Posts Tagged ‘2012’

2012 Medicare Physician Fee Schedule Is In the Crosshairs Again… AKA, “The Perils of The SGR”

In Uncategorized on February 8, 2012 at 3:21 pm

Although most of us were not around during the era of silent movies, many of you may be familiar with a genre of movie referred to as a serial motion picture….  One of the more famous of this genre was titled, “The Perils of Pauline.”   In this series, the heroine, Pauline, would be put into a perilous situation (i.e. tied to the railroad tracks with a fast approaching train, tied to a barrel filled with explosives, etc.) and during the course of the installment, Pauline would miraculously escape near certain death at the last possible moment.  Each installment would end with words to the effect, “Tune in Next Week.”

Anyone familiar with “The Perils of Pauline” series cannot help but recognize the parallels between Pauline and healthcare providers as we watch our government deal with theSGR problem.  Every few months, it seems, Congress waits until the last possible moment to fix the SGR cut and avoid the financial calamity that would ensue if Congress allowed the cut to take effect. 

As we all know, in the latest “Perils of SGR,” Congress voted to delay any resolution of the SGR – and the potential 27% reduction in the Medicare Physician Fee Schedule — in late 2011.  However, that “fix” was only for two months and we were all told to, “Tune in next month,” as our intrepid Congress attempts to once again step in at the last minute to avoid yet another possible cut in physician fee schedule payments on March 1, 2012.  Unfortunately, whereas “The Perils of Pauline” was a movie, the perils of the SGR cut are all too real.

On January 24th a House-Senate Conference Committee met for the first time to begin formal work on resolving the SGR differences between the House and Senate.  Although this was the first meeting by the Representatives and Senators, their staffs had been meeting regularly leading up to this meeting.  The Conference Committee met again on February 1st and 2nd, and additional meetings are anticipated over the next few weeks, during which committee members are to present all ideas and solutions. 

Representative Renee Ellmers (R-NC), a freshman Member of Congress on the Conference Committee (and a healthcare executive prior to being elected to Congress in 2010) suggested a two-year extension for the SGR fix, thus giving the Congress time to find alternate solutions.  Follow-up remarks made by several members of the Conference Committee indicated that there was at least some bi-partisan interest in coming up with a permanent fix to the SGR rather than another in the long series of temporary fixes. 

The stumbling block for enacting a permanent SGR solution has not been the lack of an alternative formula, but rather how to pay for any fix the Congress might adopt.  Current estimates are that adopting a permanent fix would increase the federal deficit by approximately $300 billion over the next year unless corresponding spending reductions were made to offset the debt. 

The AMA and some other organizations have suggested that money saved by the ending of the war in Iraq could be used to pay for the SGRfix.  The current federal budget (which projects spending out for 10 years) assumed that theIraq war would go on for several more years and money was budgeted for that purpose.  However, with the ending of the war, the money previously budgeted will no longer be needed.  Therefore, from a budgeting standpoint, this money could technically be redirected to pay for the SGR fix, rather than being set aside for the war inIraq.  Doing so would not increase the projected federal deficit beyond current estimates as this would be viewed as a reprogramming of dollars already budgeted for another purpose.  It remains to be seen whether the Congress will pursue this budgetary line of reasoning or not. 

Although it appears unlikely that Congress would allow the 27% SGR-related cut to go into effect on March 1, there are no guarantees.  Stay tuned for the next installment…   

Adapted and reprinted with permission of Bill Finefrock, Washington Report – January 2012.


ICD-9-CM Updates Are Now In Effect… Become Familiar With & Use Them To Ensure Efficient Billing And Timely Reimbursement

In Uncategorized on October 12, 2011 at 4:16 pm

It’s that time of year again…  time to implement the ICD-9 coding updates. 

It is critical to your practice’s continuous income-flow that you review the following documents which detail the 2012 ICD-9 coding changes: 

  1. The ICD-9 “conventions” – essentially guidance on the symbols, abbreviatioins, etc…  found in the ICD-9
  2. The Complete 2012 ICD-9-CM Coding Updates & Rationales, which will comprise of documentation tips, an abbreviation/acronym guide, and the complete listing of all changes and rationales
  3. The summary listing of all of the code changes (this is more of a helpful tool – it should not necessarily include any information not otherwsie included in #2, above).

In order to ensure accurate and proper coding and billing, you should review these documents in order to identify any changes/updates made to diagnosis codes used by your practice.  Be sure to note any such changes so that claims can be submitted with minimal errors, or subsequent requests for notes (as is often the case when unspecified codes are utilized).

Please do not hesitate to contact M.E.D.I.C., Inc. should you have specific questions regarding this matter.

Coding & Billing Medicare Influenza Vaccines – Q Code Selection

In Uncategorized on October 12, 2011 at 1:14 pm

As 2011 is drawing to a close, and new coding guidelines are being published and disseminated, M.E.D.I.C., Inc. wanted to take this opportunity to alert you to updates regarding seasonal influenza vaccine pricing.  As of September 1, 2011, payment allowances for flu vaccines have changed. 

In 2011, CMS stopped accepting CPT code range 90654-90662 for the influenza vaccine (note that commercial carriers still accept them, but Medicare will not).  Rather, those codes have been replaced by a series of Q codes which relate to the brand name of the vaccine:  Q2035 relates to Afluria; Q2036 relates to Flulavel; Q2037 relates to Fluvirin; Q2038 relates to Fluzine; and Q2039 relates to those not otherwise specified… all are defined as “Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use.”

Per CMS (, the pricing allowance from September 1st, 2011 through August 31st, 2012 will be as follows:  95% of the Average Wholesale Price, as listed below: 

  • Q2035 (Afluria): $11.543
  • Q2036 (Flulaval): $8.784
  • Q2037 (Fluvirin): $13.652
  • Q2038 (Fluzone): $13.306
  • Q2039 (N.O.S.): locally priced

Because the compensation differs for each product, providers must be sure to alert their billing staff/billing company to the specific brand of flu vaccine that is being administered to patients, so that they can ensure that claims are submitted to Medicare with the appropriate corresponding code.  In the event that the Q2039 “not otherwise specified” code is used, the claim will likely be denied, and additional information in the form of visit notes will be sought.  So, please – be sure to provide the brand specificity at the outset to ensure efficient processing and payment of your claims.

Furthermore, in addition to the Q codes, the HCPCS code G0008 for the Administration of the Influenza Vaccine must still be used for the administration of the flu vaccine for all Medicare patients.

Annual Part B deductible and coinsurance amounts do not apply for the influenza virus and the pneumococcal vaccinations. 

All physicians, non-physician practitioners, and suppliers who administer these vaccinations must take assignment on the claim for the vaccine.

When billing flu shots to commercial carriers (i.e., non-Medicare), the Q codes are not applicable.  Practices will generally  code the following (but remember, the code used will depend on the route of administration (intramuscular vs. intranasal), the age of patient, the formulation, and whether the vaccine is preservative free, and split or live virus — each of which relate to influenza vaccine codes 90654-90668):

  • CPT 90471 – Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid), and
  • CPT 90658 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use