Crosswalk from consultations to other visit codes

Frank Cohen (www.cpahealth.com) provided us with the table below; this will be important for predicting future utilization and revenue (cash flow) since CMS is doing away with consult code billing.  This is the official crosswalk table from CMS.

  

 

OFFICE CONSULTATION CODES				INPATIENT CONSULTATION CODES
SOURCE	DESTINATION	MAPPING		SOURCE	DESTINATION	MAPPING
99241	99201	50%		99251	99221	70%
	99211	50%			99304	30%
99242	99202	50%		99252	99221	35%
	99212	50%			99222	35%
99243	99203	50%			99304	15%
	99213	50%			99305	15%
99244	99204	50%		99253	99222	70%
	99214	50%			99305	30%
99245	99205	50%		99254	99222	35%
	99215	50%			99223	35%
					99305	15%
					99306	15%
				99255	99223	70%
					99306	30%

Physician Fee Schedule Promises Significant Reimbursement Changes in the Coming Year

by Julie E. Kass and Mark A. Stanley, Ober Kaler, www.ober.com

CMS has released its Calendar Year (CY) 2010 Final Rule with Comment Period for practitioners who are paid under the Physician Fee Schedule (PFS). Some specialists can expect to see a substantial drop in Medicare payment rates under changes made in the final rule. The rule may be viewed here [PDF].

Among other changes, the rule:

• Eliminates billing codes for consultation services except for telehealth services;
• Ties reimbursement under the PFS to the Physician Practice Information Survey (PPIS);
• Establishes a system for accreditation with respect to suppliers of the technical component (TC) of advanced diagnostic imaging services;
• Clarifies the definition for "stand in the shoes" under the physician self-referral rules;
• Revises the utilization estimates for certain high cost, non-therapeutic equipment; and
• Solicits comments regarding whether CMS should define the meaning of "performed the DHS" in the context of the self-referral rules, and which factors to consider if it adopts such a definition.

Elimination of Consultation Codes

Consultation codes are used for evaluation and management services that are provided by physicians, based on a request by another physician or appropriate source. The final rule eliminates consultation codes in the context of everything but initial visits for telehealth services. Any other services that are currently billed using consultation codes must now be billed as new or established office visits, initial hospital visits, or initial nursing facility visits. CMS will increase the relative value units (RVUs) associated with new and established office visits, and with initial facility visits for hospitals and nursing homes in order to offset the reimbursement effect of eliminating consultation codes. Physicians may notice that, while the proposed rule anticipated a 2% increase in RVUs for hospital and nursing facility visits, the final rule provides for only a 0.3% increase. The final rule offers no explanation for this significant discrepancy, but a CMS representative responded to an inquiry on the subject by indicating that a correction notice will be forthcoming "that will look more like" the proposed rule. Click to continue...

Death and NPI

I had this posted on my blog site. Not knowing the answer, I posed it to my colleagues at the National Society of Certified Healthcare Consultants (www.nschbc.org); their answers follow the blog post:

 

Have a provider who is deceased after obtaining an NPI # which is now deactivated from NPPES site and now NGS contractor for Medicare in NY cannot crosswalk their system to NPPES to verify his NPI. NGS system has NPI # as not active. Cannot get NPPES to reactivate his NPI # so I can get claims prior to his death processed. Now the EDI Dept to send claims will not accept his claims electronically due to their system not accepting his NPI. Want to send claims on paper but afraid they will refuse this process due to him not having a waiver letter on file to process claims on paper and he was only allowed to do them electronically. I am in a bind...seems like I have the first deceased provider in the city of NY that I am trying to bill. Also Medicaid is forcing me to send claims on paper due to his Electronic cert expiring and no one can sign for him..since it has to be his notarized signature. Please can you assist me in this matter or direct me to where I can get help. Thank you Susan

 

From: Ginny Martin, CMA,CPC,CHCO,CHBC

Healthcare Consulting Associates of NW Ohio, Inc.

 

Reed,

 

I'm wondering what was conveyed to NPPES regarding this provider's death.  Any change requires an effective date and whoever updated his file possibly used an incorrect date.  She needs to call NPPES (I have spoken to them on numerous occasions and have found them to be very helpful) explain the situation and indicate she still has claims to file.  She will then need to go to CAQH once NPPES is corrected and correct any misinformation there, making sure the deactivation effective date is after the last date of service.  It will take approximately 30 days for insurers to upload the file and they should process all claims with dates of service prior to the effective date.  The rest will be fixed when those two things are fixed.

 

She should have attempted to do that as soon as she got the 1st rejection, since now things appear to have escalated and will require a lot of effort to fix.  This is my best guess based upon the information in her blog.

 

Hope that is helpful.

 

Ginny

 

From: David J Zetter

www.cavmich.com

 

Ginny is absolutely right.  NPPES will follow YOUR lead and information YOU provide.  The date should have been the last date of service provided by the physician.

 

Call this number 1-800-465-3203 (NPI Toll-Free)

 

From: Kathryn Moghadas, RN, CLRM, CHBC, CHCC, CPC

Principal of Associated Healthcare Advisors

 

Dang good questions today! Someone must have power of attorney to act on his behalf. With the proper POA on hand a limited POA can be issued to the billing office manager which will assist her in remedy his NPPES status. We talk to NPPES frequently and they are real helpful and usually kind in our experience. Once that is cured then it is a systematic process of paper filing. Since he probably does not have electronic agreements on file they will have to just be scrupulous in their hard copy filings. Kathy

RAC update

Connolly Healthcare, the Recovery Audit Contractor for Region C, has posted three (3) new approved issues on its website. Two of these issues, Wheelchair Bundling and Urological Bundling, relate specifically to durable medical equipment suppliers. The third issue, Clinical Social Worker Services, relates to clinical social work providers. Additional information on each of these issues can be found on the Connolly Healthcare website at www.connollyhealthcare.com/RAC/pages/approved_issues.aspx.

In other RAC news, CGI Federal, the Recovery Audit Contractor for Region B, posted its first three (3) approved issues on its website. These issues include Blood Transfusions, IV Hydration and Bronchoscopy Services. Additional information on each of these issues can be found on the CGI Federal website at http://racb.cgi.com/Issues.aspx?st=1. All three of these issues have been approved for review in Region C and Region D.

Also, here is a list of RAC contractors as compiled by Frank Cohen (www.cpahealth.com):

Region A: 

Diversified Collection Services 

www.dcsrac.com 

info@dcsrac.com

1‐866‐201‐0580 

Region B: 

CGI 

http://racb.cgi.com/

racb@cgi.com 

1‐877‐316‐7222 

Region C: 

Connolly Consulting 

www.connollyhealthcare.com/

RACRACinfo@connollyhealthcare.com 

1‐866‐360‐2507 

Region D: 

HealthDataInsights 

http://racinfo.healthdatainsights.com/Public/RegionD.aspx 

racinfo@emailhdi.com

Part B: 866-376-2319

Relocation and NPI notification

If a health care provider with a National Provider Identifier (NPI) moves to a new location, must the health care provider notify the National Plan and Provider Enumeration System (NPPES) of its new address?

The answer is yes. A covered health care provider must notify the NPPES of the address change within 30 days of the effective date of the change. We encourage health care providers who have been assigned NPIs, but who are not covered entities, to do the same. A health care provider may submit the change to NPPES via the web (https://nppes.cms.hhs.gov/) or by paper. If paper is preferred, the health care provider may download the NPI Application/Update Form (CMS-10114) from the Centers for Medicare & Medicaid Services' forms page (www.cms.hhs.gov/cmsforms) or may call the NPI Enumerator (1-800-465-3203) and request a form.

OIG Eyes Unqualified Help in Incident-to

The Office of Inspector General (OIG) is worried physicians are billing for services provided by unqualified help, so it just audited Medicare incident-to claims for 2007. What it found made the agency ask the Centers for Medicare & Medicaid Services (CMS) to review its incident-to policies.

What the OIG discovered, as described in its August 2009 report entitled “Prevalence and Qualifications of Nonphysicians Who Performed Medicare Physician Services,” was the following:

• When Medicare allowed physicians more than 24 hours of services in a day, half of the services were not performed personally by a physician.
• In the first quarter of 2007, physicians who were allowed services that exceeded 24 hours of physician work time in a day personally performed approximately half of these services. Nonphysicians performed the remaining services, which physicians may have billed as incident-to services. Medicare allowed $105 million for approximately 934,000 services that the physicians personally performed and approximately $85 million for approximately 990,000 services that nonphysicians personally performed during this three-month period.
• Nonphysicians performed almost two-thirds of the invasive services that Medicare allowed the physicians. An invasive procedure involves entry into the living body (as by incision or by insertion of an instrument). Nonphysicians performed almost half of the noninvasive services that Medicare allowed the physicians.
• Unqualified nonphysicians performed 21 percent of the services that physicians did not perform personally. In the first three months of 2007, Medicare allowed $12.6 million for approximately 210,000 services performed by unqualified nonphysicians. These nonphysicians did not possess the necessary licenses or certifications, had no verifiable credentials, or lacked the training to perform the service. Nonphysicians with inappropriate qualifications performed 7 percent of the invasive services that physicians did not perform.

OIG recommends the following to CMS in the report:

1. Seek revisions to the incident-to rule. The rule should require that physicians who do not personally perform the services they bill to Medicare ensure no persons except:

a. licensed physicians personally perform the services or

b. nonphysicians who have the necessary training, certification, and/or licensure, pursuant to state laws, state regulations, and Medicare regulations personally perform the services under the direct supervision of a licensed physician.

2. Require physicians who bill services to Medicare to identify the services they do not personally perform on their Medicare claims by using a service code modifier. The modifier would allow CMS to monitor claims to ensure physicians are billing for services performed by nonphysicians with appropriate qualifications.

3. Take appropriate action to address the claims for services the OIG detected that:

a. were billed by physicians and performed by nonphysicians that were, by definition, not incident-to services; and

b. were for rehabilitation therapy services performed by nonphysicians who did not have the training of a therapist.

 

How can a health care provider apply for and obtain a National Provider Identifier (NPI)?

I’ve covered this ground before but it seems the question still arises. A health care provider may apply for an NPI in one of three ways:

1. Apply through a web-based application process – this is the easiest and fastest way. The web address to the National Plan and Provider Enumeration System (NPPES) is https://nppes.cms.hhs.gov.

2. If requested, give permission to have an Electronic File Interchange Organization (EFIO) submit the application data on behalf of the health care provider (i.e., through a bulk enumeration process). If a health care provider agrees to permit an EFIO to apply for the NPI, the EFIO will provide instructions regarding the information that is required to complete the process. More information on this option is available at: www.cms.hhs.gov/NationalProvIdentStand/04_education.asp#TopOfPage.

3. Fill out and mail a paper application form to the NPI Enumerator. A copy of the application form (CMS-10114), which includes the NPI Enumerator’s mailing address, is available only upon request through the NPI Enumerator. The NPI Enumerator’s phone number is 1-800-465-3203 or TTY 1-800-692-2326.

When applying for an NPI, providers are encouraged to include their Medicare identifiers, but also those issued by any other health plans. If reporting a Medicaid identification number, include the associated State name. The legacy identifier information is critical for health plans in the development of crosswalks to aid in the transition to the NPI. Once the NPI application information has been submitted and the NPI assigned, NPPES (or an EFIO, if the health care provider was enumerated by way of an EFIO) will send the health care provider a notification that includes their NPI. This notification is proof of NPI enumeration and provides the information that will enable trading partners to verify a health care provider’s NPI.

RAC Update

The following is from Lathrop Gage:

 

Connolly Healthcare, the Recovery Audit Contractor for Region C (which includes Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, North Carolina, New Mexico, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia, and the territories of Puerto Rico and U.S. Virgin Islands) has posted on its website the first CMS-approved audit issues. Unlike the RAC demonstration program, the permanent program requires a RAC obtain CMS approval before commencing audits addressing a specific issue. CMS has given the green light to Connolly to commence automated reviews for the following types of claims submitted by hospitals and physicians in South Carolina:

(1) Blood transfusions: CPT codes 36430, 36440, 36450, and 36455 (excluding claims with any modifiers) should be billed as one (1) per session, regardless of the number of units transfused on that date of service.
 

(2) Untimed codes: CPT Codes (excluding modifiers KX, and 59) where the procedure is not defined by a specific timeframe (untimed codes), the provider should enter a one (1) in the units billed column per date of service.
 

(3) IV Hydration Therapy: Based on the definition of CPT 90760 (excluding claims modifier-59 ), the maximum number of units should be one per patient per date of service. Beginning 1.1.09, code 90760 was replaced with code 96360.
 

(4) Bronchosopy Services: CPT Codes 31625, 31628 and 31629 should be billed with a maximum number of units of one per patient per date of service (excluding claims with modifier 59) should only be reported with one unit per date of service.
 

(5) Once in a Lifetime Procedures: By virtue of the description of the CPT code, these codes can be performed only once per patient lifetime.
 

(6) Pediatric Codes Exceeding Age Parameters: Newborn/Pediatric CPT codes being applied/billed for patients which exceed the age limit defined by the CPT code.
 

(7) J2505 (Injection, Pegfilgrastim, 6 mg): By definition HCPC Code J2505 represents 6 mg per unit. The code should be billed at one unit per patient per date of service.
 

For each, Connolly has identified resources available to providers concerning the subject, including CMS manual provisions, transmittals, and MLN Matters articles. More information is available at http://www.connollyhealthcare.com/RAC/pages/approved_issues.aspx. For now, these audits will be limited to hospitals and physicians in South Carolina. But there's every reason to believe CMS will approve the same automated reviews for the other RACs, and eventually all providers will be subject to these reviews. It's time for your RAC task force to review your practices in these areas and identify and correct any potential compliance issues.

"Organization" providers and NPI

What types of business structures are considered organization health care providers and thus eligible for organization NPIs? What types are not? The final NPI rule defines “organization health care providers” as providers who are not individuals (persons). These are classified as entity type 2 providers. Examples are hospitals, home health agencies, clinics, nursing homes, residential treatment centers, laboratories, ambulance companies, group practices, health maintenance organizations, suppliers of durable medical equipment or pharmacies.

Some health care provider organizations are made up of components or business units that function somewhat independently of the ”parent” health care organization of which they are a part. These components, which are referred to as “subparts” in the regulation, might conduct their own standard transactions, might be at the same or at a different address than the organization provider “parent”, might furnish a type of service different than the organization provider “parent.” These subparts or business units might be required by Federal regulations to have unique identifiers for billing purposes. Each organization must make a determination regarding the status of its subparts, and apply for NPIs as it deems appropriate. The Work group for Electronic Data Exchange (WEDI) has a white paper on this topic that can be helpful to covered entities in making their decisions.

A sole proprietorship is a form of business in which one person owns all of the assets of the business and is solely liable for all debts on an individual basis. Sole proprietors are individuals, and they must apply for their NPIs as Individuals (Entity Type I). The subpart concept does not apply to a sole proprietorship, even one with multiple locations, because the sole proprietorship is not an organization as defined in the Final NPI Rule (69FR3434).

State laws enable the creation of many other different types of businesses. While we cannot address every possible type of business structure, we apply the following broad principle to determine whether a business is eligible for an organization NPI: Any organization that is recognized by the State as separate and distinct from the individual is eligible for an organization NPI. The law in each State will govern how different business types are recognized by the State.

Striking with speed – Feds go after Medicare fraud

Using cutting-edge technology, the strike force can identify Medicare irregularities at unprecedented speeds, completing in days what used to take months. The strike force harnesses resources from the Justice Department, U.S. Health and Human Services and law enforcement.......seems the government has been busy in my backyard of Houston, Texas (as well as other places around the country):

 

http://www.chron.com/disp/story.mpl/breaking/6525026.html

 

And by the way, if you don’t think the government is serious about cracking down on healthcare fraud; consider the following 2008 statistics from the U.S. Department of Health and Human Services:

 

Healthcare fraud recovered: $2.35 billion;

Individuals or entities barred from billing Medicare or Medicaid: 3,100

Criminal actions involving healthcare fraud: 575

Civil actions involving healthcare fraud: 342

 

This is just another example of why you need a compliance plan in your office and you need an annual compliance review by an outside third party.