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IN THIS ISSUE
July 13, 2015 | Vol. 29, Issue 27
All Medicare fees are par, office, national unless otherwise noted.
Physician fee schedule 1
Stricter incident-to rules CMS proposes could
mean less revenue for practices
ICD-10 1, 5
CMS tells doctors: Close enough is good
enough for one year in ICD-10
CMS: Final ICD-10 acknowledgment testing
week was successful
Accountable care organizations 2, 3
Rural, small practices gain opportunity in
Medicare’s ACO Investment Model
OIG looking at whether shared savings groups
exchange data to coordinate care
Chronic care management 4
Watch out on double-booking CCM as CMS
guides hospitals in proposed OPPS rule
Ask Part B News 5
Understand the difference between CCI edit,
medically unlikely edit
Benchmark of the week 7
Watch out when billing E/M, procedure together
on new patient codes
(see Fee schedule, p. 5)
Break down proposed 2016 fee schedule changes
Don’t waste your time going through each of the 815
pages of the proposed 2016 Medicare physician fee
schedule when Betsy Nicoletti can do it for you and break
down the important pieces that affect your practice. Reg-
ister now for the July 29 webinar Proposed Physician Fee Schedule
— Prepare Now for Revenue Changes in 2016. Learn more at
www.decisionhealth.com/conferences/A2609.
W W W
ICD-10
CMS tells doctors: Close enough is good
enough for one year in ICD-10
The dream of a “grace period” for ICD-10 users came
partially true with a surprise joint announcement from CMS
and the AMA promising that Medicare contractors “will not
deny” claims that lack certain specificity in ICD-10 for one
year after Oct. 1.
But because the required level of specificity is ill-defined
and valid codes will be required, it’s unclear how big of a
break it will be.
The July 6 announcement said CMS will instruct Medicare
Physician fee schedule
Stricter incident-to rules CMS proposes
could mean less revenue for practices
The doctor who initiates a patient’s care will have to be in
the office when her patients are being seen by non-physician
practitioners (NPP) if the practice wants to bill incident-to
services, according to a CMS proposal in the proposed 2016
Medicare physician fee schedule, released July 8.
Currently, the physician supervising the incident-to service
does not need to be the same one who originally saw the
patient. CMS seeks to remove a sentence in the regulation that
allows that and replace it with the new policy.
(see ICD-10, p. 8)
4. July 13, 2015 Part B News
Exclusive web content and searchable CMS documents at www.partbnews.com.4
ing, she adds.
Vendors aren’t always motivated to think about
interoperability because they’re looking to build market
share for their own systems, which hasn’t always made
them willing to work with other vendors and state health
information exchanges, according to Deb Bass, chief
executive officer for the Nebraska Information Exchange.
Providers participating in an ACO are getting more
rights to access data across the ACO, but physician prac-
tices sometimes struggle with the expertise needed to
contextualize and process the information and manage
the vendor, Bass notes. The result becomes a system of
workarounds that makes it more difficult to achieve true
interoperability, she adds.
As a result, EHR systems sometimes “stop at the hos-
pital door,” Bass says. What she means is that the HIEs
and others want to look at all data across all settings,
but other sites, such as physician practices and assisted
living facilities, can’t always access the same robust data
as easily as the hospital EHR.
Physicians have generally been competent adopt-
ers of EHR systems, but vendors rushed new products
to market starting in 2011 that didn’t work effectively at
meaningful use until 2013 and 2014, Hartley believes.
Physicians paid the price, correcting mistakes made in
the early days of meaningful use without getting any
sympathy from OIG, she adds.
OIG should have access to 2015 CEHRT testing criteria
to determine which EHR vendors are capable of support-
ing ACOs and interoperability. Many vendors cannot or
will not support ACOs without substantial investments,
Hartley points out.
Security also is a growing problem. Not only are
instances of hacking on the rise, privacy and security
officials struggle to enforce existing sanctions against
those who don’t follow data security policies, Hartley
adds. — Scott Kraft (pbnfeedback@decisionhealth.com)
Chronic care management
Watch out on double-booking CCM as CMS
guides hospitals in proposed OPPS rule
New guidance from CMS may encourage some
hospitals to claim chronic care management (CCM) on
practice patients, including yours; make sure your patient
isn’t over-served.
The 2016 Hospital Outpatient Prospective Payment
System (OPPS) and Ambulatory Surgical Center (ASC)
proposed rule, published July 8, included proposed
guidance on hospital billing for CCM code 99490, which
CMS said it was supplying because it had “received ques-
tions about specific requirements for hospitals to bill this
code” beyond the requirements in the 2015 Medicare
physician fee schedule.
The OPPS rule proposes “that a hospital would be
able to bill CPT code 99490 for CCM services only when
furnished to a patient who has been either admitted to
the hospital as an inpatient or has been a registered out-
patient of the hospital within the last 12 months and for
whom the hospital furnished therapeutic services.”
“The hospital-employed physician clinic must be
treated consistently as a hospital outpatient department
or a physician practice,” explains Martie Ross, a principal
at consultancy PYA in Kansas City, Mo. “If it’s a hospital
outpatient department, all claims for CCM would be filed
as having been furnished in a hospital outpatient depart-
ment. Under the proposed OPPS, the patient does not
have to be a former inpatient — she also can be a former
outpatient as well — and that would include a patient in
a physician clinic that’s operated as a hospital outpatient
department.”
This could lead to a situation where the hospital and
the practice physician are both billing for CCM on the
same patient with a Part B claim submitted for the physi-
cian professional services and a Part A claim submitted
by the hospital for the facility fee — putting the patient
on the hook for two separate copays. “Hospitals will
often be a natural place where patients with multiple
chronic conditions can be identified,” says William Mills,
M.D., president of Kindred House Calls in Louisville, Ky.
“I see no reason why a well-intended integrated health
system couldn’t refer patients not in a CCM program
already to its own program.”
But chronic care patients “aren’t necessarily the best
historians of their own care,” and they may miss that the
service has been charged to them twice, says Michelle
McKamy, director of special projects for SmartCCM in
Dallas. “CMS will only pay for one physician to provide
CCM, regardless of whether that physician is practicing
Correction
In “Avoid pain drug trouble by spotting, counseling drug-seeking
patients” (PBN 6/29/15), Part B News erroneously reported the
name of the practice for Kery Feferman, M.D. His practice is
Austin Pain Associates. Part B News regrets the error.
6. July 13, 2015 Part B News
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PAS 2015
(continued on p. 8)
as standard forms [with completion of such forms, when
performed], by the physician or other qualified health
professional; each additional 30 minutes [List separately
in addition to code for primary procedure]).
The codes “should be reported when the described
service is reasonable and necessary for the diagnosis or
treatment of illness or injury,” according to the rule.
CMS cautions that they have not made a national
coverage determination on these codes and “contractors
remain responsible for local coverage decisions in the
absence of a national Medicare policy.”
CMS is coy about the payment for such codes, not stat-
ing a figure but alluding to the AMA Specialty Society Rela-
tive (Value) Update Committee (RUC) recommendations
for the codes’ values for work relative value units (RVUs),
time and direct practice expense inputs. CMS noted a 1.50
RUC-recommended work RVU for 99497 and 1.40 for 99498
in the final 2015 Medicare physician fee schedule.
Conversion factor not affected by SGR
In this first fee schedule since the sustainable growth
rate (SGR) repeal, CMS estimates the 2016 conversion
factor at $36.1096, “which reflects a budget neutrality
adjustment of 0.9999 and the 0.5% update factor” speci-
fied under the Medicare Access and CHIP Reauthoriza-
tion Act (MACRA).
The anesthesia conversion factor is estimated to be
$22.6296, reflecting “the 0.9999 budget neutrality adjust-
ment, a 0.99602 anesthesia fee schedule adjustment
practice expense and malpractice adjustment” as well as
the MACRA adjustment.
CMS makes changes to PQRS
The proposed rule changes measures for the Physi-
cian Quality Reporting System (PQRS) and starts on the
Merit-based Incentive Payment System (MIPS). PQRS will
remain up and running until 2018, but Medicare is seek-
ing comment on the shape of MIPS, the all-in-one quality
program that will combine quality reporting, value-based
payment modifier and meaningful use.
Under the proposed rule, the basic requirements
for PQRS participation will stay the same — a provider
will report nine measures, including one cross-cutting
measure, across three national quality strategy domains.
But don’t assume the quality measures you reported this
year will be available in 2016. Medicare intends to delete
12 individual measures, add 45 individual measures
including four cross-cutting measures and shift reporting
methods and national quality domains for another 18.
You’ll also see three new measures groups if Medicare’s
proposed rule remains unchanged.
The proposed rule opens the door to comments on
the shape of MIPS. For example, CMS proposes that for
the first two years of the program, the value modifier
would apply only to physicians, nurse practitioners, phy-
sician assistants, certified registered nurse anesthetists
and certified nurse specialists. Providers such as physi-
cal therapists and anesthesia assistants would not be
subject to a pay cut.
Stay tuned to Part B News for more analysis of the
proposed 2016 Medicare physician fee schedule.
— DecisionHealth staff
8. July 13, 2015 Part B News
Exclusive web content and searchable CMS documents at www.partbnews.com.8
Even if CMS means “category,” for some specialties,
the concessions may not provide much relief because
codes may require seven characters to be valid, Vaught
says. For example, code S64.20 (Injury of radial nerve
at wrist and hand level of unspecified arm) requires
seven characters to be valid, according to ICD-10 coding
rules. So for initial treatment, you’d report the code as
S64.20xA.
CMS promises further clarification in future guidance,
including a provider call scheduled for Aug. 27.
Mixed opinions on the policy
Industry leaders seem encouraged by the move,
though not completely satisfied. The policy doesn’t
address the dilemma of practices that haven’t been able
to upgrade or replace billing software because of finan-
cial or vendor issues, says Robert Tennant, senior policy
adviser for the Medical Group Management Association
(MGMA) in Washington, D.C. “We will continue to push
the agency to allow for a transition where both code sets
are permitted to be used. This would mirror the 2012
transition to version 5010.”
CMS’ plan to establish an ICD-10 ombudsman to
assist providers could help, but “the team supporting
the ombudsman has to know about coding and billing
cycles,” cautions Carolyn Hartley, CEO of Physicians EHR
Inc. in Cary, N.C., and a noted ICD-10 expert.
“I think the announcement will likely ease the transi-
tion, as it will give physicians the perception that the
AMA has ‘won’ something for them and that it won’t be
as bad as they originally feared,” says Minnette Terlep,
business development/chief compliance officer for
Amphion Medical in Madison, Wis.
If you’re part of a health system that has other types
of providers, take note: This announcement is “focused
on physicians and other practitioners who bill under the
physician fee schedule” and does not apply to Part A
providers, a CMS official explained to Part B News’ sister
publication Home Health Line. — Roy Edroso (redroso@
decisionhealth.com) and Laura Evans (levans@decision
health.com)
Resources:
`` CMS FAQ: www.cms.gov/Medicare/Coding/ICD10/Downloads/
ICD-10-guidance.pdf
`` AMA President Steven J. Stack’s editorial on the guidance:
www.ama-assn.org/ama/ama-wire/post/cms-icd-10-transition-less-
disruptive-physicians
ICD-10
(continued from p. 1)
administrative contractors (MACs) and recovery auditors
(RACs) not to deny claims “through either automated
medical review or complex medical record review based
solely on the specificity of the ICD-10 diagnosis code as
long as the physician/practitioner used a valid code from
the right family.” Providers will get a similar break on
Physician Quality Reporting System (PQRS), value-based
modifier (VBM) and meaningful use 2 (MU) program pen-
alties that are caused by similar ICD-10 coding shortfalls.
Also, if MACs have trouble processing claims as a
result of ICD-10 issues, “an advance payment may be
available” if the claim is otherwise valid, pending sub-
mission of a request by the provider to the appropriate
MAC,” according to CMS.
CMS and AMA still stressed — in boldface type — that
ICD-10 codes will be required starting Oct. 1. Also, there
is no indication that this indulgence will persist past Oct.
1, 2016.
An ICD-10 grace period for providers has been the
subject of some recent Congressional bills as well as an
AMA House of Delegates resolution passed June 8 (PBN
6/15/15).
Unclear definition of family for ICD codes
How specific codes need to be to avoid denials is
unclear as “family” is not an appropriate term for ICD
codes — the preferred nomenclature is “category” or
“subcategory,” explains Betsy Nicoletti, president, Medi-
cal Practice Consulting in Northampton, Mass. “Family”
is a term used with CPT codes.
By “code family” CMS appears to mean the three-digit
code category headings for codes, says coding consul-
tant Margie Scalley Vaught, CPC, in Chehalis, Wash. For
example, M16 is the heading for all the codes for osteo-
arthritis of the hip, while M17 codes would describe all
osteoarthritis of the knee, she says. But CMS was not
clear in the announcement and has not responded to
Part B News inquiries.
Editor’s note: Be ready for the changes coming your
way in 2016 by registering now for the webinar Proposed
Physician Fee Schedule — Prepare Now for Rev-
enue Changes in 2016 on July 29. For more information,
visit www.decisionhealth.com/conferences/A2609.
(continued from p. 6)
