreditation of Allied Health Education Programs [CAAHEP] and the Committee on Allied Health Education and Accreditation [CAHEA]) or џPassed the national certification examination administered by the National Commission on Certification of Physician Assistants (NCCPA) and џ Be licensed by the state to practice as a PA Covered Services Services are covered if they meet all four of the following criteria: џConsidered physician's services if provided by a doctor of medicine or osteopathy (MD/DO) Performed by a person who meets all the PA qualifications and is legally authorized to perform the services in the state in which they are performed
џPerformed under the general supervision of an
MD/DO џNot otherwise precluded from coverage because of one of the statutory exclusions. Types of PA Services That May Be Covered Pas may provide services billed under all levels of CPT evaluation and management codes, and diagnostic tests, if furnished under the general supervision of a physician. Examples of services that PAs may provide include services traditionally reserved to physicians, such as examinations (including the initial preventive physical examination), minor surgery, setting casts for simple fractures, interpreting X-rays, and other activities that involve an independent evaluation or treatment of the patient's condition. Services Otherwise Excluded From Coverage PA services may not be covered if they are otherwise excluded from coverage even though a PA may be authorized by state law to perform them. Physician Supervision The PA's physician supervisor (or a physician designated by the supervising physician or employer as provided under state law or regulations) is primarily responsible for the overall direction and management of the PA's professional activities and for assuring that the services provided are medically appropriate for the patient. The physician supervisor (or physician designee) need not be physically present with the PA when a service is provided to a patient and may be contacted by telephone, if necessary, unless state law or regulations require otherwise. Source: www.emblemhealth.com
WCH Newsletter Fall 2013 www.wchsb.com
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Jurisdiction K Part B Prepayment Audit Results for CPT Code 9700197799 and G0283 A service-specific prepayment audit was recently conducted by the National Government Services Medical Review Department for Jurisdiction K Part B claims in Connecticut and New York. The audit focused on claims billed with current procedural terminology (CPT) codes 9700197799 and G0283, with the exclusion of codes 97602, 97597, and 97598 for family practice providers (08). This article includes the results of that audit and recommendations to help providers submit these types of claims correctly in the future. Records are reviewed to determine if the billed procedure code met all documentation requirements as referenced in Local Coverage Determination (LCD) for Outpatient Physical and Occupational Therapy Services (L26884). To be considered reasonable and necessary, the services must meet these Medicare guidelines however, not all providers follow the initial steps. The most common errors stated are errors that can have been avoided if providers pay closer attention in the steps they are taking when creating a bill. Services for CPT therapy codes were denied or reduced if documentation did not support the service billed as defined in LCD L26884 and the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220-230, “Covered Medical and Other Health Services.” Medicare follows basic straight forward guidelines which are available to all providers. If every provider follows Medicare guidelines, than claims will be submitted correctly in the future, and many denials will be avoided.
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WCH Newsletter Fall 2013 www.wchsb.com
It is needed to be enforced that providers follow these guidelines as it is mandatory by Medicare and it will also be beneficial to their claims processing. Audit Findings џ The following results are based upon the completion of the review for JK Part B. џ In May 2013, there were 857 services billed with 850 (99.2%) cutback or denied џ In June 2013, there were 794 services billed with 790 (99.5%) cutback or denied џ In July 2013, there were 1,024 serviced billed with 1,018 (99.4%) cutback or denied REASONS: џ Lacks referral for therapy џ Lacks initial evaluation/plan of care џ Initial evaluation did not meet documentation requirements outlined in LCD џ Lacks functional limitations and effects on activities of daily living to establish baseline data necessary for assessment of rehabilitation potential џ Billed number of services were not supported (i.e., the billed units exceed the allowable units for the documented time) џ Codes and/or units billed did not match the modalities or times documented џ Up-coding E-stim services and lacking documentation of 1:1 per CPT requirement of specific services џ Lacking progress reports with CMS-required elements џ Nonresponse to development letters џ Illegible documentation џ Missing or illegible provider signature џ Incomplete or missing beneficiary information Source: ngsmedicare.com
New York State Medicaid Update The Centers for Medicare & Medicaid Services (CMS) and the New York State Department of Health (DOH) have established a federal-state partnership to implement the Medicare-Medicaid Alignment Initiative (Demonstration) that will better serve individuals eligible for both Medicare and Medicaid. Under the partnership, DOH and CMS will contract with Fully Integrated Duals Advantage Plans in providing integrated services that address individual's medical, behavioral, and social needs. The effective date is expected to begin on July 1, 2014 and it will continue until December 31, 2017. The FIDA will provide New York eligible individuals with seamless access to all physical health, behavioral health, and long-term supports and services; a choice of plan and providers with choices being facilitated by an independent broker; and care planning and coordination by patient- centered interdisciplinary teams. In addition, this demonstration will allow FIDA plans to test alternative payment arrangements with their network provider. Source: www.health.ny.gov
New Codes for Clinical Psychologist Effective on April 1, 2013 the following CPT procedure codes were added: џ 90791 - PSYCHIATRIC DIAGNOSTIC EVALUATION-Practitioner Non-Facility Fee is $93.26 and Facility Fee is $59.78. џ 90846 - FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT)- Practitioner Non-Facility Fee is $52.48 and Facility Fee $42.92. Source: www.health.ny.gov
Influenza Vaccine Coverage Expanded For dates of service on or after August 1, 2013, the following influenza vaccine codes will be available for billing for certain age groups: For influenza vaccine codes, the following would be available for billing for certain age groups: џ 90672 INFLUENZA VIRUS VACCINE, QUADRIVALENT, LIVE, FOR INTRANASAL USE. For beneficiaries 2 years of age to 49 years of age: џ 90685 INFLUENZA VIRUS VACCINE, QUADRIVALENT, SPLIT VIRUS, PRESERVATIVE FREE, WHEN ADMINISTERED TO CHILDREN 6-35 MONTHS OF AGE, FOR INTRAMUSCULAR USE. For beneficiaries 6 months to 35 months only: џ 90686 INFLUENZA VIRUS VACCINE, QUADRIVALENT, SPLIT VIRUS, PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARS OF AGE AND OLDER, FOR INTRAMUSCULAR USE. Source: www.health.ny.gov WCH Newsletter Fall 2013 www.wchsb.com
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Low Back Pain Coverage Guidelines The following mentioned are based on limitations because of not being medical necessity. Effective November 1, 2013 the following procedures and subjected to limitation, as they are considered ineffective for the treatment of chronic low back pain: џ 62290 Injection procedure for discography, each level; lumbar. џ 72295 Discography, lumbar, radiological supervision and interpretation. The following conditions also are considered not to be medical necessity: џ Lumbago, low back pain syndrome, lumbalgia, as represented by 2013 ICD-9 code 724.2. џ Unspecified backache, vertebrogenic syndrome not otherwise specified, as represented by 2013 ICD-9 code 724.5. Source: www.health.ny.gov
Limitation to Coverage for Functional Electrical Stimulation (FES) Effective November 1, 2013 also for Medicaid fee-for-service beneficiaries, and for Medicaid Managed Care and Family Health Plus (FHPlus) enrollees, services/procedures, Durable Medical Equipment, and supplies to provide Functional Electrical Stimulation via transcutaneous, percutaneous, and implanted devices, are subject to limitation. Medicaid will continue to cover Functional Electrical Stimulation for other indications, if medically necessary. For those patients with electrodes and/or stimulators implanted prior to October 1, 2013, Medicaid will continue to cover the devices and supplies, and provide reimbursement to replace/revise/remove devices as medically necessary, regardless of patient diagnosis. In addition, there is no change to the policy regarding, and no limitation to the use of: џ Diaphragmatic/phrenic pacing device and related services and supplies (implantation of this device can be represented by CPT codes 64575, 64580, 64585, 64590, and 64595); џ Vagus nerve stimulator device and related services and supplies (implantation of this device can be represented by CPT codes 61885, 61886, 64553, 64568, 64569, 64570); џ Sacral nerve stimulator device and related services and supplies (implantation of this device can be represented by CPT codes 64561, 64581, 64590). The following limitations consist of: џ Spinal cord injury, as represented by ICD-9-CM codes 952.xx, 907.0-907.2, 767.4, 806.x 806.xx. џ Head injury (850.11-850.12, 850.2-850.9, 851.xx, 852.xx, 853.xx, 854.xx). џ Cerebral palsy (343.0-343.9). Upper motor neuron diseases (Parkinson's Disease, 332.0-332.1; Late effects of Acute Poliomyelitis, 138; Anterior horn cell diseases, 335.0, 335.10-335.19, 335.20-335.29, 335.8-335.9; Multiple Sclerosis, 340; Other demyelinating diseases, 341.0-341.1, 341.8-341.9, 341.20-341.22). Source: www.health.ny.gov
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WCH Newsletter Fall 2013 www.wchsb.com
News by Specialty
Cardiology Outpatient Cardiology Prior Authorization Program for Unitedhealthcare community Plan Beginning November 1, 2013 , UnitedHealcare Community Plan's new Outpatient Cardiology Prior Authorization program will take effect .Once a prior authorization request for the planned service is received, a clinical coverage review will be conducted to determine whether the service is medically necessary. Cardiology Prior Authorization The ordering provider must notify UHC prior to scheduling any of the following cardiology services for UnitedHealthcare Community Plan members џ Diagnostic cauterizations џ Electrophysiology implants џ Echocardiograms џ Stress echocardiograms Note: Ordering providers are not required to notify UHC of cardiology services rendered in emergency rooms, observation units, urgent care facilities, or during inpatients stays except for electrophysiology implants. Rendering providers must notify us prior to providing electrophysiology implant services in an inpatients setting.
Additional details about the Cardiology Prior Authorization program, included answers to Frequently Asked Questions, Quick Reference Guides, the complete list of procedure codes requiring prior authorization and evidence based clinical guidelines are available at UnitedHealthcareOnline.com . Clinical recourses. For additional questions, contact your UnitedHealthcare network Management representative or call 888-362-3368 Source: www.unitedhealthcareonline.com
Radiology Two New Approved Radiology Codes for Urologists — Effective September 1, 2013 Effective immediately, the following two radiology codes have been approved for urologists, as part of the Self-Referral Payment Policy. These procedure codes do not require additional accreditation. џ CPT 74455 — Urethrocystography, voicing, radiological supervision and interpretation џ CPT 76775 — Ultrasound, retro peritoneal, real time with image documentation; limited Source: www.emblemhealth.com
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Behavioral Health Fidelis Modification of Behavioral Health authorization requirements Fidelis Care is pleased to announce changes in the authorization requirements for outpatient behavioral health (BH) services that will significantly simplify and streamline the process for providers and members. Effective for dates of service on or after September 1, 2013, authorizations will no longer be required for most outpatient behavioral health (mental health and substance abuse) services and behavioral health professional home care visits provided by participating providers. All BH services provided by non-participating providers will continue to require authorization. These changes apply to all products offered by Fidelis Care. Source: www.fideliscare.org
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News by State
Announcing a Service-Specific Prepay Audit of CPT CODE 98942 for Illinois, Minnesota and Wisconsin Data analysis reveals a potential problem with the billing and utilization of chiropractic services in all Jurisdiction 6 (J6) Part B states (Illinois, Minnesota, and Wisconsin). Recent BESS data showed utilization of 12.0% of the nation's Medicare services with J6 having 7.73% of the Medicare population.The Contractor Error Rate Testing (CERT) contractor has found the highest chiropractic manipulation error level for current procedural terminology (CPT) code 98942, chiropractic manipulative treatment (CMT); spinal, five regions has shown a high error rate. To better identify common billing errors, develop educational efforts, and prevent improper payment, National Government Services, Inc. Medical Review will be implementing a widespread service-specific prepayment review of CPT 98942. Services billed for CPT 98942 must meet the Medicare coverage and documentation
requirements as found in the Centers for Medicare and Medicaid Services Internet-Only Manual 10002, Medicare Benefit Policy Manual, Chapter 15, Section 240 the Local Coverage Determination (LCD) for Chiropractic Services (L27350), and the Supplemental Instructions Article for Chiropractic Services (A47385). Illinois, Minnesota, and Wisconsin providers will receive an Additional Development Request (ADR letter) detailing the specific documentation being requested for the billed service. If you receive an ADR letter for this service-specific review, please submit the requested information within 30 days of receipt of the request. Failure to submit the requested documentation in a timely manner may result in denial of the billed service. Source: www.cms.gov
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Questions & Answers Question:
How long is a medical practice required to keep their Explanation of Benefits Retention of financial records?
Question:
How do I know who to choose in my practice as the Privacy Officer?
Answer:
Answer:
All financial records and supporting documents are to be retained for 3 years by a designated, responsible individual of the outgoing contract or in accordance with Government contract requirements. If any litigation claims or audits are begun before the expiration of the 3-year period, all records shall be retained until the completion of the action or until the end of the regular 3-year period, whichever comes last. The 3year period begins on the date the outgoing contractor submits its final deliverables, as listed in Section F of the QIO contract, to CMS. The name, address, and telephone number of the designated individual responsible for retaining records should be given to the PO. Elizaveta Bannova Billing Department Vice Manager, CMRS, CFPC Skype: wchsb.lizab e-mail: lizab@wchsb.com Source: www.cms.gov
There are a few answers to this question, and not necessarily a correct answer in the bunch. I cannot tell you who should automatically qualify as the Privacy Officer, but answers include: (1) the practice owner or a managing partner; (2) the individual versed in the privacy laws and responsible for staying up to date; or (3) the individual responsible for resolving patient HIPAA issues. In some practices the individual qualifying for each point set forth above is the same person; for many practices there is not one person meeting each of the 3 requirements set forth above, and the decision of who to anoint Privacy Officer is more difficult. If the latter describes your practice arrangement, let me take this opportunity to caution against forcing this responsibility upon an unwilling employee, or an individual who has not been with the practice for an extended period of time with experience in compliance. Another consideration when selecting your privacy officer, remember - the practice owner is the captain of the ship and will be held responsible should the practice not remain in compliance (and discovered), and therefore, may be the best person to be named as the responsible party. Answered by: Jennifer Kirschenbaum, Esq. Kirschenbaum & Kirschenbaum, P.C. 200 Garden City Plaza Garden City, New York 11530 (516) 747-6700 (tel) (516) 747-6781 (fax)
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WCH Newsletter Fall 2013 www.wchsb.com
Question:
Does Medicare conduct a site visit for Intensive Cardiac Rehabilitation Suppliers enrollment?
Answer:
No, they are not on the list of providers due for site visit. This list includes Ambulance Suppliers, Independent Clinical Laboratory, IDTF, Physical Therapists Enrolling as Individuals or Groups, and Portable Xray Suppliers George Osipyants Credentialing Specialist e-mail: georgeo@wchsb.com
Question:
Can I be reimbursed for the sign language interpreter?
Answer:
The only code exist is T1013 Sign language or oral interpretive services, per 15 minutes which in only covered by Medicaid. The health care professional or facility responsible for the care must pay for the cost of an interpreter. Health care professionals or facilities cannot impose a surcharge on an individual with a disability directly or indirectly to offset the cost of the interpreter. The cost of the interpreter should be treated as part of overhead expenses for accounting and tax purposes. Tax relief is available for expenditures made toward interpreters. The Internal Revenue Service may allow a credit of up to 50% of cumulative eligible access expenditures made within the taxable year that exceed $250 but do not exceed $10,250. This tax credit may be applied to reasonable and necessary business expenditures made in compliance with ADA standards in order to provide qualified interpreters or other accessible tools for individuals with hearing impairments.� Source: www.drlaw.com
WCH Newsletter Fall 2013 www.wchsb.com
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