Posts Tagged Medicare

Impact of Sequestration on Provider Reimbursement

By  Delly Parham, CPC

As of April 1, the deficit control measure known as sequestration mandated a 2 percent decrease on payments to fee-for-service healthcare providers for services to Medicare Part A and B beneficiaries. Although hardly good news, cuts to the Medicare program are lower than cuts made to other federal programs. Here is what you should know about how the 2 percent decrease affects your reimbursement.

Under sequestration, be aware that:

  • The current allowed fees remain unchanged
  • The 2 percent reduction will not apply to the deductible or coinsurance owed by the patient
  • The 2 percent is calculated only on the amount actually paid to the provider or patient, and not to the amount allowed
  • The effects of sequestration apply differently for participating and non-participating providers

The 2 percent reduction began with dates of service and dates of discharge after April 1, 2013 (The mandate is divided into two parts: Part one of this two-part mandate covers only the period through 12/31/13. Part two covers the period 2014 through 2021, but there could be many changes by 2014.)

Participating Providers

If you are a participating provider with Medicare (this means enrolled in the Medicare program for Part A or Part B beneficiaries), Medicare will apply the 2 percent reduction only to the amount paid to you. In other words, the 2 percent will be taken from only the calculated payment amount after the deductible is met, and it does not include the co-insurance. For example:

Medicare approved amount $100.00 Medicare allowable before deductible & coinsurance
Deductible $50.00 Patient pays this amount
Amount after deductible $50.00 Medicare will pay 80 percent of this amount
Patient 20 percent coinsurance $10.00 Patient pays this amount
Medicare payment to provider $40.00 Before 2 percent reduction
$00.80             2 percent reduction
Paid to provider after reduction $39.20 Provider is paid this amount

 

 

 

 

 

The claim adjustment reason code 223 will be displayed next to the line item on the electronic or paper remittance advice for Part B providers, and at the end of the claim for Part A providers.

Non-Participating Providers

If you are a non-participating provider (not enrolled in the Medicare program), and you see Medicare Part A and Part B patients, you will not be affected by this reduction; however, you must take the following actions:

• You must notify Medicare patients of this mandate.

• Your Medicare patients will be liable for the full limiting charge (115 percent of Medicare allowable). For example, if the total limiting charge is $109.25, you may collect this amount from the patient.

• Medicare will apply the 2 percent reduction to the actual amount paid to your patients, for example:

Medicare approved amount $95.00 Medicare allowable before deductible & coinsurance
Deductible $50.00 Patient is responsible for this (not reduced)
Amount after deductible $45.00 Medicare pays 80 percent of this amount
Amount to patient before2 percent reduction $36.00 Apply 2 percent reduction
$00.72 2% Reduction
Reduced Payment $35.28 Patient will receive this amount

If you have any questions specific to your practice, contact your Medicare carrier or Medicare Administrative Contractor (MAC) in your region.

Sources:

(http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-03-08-standalone.pdf

http://medicare.fcso.com/Fee_news/251772.asp, Federal Sequestration Payment Reductions

April 19th, 2013

No Comments

Get the Most Out of Locum Tenens Physicians

By Delly Parham, CPC
Smiling successful team of doctors.

Using locum tenens physicians to fill in for regular physicians may cost your practice instead of helping it if you don’t understand how to bill for their services. To ensure you get paid and stay in compliance, you must adhere to Medicare and commercial payer guidelines.

Practices usually use locum tenens (Latin for “lieutenant”) physicians when the regular physician is absent because of vacation, illness, childbirth, business, education, active duty, or having left the practice. The advantages of hiring a locum tenens physician versus using a physician in the same practice or in the same area are that it:

  • Retains the regular physician’s existing patients
  • Introduces new patients to the practice
  • Maintains the patient level
  • Keeps revenue with the regular physician

Most practices using the services of a locum tenens go through a recruiting agency, such as Comp Health. These companies handle the licensing requirements, professional liability insurance, and screening of the locum tenens, taking the liability and burden off practices. The practice or group pays the recruiting agency, and the agency pays the locum tenens physician. If your practice chooses to hire the locum tenens directly, you must:

  • Check your state licensing laws for licensing requirements. Most – if not all – states require physicians be licensed in that state.
  • Check with your professional liability insurance carrier.
  • Make sure the locum tenens is in good standing and get his or her professional liability insurance certificate, verifying it covers the services the locum tenens will be performing for the regular physician.

Whether you use a recruiting agency or hire the locum tenens physician directly, the practice must:

  • Train staff with information about locum tenens physician to retain patients with the regular physician and give them incentive to see locum tenens without fear, for example:
    • The locum tenens is temporary and will only see them once or for a short period of time.
    • The locum tenens’ experience and expertise as a physician.      

The period for which a single locum tenens physician may substitute cannot be more than 60 continuous days. The 60-day period begins the first day the locum tenens physician provides services for Medicare patients of the regular physician. An exception to this 60-day rule is for regular physicians who are called to active duty in the armed forces. The time is unlimited. See Social Security Act at section 1842(b)(6)(D.)

The regular physician:

  • Must schedule appointments under his or her schedule.
  • Is the only physician who can break the locum tenens’ 60-day period.
  • May re-set the 60-day period by returning to practice and see patients only one day after the initial 60-days and use the same locum tenens.
  • Must bill for the services of the locum tenens.
  • Must put his or her NPI number on all claims filed.
  • May use more than one locum tenens to substitute for absences during the 60-day period.
  • May reimburse the locum tenens a fixed amount per diem or similar fee for time.
  • Must keep a record of each service furnished by the locum tenens physician and the NPI.

A locum tenens physician:

  • Fills in for the regular physician for 60 continuous calendar days.
  • Can substitute only if the regular physician is absent for any of the reasons above.
  • Cannot substitute more than 60 continuous calendar days, unless there is a break in the 60-day by the regular physician.
  • Cannot re-set the 60-day clock by taking a day off.
  • Generally does not have a practice of his or her own and moves from area to area as needed.
  • Is usually an independent contractor of the regular physician or group rather than an employee.
  • Does not have to be enrolled in the Medicare program to see Medicare patients
  • Cannot be a non-physician practitioner (e.g., NPs, CRNAs, PAs).
  • Cannot bill Medicare for services within the 60-day continuous period in his or her name or NPI.

The regular physician bills and receives payment from Medicare and other payers who follow Medicare’s guidelines for the locum tenens physician’s services as though the regular physician performs the services. The regular physician must put the regular physician NPI in box 24J and his or her name in box 31 of CMS 1500 and the regular physician or group name and NPI in box 33 of the CMS 1500. Other Medicare rules include:

  • Use the name and NPI of the regular physician or group.
  • Use modifier Q6 after the procedure code (Q6 identifies services by locum tenens physician).
  • If the only service a locum tenens physician performs is post-operative for an operation within a global period, it cannot be billed with Q6 modifier because the regular physician is paid a global fee, and it is not necessary to include the service on the claim.
  • If a regular physician requires that the locum tenens physician provides services for longer than 60 continuous days without a break, the locum tenens physician must enroll with the practice.

Other payers have different rules. TRICARE requires that non-contracted locum tenens physicians complete a certificate or other document to be linked to the regular physician or group tax identification number. Some Medicaid programs (e.g., Florida Medicaid) require the locum tenens physician bill under his or her own name and NPI. Blue Cross Blue Shield adheres to the guidelines of Section 125b of the Social Security Act.  (BCBS Manual for Physicians and Providers, May 2010).

Sources:

Medicare Claims Processing manual, Chapter 1, Section 30:2.11, www.cms.hhs.gov/manuals/downloads/clm104

www.cms.hhs.gov/transmittals/dowloads/R1486cp

6 Comments

Stop Waving Compliance Red Flags

By Robert A. Pelaia, Esq., CPC, CPCO

It’s foolish to ignore the signs that set off Office of Inspector (OIG) radar. Look around your work environment. If an OIG investigator walked into your office right now, what would he or she see (or not see) that shows compliance is not taken seriously in your practice?

Here are 10 telltale signs, in no particular order, to show investigators that they should take a second look at your compliance activities:

1. Patient Records are in Plain Sight: This is a big Health Insurance Portability and Accountability Act (HIPAA), red flag. It shows that you have no regards for confidentiality of patient information.

2. You Have No Compliance Contact: Your office should designate someone to be in charge of compliance activities. Whether you have an individual or group of individuals responsible for compliance, it’s important to have a “go-to” person for compliance issues.

3. Coding Books Are Outdated: Coders must keep on top of all the newest coding changes and if coders are using outdated coding books or software, that’s a compliance risk. It’s good to keep old coding books around as a historical reference; however, never code from outdated books.

4. Free Limousine Transportation Offered to Medicaid Patients: Section 1128A(a)(5) of the Social Security Act, enacted as part of HIPAA, imposes significant civil money penalties on providers who offer free gifts or services to Medicare or Medicaid beneficiaries that can influence the beneficiary to order items or services from the provider.

5. Coder “Cheat Sheets” Are Posted: It’s alright for coders to have code lists to help work more efficiently; however, an OIG investigator might have a significant problem if the “cheat sheet” only reflects high level codes. For example, if you are listing new patient evaluation and management (E/M) codes on your “cheat sheet,” make sure you list all five levels of new patient E/M codes, not just ones that pay the most money.

6. Memos Posted Instructing Coders to Change Diagnosis Codes: It’s okay to have a list of “covered” diagnoses, but it is not appropriate for the coder to change the diagnosis to one not supported in the medical record. Posted memos telling coders to use particular codes only when submitted with certain “covered” diagnoses and to change to another code if the “wrong” diagnosis is submitted is a red flag to OIG investigators.

7. Coders Get Bonuses when Revenue Increases: The government will closely scrutinize a bonus structure paid to a coder based on increases in revenue because the arrangement might be an incentive for an unscrupulous coder to “up-code.” Coding is complex enough without muddying the water with bonus structures tied to revenue. The less risky route is to base the incentive on productivity, timeliness, or accuracy, rather than revenue.

8. Dusty Compliance Manual: A compliance manual should not sit on the bookshelf, as it should be a useful and comprehensive reference tool used often and updated periodically.

9. Employee Complaints with No Follow-up: An organization that receives complaints or uncovers evidence of improper billing must demonstrate it responded appropriately to the situation, including taking necessary steps to prevent further similar offenses. If the organization’s management personnel fail to investigate employee complaints promptly, this questions the effectiveness of the program.

10. Not Employing “Certified” Coders: You can tell a lot about a health care employer by the company it keeps—it is true that you get what you pay for. Employers who hire certified coders are employers who maintain higher standards, value integrity, and understand that compliance activities are a requirement.

Disclaimer: Information published in this article is the personal views of the author and is not intended to be, nor should it be considered, legal advice. Readers should consult with an attorney to discuss specific situations in further detail.

April 16th, 2013

No Comments

Follow 7 Rules for Billing Anesthesia Medical Direction

By Marcella Bucknam, CPC, CPC-H, CPC-P, CPC-I, CCC, COBGC, CCS-P, CCS

When anesthesiologists work with other qualified anesthesia providers, such as certified registered nurse anesthetists (CRNA) and anesthesia assistants (AA), they must follow special documentation requirements to be paid for their medical direction of the case.

The medical direction rules apply when an anesthesiologist works with one to four other qualified providers in overlapping cases. If more than four cases overlap, even for a single minute, this is considered to be medical supervision. Most payers will not reimburse the anesthesiologist for this service. The rules also may be different in teaching hospitals, where residents are involved in patient care.

The American Society of Anesthesiologists and Medicare have agreed on seven elements that must be documented for the anesthesiologist to bill his or her medical direction services. Most other payers also require this documentation. The seven elements are:

1. Perform a pre-anesthetic examination and evaluation.

The anesthesiologist must personally perform an exam and evaluation prior to the anesthetic session. Although there are no specific rules about what must be evaluated or examined, it’s not sufficient simply to document that an exam was performed. The specific system(s) or body area(s) examined and the findings also must be documented.

2. Prescribe the anesthesia plan.

The anesthesiologist must personally decide on the appropriate anesthetic for the procedure (e.g., general anesthesia, regional block, monitored anesthesia care [MAC], etc.), and must document that decision.

3. Personally participate in the most demanding procedures in the anesthesia plan, including (if applicable) induction and emergence. 

The anesthesiologist must be in the room and must participate in induction and emergence when those are elements of the service provided. If there are other demanding aspects of the service, depending on the type of anesthesia, the anesthesiologist must be in the room during those services and must document his or her presence and participation.

This requirement can be challenging for a busy anesthesiologist with several cases kicking off at the same time; however, if the anesthesiologist cannot be in the room for one of these “most demanding” elements of the case, he or she cannot bill for medical direction (or the entire case).

4. Ensure a qualified individual performs any procedures in the anesthesia plan that the anesthesiologist does not personally perform.

There are no specific special documentation requirements for this element, but the anesthesiologist must be aware that everyone who participates in the anesthesia care is qualified to perform the service. Everyone who participates in the service must sign in to the case, appending his or her license or certification (e.g., MD, CRNA, AA).

5. Monitor the course of anesthesia administration at frequent intervals.

Although it is not necessary for the anesthesiologist to be in the room for the entire case, he or she must provide appropriate monitoring throughout the case. Monitoring means actual presence in the room where anesthesia is being administered.

6. Remain physically present for all key and critical portions of the procedure, and be available for immediate diagnosis and treatment of emergencies. 

The sixth rule is the one that seems to trip up anesthesiologists most often. Because the anesthesiologist is providing direction for several cases, and may have new cases starting while other patients are being transported to the post-anesthesia care unit, and still have other ongoing cases, it’s easy for him or her to break medical direction by providing personal anesthesia services to one patient while directing patients in other rooms.

To meet the medical direction requirements, the anesthesiologist cannot be personally providing anesthesia care or handling other services that take more than a few minutes, or that take him or her out of the immediate area where the anesthesia services are being provided.

There are a limited number of services that can be performed without breaking the medical direction rule to remain present and available during the case, including:

  • Addressing an emergency of short duration in the immediate area
  • Administering an epidural or caudal anesthetic to ease labor pain
  • Periodically (rather than continuously) monitoring an obstetrical patient
  • Receiving patients entering the operating suite for surgery
  • Checking on or discharging patients in the recovery room
  • Handling scheduling matters

If the physician leaves the immediate area of the operating suite for other than short durations, devotes extensive time to an emergency case, or is not otherwise available to respond to the immediate needs of the surgical patients, the physician’s services to the surgical patients are supervisory in nature and are not billable as medical direction.

7. Provide post-anesthesia care as indicated.

Anesthesia time continues to run, and the anesthesiologist remains responsible for the patient, until the care of the patient is transferred to another caregiver. The anesthesiologist should document any services performed during post-anesthesia time, especially if the patient requires more care due to adverse reactions. Even if the patient is doing fine, the anesthesiologist is expected to document, at a minimum, that the patient is safe to transfer to someone else.

The anesthesiologist must personally document the above seven components. It’s not adequate if someone else documents that he or she did the work, or was present. This information must be documented whenever the anesthesiologist is performing medical direction, no matter what type of anesthesia or analgesia is provided, including MAC.

Some payers may require documentation of these elements for all anesthesia services, even when the anesthesiologist is personally providing the anesthesia service without medical direction.

Other than the anesthesiologist not being allowed to document the required information before the service is performed, there are no specific rules about how monitoring must be documented. For paper records, an anesthesiologist might initial the chart tracking the patient’s vital signs, administration of drugs, and other information each time he or she comes into the room and checks on the patient. In electronic records, the anesthesiologist may add a statement that he or she was present for monitoring each time he or she is in the room checking on the patient, or may document at the end of the record that he or she monitored the patient throughout the course of the case. Either solution is acceptable.

Marcella Bucknam, CPC, CPC-H, CPC-P, CPC-I, CCC, COBGC, CCS-P, CCS, is internal audit manager at Chan Healthcare. She is the long-time consulting editor for General Surgery Coding Alert, and has presented at five AAPC National Conferences.

April 1st, 2013

No Comments

Obvious RAC Error? Move Fast and Rebut

If you receive a letter from a Medicare recovery audit contractor (RAC) regarding overpayment, don’t panic! You may think you only have two options: pay up or launch an appeal. There is another option, however, if you move fast (before a formal appeals process starts) and are certain the RAC is mistaken about the overpayments.

According to David M. Vaughn, JD, CPC, of Vaughn & Associates, LLC, “42 CFR 405.374 allows the provider at least 15 days for an informal rebuttal before the formal appeal process starts. The typical RAC letter will state that you have 15 days to informally respond prior to the time the RAC submits its results to the Medicare administrative contractor (MAC), who then issues the formal demand letter. So the first step in the process is to quickly figure out why the RAC is incorrect, and advise it within 15 days; and if you are correct, the RAC will correct the audit mistakes and reissue a revised letter to you and the MAC.”

Section 405.374 “Opportunity for rebuttal,” states:

(a) General rule. If prior notice of the suspension of payment, offset, or recoupment is given under § 405.372 or § 405.373, the Medicare contractor must give the provider or supplier an opportunity, before the suspension, offset, or recoupment takes effect, to submit any statement (to include any pertinent information) as to why it should not be put into effect on the date specified in the notice. Except as provided in paragraph (b) of this section, the provider or supplier has at least 15 days following the date of notification to submit the statement.
(b) Exception. The Medicare contractor may for cause:
(1) Impose a shorter period for rebuttal; or
(2) Extend the time within which the statement must be submitted.

Vaughn, who has defended several RAC audits, said, “All the ones I’ve defended did have the 15 day limit in their letter. I have used it successfully once, where the RAC made a mistake denying over $100,000 in services as ‘services not rendered’ when the real issue was that the incident-to rules weren’t followed, but the services should have been allowed in the name of the NP. They reversed that component of the audit before submitting the demand letter to the MAC. In that case, I actually called them and got an extension of the 15 days, and they granted it. I then submitted our position in writing, and they agreed.”

“RACs are fairly inaccurate—unlike the ZPICs [zone program integrity contractors], which are much more accurate in my experience—so I think the rebuttal process can be a good tool with the RACs, not ZPICs,” according to Vaughn.

Michael D. Miscoe, Esq., CPC, CASCC, CUC, CCPC, CPCO, CHCC, founding partner of Miscoe Health Law, LLC, said that in his experience, mostly with ZPICs, “I would generally use rebuttal ONLY when the client intended to pay, but there was concern about blind acceptance of the audit result leading to allegations of knowledge of the error down the road.” Miscoe’s bottom line is:

  • “Providers should weigh (with the advice of counsel) the expense vs. the benefits of attempting a rebuttal rather than a formal appeal. Engaging in this process is more likely to be successful in response to a RAC audit with obvious errors.
  • In cases where the provider chooses not to appeal when faced with a minimal refund demand (as in a probe audit), the rebuttal process is a mechanism for putting your objections to the audit findings on record. That way, mere payment cannot be construed later as agreement (and knowledge as in False Claims Act (FCA) context) with the audit result.”

March 26th, 2013

3 Comments

« Older Entries