Endonomics™ is an e-newsletter from the Socioeconomics & Member Advocacy Office of the American Association of Clinical Endocrinologists (AACE).
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Do you know the purpose of the CERT contractor? The CERT contractor checks to see that providers are billing correctly and contractors are paying correctly. They select and review claims, assign improper payment categories, calculate improper payment rates and provide education to change behaviors.
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What is HPID? It's a Health Plan Identifier and is a standard, unique health plan identifier required by HIPAA. All controlling health plans, except small plans, were required to obtain HPIDs by Nov. 5, 2014.
Click here for more information.
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Endonomics™ is distributed free to both AACE members and non-members. The goal is to provide the latest industry news to those who work in the business side of an endocrinology practice.
Be Part of the Network
To be added to the distribution list, email your name, title, name of practice/business, phone and fax, and preferred email to: Endonomics@aace.com.
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 Visit AACE's
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October/November/December 2015
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Dear Practice Support Subscriber,
Welcome to another edition of
Endonomics™ ,
an
e-newsletter for physicians, practice management specialists, office administrators, coders, billers, collectors and other endocrinology business office staff.
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 Attention Florida Members
Please alert the appropriate coding, billing and management staff.
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Coding and Billing Vitamin D Assay Testing
- NGS (IL, IN, KY, MI, M
- *FCSO
- CGS
- Noridian
- Cahaba
- *WPS
- Novitas
*Vitamin B12 LCDs updated too
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"Incident to" Policy for Calendar Year 2016
In calendar year 2014 PFS final rule, CMS required that as a condition for Medicare Part B payment, all "incident to" services and supplies must be furnished in accordance with applicable state law. The definition of auxiliary personnel was also clarified to require that the individual furnishing "incident to" services must meet any applicable requirements to provide such services, including licensure imposed by the state in which the services are furnished.
In some cases, the physician or practitioner supervising the service is not the same individual treating the patient more broadly. For 2016, CMS is finalizing a proposal to specify that, in those cases, only the supervising physician or practitioner may bill Medicare for "incident to" services. Additionally, CMS is finalizing a proposal to require that auxiliary personnel providing "incident to" services and supplies cannot have been excluded from Medicare, Medicaid, or other federal health care programs by the Office of Inspector General, or have had their enrollment revoked for any reason at the time that they provide such services or supplies.
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CMS has published the
final rule with comment period for the Medicare and Medicaid EHR Incentive Programs, which provides new criteria that eligible professionals, hospitals, and critical access hospitals (CAHs) must meet in order to successfully participate in the EHR Incentive Programs 2015 through 2017 and Stage 3 in 2018 and beyond.
Click here for the EHR Incentive Program and Health IT Certification program final rule.
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Considering Opting Out of Medicare to Meet the Prescriber Enrollment Requirements?
Beginning June 1, 2016, prescribers who write prescriptions for Part D drugs must be enrolled in an approved status or have a valid opt-out affidavit on file with Medicare in order for their prescriptions to be covered under Medicare Part D. Before opting out of Medicare, you should consider the following impacts:
- You will not be able to participate in a Medicare Advantage plan, and
- Your opt-out status lasts for two years and cannot be terminated unless within 90 days of your opt out designation
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Part D Prescribers Must Enroll in Medicare: Submit Your Application by January 1
Two free ways to enroll in Medicare, so you can prescribe Part D drugs:
- Use the PECOSwebsite. Download instructions or watch thevideo tutorial
- Submit a paper application to your Medicare Administrative Contractor (MAC). MACs process Medicare claims, enroll health care providers in the Medicare program, and educate providers on certain Medicare requirements.
For more information:
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Click here
for the January 2016 Quarterly Average Sales Price (ASP) Medicare Part B drug pricing files and revisions to prior quarterly pricing files.
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- Bone Mass Measurements
- DSMT
- MNT
- Diabetes Screening
- Glaucoma Screening
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Click here for the Influenza Vaccine Payment allowances for 2015-2016 season.
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ALERT
Some EMR systems may not allow multiple diagnosis codes to be reported together on a claim due to the Excludes1 ICD-10 guidelines.
For example:
Under Abnormal findings on examination of blood, without diagnosis (R70-R79) there is an Excludes1 note that includes codes for Disorders of lipoprotein metabolism and other lipidemias (E78.-). This means if a medical record supports code R73.01 (impaired fasting glucose) and pure hyperglyceridemia (E78.1) they can not be reported together per the Excludes note. Another endocrine example is under the Metabolic Disorders (E70-E88). The Excludes1 notes indicates code E29.1(testicular hypofunction) can not be reported with codes from E70-E88 on the same encounter.
Under the CDC's homepage, there is interim advice on Excludes1 note on conditions unrelated that is considered a temporary fix until the new ICD-10 guidelines come out October 1, 2016; however this means that the provider will have to override the EMR edit(s). The AHA has been contacted and is expected to provide additional clarification to the CDC's notice shortly.
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Alert for Proivders in IA, KS, MO, NE, IN, MI
ICD10 Denial Errors for Lucentis™
An ICD-10 formatting issue for J2778 Ranibizumab led to incorrect claim denials. The error occurred with the retinal edema code H35.81 being required in addition to all other ICD-10 codes in the policy section for J2778 Ranibizumab. The corrected version requires H35.81 and one other code for central retinal vein occlusion (H34.811, H34.812, H34.813) or branch retinal vein occlusion (H34.831, H34.832, H34.833) for coverage. WPS is in the process of resolving this issue and adjust any claims that have been denied incorrectly. The LCD policy was corrected on their website November 1. No provider action is required.
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ICD-10 Ombudsman and ICD-10 Coordination Center
It's important that you know help's available if you have problems with ICD-10:
CMS offers these videos to help you prepare for the transition. The videos will provide an overview of ICD-10 as well as explain the benefits of the new code set. It will also provide implementation guidance and coding examples.
The following videos are currently available for viewing on our YouTube channel:
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Click here
for information on how UnitedHealthCare aligns with CMS's Medically Unlikely Edits (MUEs) during the first quarter of 2016.
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Click here for information on Osteopenia ICD-10 Codes added to the National Coverage Determination (150.3) for Bone Mass Measurements. (See related MLN Matters® article MM9252)
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Disclaimers used as part of physician's signature Medicare has recently been informed of a new trend in medical record documentation, using some type of disclaimer. Examples include: "Due to possible errors in transcription, there may be errors in documentation;" or "Due to voice recognition software, sound alike and misspelled words may be contained in the documentation;" and "I am not responsible for errors due to transcription."
Providers are responsible for the medical record documentation. Disclaimers such as those above do not remove that responsibility. The provider should verify the information is complete and accurate prior to attaching his/her signature.
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Alert for Members in NC, SC, VA, WV
To facilitate correct coding and claim submission, Palmetto GBA will soon change the EOMB message from patient responsibility to contractual obligation for certain services. This will apply to services where the information submitted does not support the number or frequency of the service for a patient based on the clinical nature of the service or anatomical circumstances. Providers will be able to identify these denials with claim adjustment reason code (CARC) 151, Payment adjusted because the payer deems the information submitted does not support this many/frequency of services. This change will be for claims processed on or after September 1. Provider will begin seeing the change in financial responsibility on claims that finalize on or after this date. Because some claims may have already finalized prior to the change, providers should follow the responsibility indicator as noted for each claim on the remittance advice as. Please alert appropriate staff regarding this change.
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Alert
for Providers in NC, SC, VA,WV
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Are your HIPAA policies up-to-date and being implemented appropriately?
Have you reviewed the latest HIPAA privacy standards to make sure your office is not vulnerable to unauthorized access, use and disclosures of patient's personal health information (PHI)?
This audit
found hospitals and individual providers fall short on standards and implementation of safeguards for compliance with privacy standards and personal health information (PHI). Learn more about Health Information Privacy here.
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New Items on the OIG's 2016 Workplan
- Physicians-referring/orderingMedicare services and supplies
- Prolonged Services- reasonableness of services
- Accountable Care Organizations: Strategies and Promising Practices
- Medicare Payments for unlawfully present beneficiaries in the US
- Medicare Payments for incarcerated beneficiaries
- CMS management of ICD10 Implementation
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The Medicare Learning Network® (MLN) Products Web-Based Training (WBT) courses are designed for self-paced training via the Internet. These WBT courses provide information on a broad range of CMS topics for health care professionals and their staff. Many of these courses offer continuing education credits.
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The Affordable Care Act
requires providers to report and return any overpayments within 60 days after they were identified
or by the date any corresponding cost report was due, if applicable. $7 million settlement agreement with the OIG to resolve False Claims allegations in 20 states. Click here for the full article.
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Refresh Your Memory on Special Fraud Alerts
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Laboratory Payments to Referring Physicians The Office of Inspector General (OIG) has "repeatedly emphasized that providing free or below-market goods or services to a physician who is a source of referrals, or paying such a physician more than fair market value for his or her services, could constitute illegal remuneration under the anti-kickback statute." Violation of the anit-kickback statute constitutes a felony punishable by a maximum fine of $25,000, imprisonment up to 5 years, or both. Conviction will also lead to exclusion from Federal health care programs, including Medicare and Medicaid."
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Click here
to learn all about CLIA -- how it is administered, how providers should enroll and test meth categorization and more.
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Do you have patients that need help obtaining prescriptions?
Check out
Click here
for information on Partnership for Prescription Assistance, Delivering Hope to Millions of Patients in Need.
America's bio-pharmaceutical research companies are on a mission to improve patient health, advance medical innovation, and fuel economic growth. The medicines they create provide hope that a cure can be found, treatment will be effective, and patients' lives can be lived to their fullest. The PPA is one way to help connect qualifying patients with the assistance program that's right for them.
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Join AACE's free Practice Support Network and receive bimonthly editions of
Endonomics™ -- A Practice Management newsletter for the business side of your office. Send your name, address, phone, fax and email address to:
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All medical coding must be supported with documentation and medical necessity. **While this document represents our best efforts to provide accurate information and useful advice, we cannot guarantee that third-party payers will recognize and accept the coding and documentation recommendations. As CPT®, ICD-10-CM and HCPCS codes change annually, you should reference the current CPT®, ICD-10-CM and HCPCS manuals and follow the "Documentation Guidelines for Evaluation and Management Services" for the most detailed and up-to-date information. This information is taken from publicly available sources. The American Association of Clinical Endocrinologists cannot guarantee reimbursement for services as an outcome of the information and/or data used and disclaims any responsibility for denial of reimbursement. This information is intended for informational purposes only and should not be deemed as legal advice, which should be obtained from competent local counsel. Current Procedural Terminology (CPT©) is copyright and trademark of the 2015 American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT©. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
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Copyright © 2015. All Rights Reserved.
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