Posts Tagged ‘CMS/Medicare’

CMS Sets New Date For ICD-10 Implementation

In Uncategorized on August 24, 2012 at 7:27 pm

The medical community can breathe a short sigh of relief, after having been granted a 1-year reprieve from ICD-10 implementation.  HHS Secretary Kathleen Sebelius announced this morning a final rule establishing a one-year delay – from Oct. 1, 2013, to Oct. 1, 2014- in the compliance date for use of the ICD-10 Coding system, thereby allowing providers and payers additional time to implement the new code set.   The rule is one of a series of changes intended to cut red tape in the health care system.

In making the announcement, Sebelius said, “These new standards are a part of our efforts to help providers and health plans spend less time filling out paperwork and more time seeing their patients.”

In addition to announcing the new ICD-10 deadline, the rule would also establish a mechanism for assigning a unique health plan identifier (HPID) for all health plans in the United States. 

Currently, when a health care provider bills a health plan, that plan may use a wide range of different identifiers that do not have a standard format.  It is hoped that the adoption and use of Health Plan IDs will allow for a higher level of automation for health care provider offices, particularly for provider processing of billing and insurance related tasks, eligibility responses from health plans, and remittance advice that describes health care claim payments.

A preview of the final rule (200+ pages) is available for inspection.  The actual final rule should be published in the Federal Register September 5th. 


New Docs Can Apply To Medicare Earlier!

In Uncategorized on May 10, 2012 at 3:47 pm

CMS, after considerable pressure from many medical and billing advocacy groups and organizations, has announced a change in its provider enrollment process that will allow providers to enroll in Medicare up to 60 days prior to their start date. Until now, providers were prohibited from enrolling in Medicare more than 30 days prior to their start date.  This is great news, which will only enhance providers’ ability to recoup funds for services provided to patients.

 The announcement is included in a MedLearn Matters article released earlier today. The new policy is effective May 14th.

 The new policy does not apply to:

                         (a) providers and suppliers submitting a Form CMS-855A application, 
                        (b) Ambulatory Surgical Centers (ASCs), or 
                        (c) Portable X-ray Suppliers (PXRSs)

Please contact M.E.D.I.C., Inc. should you have any questions.

reprinted in substance with permission of HBMA

The Fix Is In… for 2012

In Uncategorized on February 29, 2012 at 5:12 pm

The House and Senate have both voted to approve, and the President has signed into law, legislation preventing the scheduled 27.4% SGR related cut from taking effect on March 1.   While many issues are in fact addressed in this legislation – ranging from outpatient therapy caps to ambulance add-on payments; from the governments provision of bad debt payments to insitutions to the payment of the technical component of certain pathology services, etc…, by far the most anticipated and relevant item impacted by the legislation is the Medicare Physician Fee Schedule rates:

Physician Payment Rates – This provision prevents a 27.4 percent cut in Medicare physician payment rates slated to begin on March 1, 2012, and instead freezes payment rates at their current level though December 31, 2012.  This provision also requires the Government Accountability Office (GAO) and HHS to submit reports to assist Congress in the development of a long-term replacement to the current Medicare physician payment system.

Physicians can breathe a sigh of relief, as physician payments are safe for the remainder of 2012…  but a permanent fix is an ever increasing necessity, for now, physician practices will face a mounting 35% payment threat from Medicare in 2013, absent additional furture Congressional intervention.

CMS’ Revalidation Effort Delayed

In Uncategorized on November 7, 2011 at 9:28 pm

Over the past few months, much has been discussed about CMS’s “revalidation” effort.  Essentially, all providers and suppliers enrolled in the Medicare program prior to March 25, 2011, will be required to submit their enrollment information so they can be revalidated under new risk screening criteria required by the Affordable Care Act (Section 6401a).  Providers/suppliers who enrolled on or after March 25, 2011, have already been subject to this screening and need not revalidate at this time.

CMS & MACs have advised providers and suppliers not to take any action intil they have received a “revlidation letter” from their MAC, for this is going to be a staged process in which all providers and suppliers would be revalidated over the course of the next two years (by March 23, 2013).  The followig link provides an example of what a validation letter would look like:$File/J11_Revalidation_Letter_Web_Example.pdf

Once your office receives such a notice, please notify M.E.D.I.C., Inc. ASAP, for at that point, you have only 60 days in which to complete the revalidation process.  Providers failing to respond to such a revalidation request run the risk of being deactivated from the Medicare program.

Just this past week, however, CMS announced that it would “delay” this revalidation effort in order to streamline the process by improving the PECOS online registration system prior to revalidating all Medicare providers.  According to the Medical Society of Virginia’s website (–.aspx):

In order to comply with the program integrity screening provisions of the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) launched an effort to revalidate the enrollment of every provider and supplier by March 23, 2013. This effort has now been pushed back to 2015. Physicians will be among the last to revalidate.
In addition to pushing back the revalidation efforts, CMS made improvements to the online Medicare Provider Enrollment, Chain and Ownership (PECOS) system, which include:

  • E-signatures
  • Electronic document upload
  • Batch upload capability
  • Seamless password reset
  • Enhancements for authorized officials
  • Reassignment reports
  • New “my enrollments page” and “fast track view” screens
  • Fewer duplicative document submission requirements

CMS stated that the PECOS improvements will be implemented before most physicians are asked to revalidate.

eRx Exemption Deadline Is Looming… Be Sure That You Are Not Hit With A 1% MPFS Penalty!

In Uncategorized on November 4, 2011 at 9:01 pm

This past summer, I communicated with you all about the need to either start begin a consistent regimin of e-prescribing (a minimum of 25 prescriptions must have been electronically prescribed by the end of 2011), or apply for an exemption.  Initially the deadline for filing this exemption was October 1, 2011; however CMS extended it until November 1, 2011.  Just this week, CMS once again extended the deadline to November 8, 2011 — next Tuesday.  The following link is to the Medical Society of Virginia’s publication regarding this extension:–.aspx.   (see also, – this is the AMA’s information relating to the eRx exemption).

In order to qualify for the exemption, a provider must fall squarely into one of six specific categories: 

  • Registered to participate in the Medicare or Medicaid electronic medical record incentive program and have adopted certified EMR technology.
  • Were unable to prescribe electronically because of a local, state or federal law or regulation. (if possible, reference the actual code/statute that prohibits your e-prescriptions)
  • Had limited prescribing activity.
  • Had insufficient opportunities to report e-prescribing for eligible patient visits.
  • Practiced in a rural area without sufficient high-speed Internet access.
  • Practiced in an area without a sufficient number of pharmacies that accept electronic prescriptions.

Once you have determined that you do in fact qualify under one of these aforelisted categories, then you must submit a specific form, which is located at    Click “Communication Support Page” (at the bottom of the top box on the left side of the page) and fill out the exemption request form per individual NPI. 

Should you have issues accessing the actual form (I did, but the QualityNet Help Desk, walked me through setting preferences to access the document), follow these steps: 

  • Click Tools drop down
  • Select Internet Options (bottom of list)
  • Select “Advanced” tab (far right)
  • Scroll down to the bottom and check the box “Use TLS 1.0”
  • Click APPLY
  • Then try accessing the page again…  it should work

I was advised that only the individual associated to the NPI is available to complete the exemption form…  office staff are NOT allowed to do this on the behalf of the doctors.  The email must be the individual provider’s own email address and the requestor relationship field must have Health Care Provider marked when filing for an eRx Hardship Exemption.  The other options on the requestor relationship field are there merely because anyone can request a feedback report. 

Providers failing to either e-prescribe or submit an exemption are at risk of incurring a 1% Physician Medicare Fee Schedule payment penalty on all claims.

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

CMS Sets National 5010 Testing Day For June 15, 2011

In Uncategorized on May 12, 2011 at 6:56 pm

Beginning on January 1, 2012, a federal mandate requires health plans, clearinghouses, and providers to use new standards in electronically conducting certain health care administrative transactions at the heart of daily operations, including claims, remittance, eligibility, and claims status requests and responses.
Upgrading from the current HIPAA 4010A1 transaction standards to the new 5010 standards addresses several key goals:

  • Increase transaction uniformity
  • Support pay for performance
  • Streamline reimbursement transactions

As the deadline approaches, affected health care organizations need to upgrade and test their claims management systems to accommodate 5010 and prevent operational disruptions.

Two key factors prompted the upgrade to 5010: 1) the government and industry’s shared goal of providing higher quality, lower cost health care, and 2) the need for a comprehensive electronic data exchange environment for the vastly expanded ICD-10-CM and PCS code set transition mandated for compliance by October 1, 2013.

To this end, the Centers for Medicare and Medicaid Services is encouraging all Medicare trading partners to participate in National 5010 Testing Day on June 15 as part of preparations to comply with the HIPAA 5010 transaction sets by January 2012.

Local Medicare Administrative Contractors will be disseminating information on transactions being tested on June 15 and some Medicaid programs also will participate, with details to come.

Medicare Claims Processing (For Dates Of Service Post-June 1st) On Hold Again

In Uncategorized on June 25, 2010 at 5:34 pm

As mentioned in our last post, the House approved legislation last night rescinding the 21.3% SGR cut and replacing it with a 2.2% increase. This increase is retroactive to claims for services provided on or after June 1, 2010 and will be in place for services provided through November 30, 2010.

The Centers for Medicare & Medicaid Services (CMS) has directed Medicare claims contractors to discontinue processing claims at the negative update rates and to temporarily hold all June 1 or later claims for services until the new 2.2 percent update rates are tested and loaded into the Medicare contractors’ claims processing systems.  According to a statement from CMS, “We expect to begin processing claims at the new rates no later than July 1, 2010.”  Claims for services rendered prior to June 1, 2010, will not reflect the 2.2% increase but will continue to be processed.

CMS has also announced that claims containing June 2010 dates of service which have already been paid at the negative update rates will be reprocessed as soon as possible.  Under current law, Medicare payments to physicians and other providers paid under the MPFS are based upon the lesser of the submitted charge on the claim or the MPFS amount. 

Please take note that claims containing June dates of service that were submitted with charges greater than or equal to the new 2.2 percent update rates will be automatically reprocessed.  Providers who submitted claims containing June dates of service with charges less than the 2.2 percent update amount will need to contact their local Medicare contractor to request an adjustment.  According to CMS, “Providers should not resubmit claims already submitted to their Medicare contractor.”

While we appreciate the steps Congress has taken to address the SGR problem, this is still only a temporary solution and the Congress must enact a permanent fix to the SGR.  Because this fix is only for 6 months, providers will be facing a reinstatement of the 21.3% cut on December 1, 2010.  Then, a SGR second cut, estimated at 25%, will occur on January 1 unless Congress takes steps to prevent these cuts from occurring.

We’ll keep you posted…

Be Sure To Enroll/Update PECOS Database ASAP!!!

In Uncategorized on June 8, 2010 at 7:00 pm

The Centers for Medicare & Medicaid Services (CMS) requires physicians and non-physician practitioners to enroll and maintain Medicare program enrollment to be eligible to receive Medicare payments for covered services furnished under Medicare.  Similarly, all Medicare providers must be enrolled in PECOS (Medicare’s Provider Enrollment, Chain, and Ownership System), the system which supports the Medicare provider and supplier enrollment process by capturing provider/supplier information from the CMS-855 family of forms.  PECOS manages, tracks, and validates enrollment data collected in both paper form and electronically via the Internet.

It is important to note that although some providers may be enrolled in Medicare, those enrollment records might not be in PECOS.  Generally, the lack of a current enrollment record in the PECOS (i.e., one that is in the PECOS and also contains the National Provider Identifier (NPI)) is a result of not having submitted any enrollment information updates since November 2003.  Such providers must update their enrollment record now.

Why all the fuss?  The Protection and Affordable Care Act, which finally passed in March of this year, provides for the verification of a referral source’s Medicare enrollment.  Under the Medicare edits in question, if an ordering/referring physician or other non-physician practitioner listed on DMEPOS claims are not in PECOS, those claims will reject.  Note that I write “DMEPOS claims” – durable medical equipment suppliers’ claims were the first categpory of claims to be targeted by this new Medicare edit, however, it is foreseeable that this edit will in fact apply to all of the following:  DME, orthotics, prosthetics, supplies, home health items/services, laboratory services, imaging services, specialist services.  Further, there is rumor of CMS’s extending the provision to Part B drugs within the next year.

CMS had originally set Jan. 4, 2010, as the effective date for the system edits, but later pushed that date out to April 5 and then to Jan. 3, 2011.  Following the recent passage of the new health care reform law, however, CMS published an interim final rule stipulating that physicians and other eligible professionals who order items and/or services (ex: durable medical equipment, tests, etc…) for Medicare beneficiaries must have an approved enrollment in PECOS by July 6, 2010 – effectively advancing the compliance date by 6 months.

NOTE – Providers who do not participate in Medicare also need to be enrolled in PECOS or any DME/tests that they order will not be reimbursed.

What Can You Do?  Basically just ensure that you and all providers referring to you have a current PECOS enrollment record.  To determine if you have a current enrollment record in the PECOS, you can utilize the national file of Medicare physicians and non-physician practitioners who are eligible to order/refer and have current enrollment records in the PECOS (  This file is made available by the Centers for Medicare & Medicaid Services’ (CMS) and contains the provider’s NPI and his/her legal name (from the PECOS enrollment record). 

If you do not have a current enrollment record in the PECOS and will be ordering or referring services, particularly items of durable medical equipment (e.g., oxygen, diabetic supplies, and wheelchairs), you should use Internet-based PECOS to complete and send your enrollment application.  For more information regarding submissions via Internet-based PECOS, you can refer to the CMS website (

CMS Orders Medicare Contractors To Hold Claims Beginning June 1st

In Uncategorized on June 1, 2010 at 2:39 pm

Congress has failed to adopt another extension of the freeze of the Medicare physician fee schedule Conversion Factor.  This means that effective for services provided on or after June 1, there is currently slated a 21.3% cut in the Medicare fee schedule payments. 
The Congress will not be in session next week due to the Memorial Day Recess, meaning that the earliest it could consider legislation reinstating the freeze (or enacting a replacement to the SGR) would be June 7th.  

Because Medicare claims are not paid any sooner than 14 days after receipt, technically Congress has until June 13th to adopt legislation avoiding the 21.3% cut.  In an effort to avoid the administrative confusion and ugliness that stems from this waffling of the Physician Fee Schedule, CMS has once again instructed its contractors to hold claims containing dates of services as of June 1st to paid under the Medicare physician fee schedule for the first 10 business days of June.  One can only hope that the SGR issue will be resolved by then!

Congressional leaders are trying to avert a 21 percent payment cut scheduled to take effect June 1 under the current fee schedule.

The 10-day hold applies to claims with dates of service of June 1 and later. According to CMS officials, the hold should have little impact on provider cash flow because electronic claims are not paid until at least 14 calendar days after receipt.