San Francisco Medical Society Blog

Medicare MAC Contract Protest Update

Mon, 29 Apr 2013 10:23:10 GMT

The U.S. Court of Federal Claims has denied two protests that were filed challenging a decision by the Centers for Medicare and Medicaid Services (CMS) to award the Medicare Administrative Contractor (MAC) contract for Medicare Parts A and B in Jurisdiction E to Noridian Administrative Services.

CMS and Noridian will now move forward to implement the new contract and expects this process to complete by mid-September 2013. SFMS/CMA has and will continue to work closely with CMS and the new contractor to ensure a smooth transition.

Jurisdiction E (previously called Jurisdiction 1) covers California, Nevada and Hawaii, as well as the U.S. territories of American Samoa, Guam and the Northern Mariana Islands. Jurisdiction E includes over 3.5 million Medicare fee-for-service beneficiaries, 500 Medicare hospitals and 86,500 physicians. MACs process Part A and Part B claims and perform other critical Medicare operational functions, including enrolling, educating and auditing Medicare providers.

CMS Confirms Sequestration Payment Cuts for EHR Incentive Program

Thu, 18 Apr 2013 16:21:55 GMT

The Centers for Medicare & Medicaid Services (CMS) has confirmed that the Medicare electronic health record (EHR) incentive program payments will be cut by 2% as required by the Sequestration Transparency Act.

The 2% "sequestration" cuts to Medicare are part of the $1.2 trillion in cuts required by the Sequestration Transparency Act, part of a deal worked out to end last year's debt-ceiling crisis.

According to CMS, the 2% reduction will be applied to Medicare EHR incentive payments for reporting periods that end on or after April 1, 2013. If the final day of the reporting period occurs before April 1, 2013, those incentive payments will not be subject to the reduction.

Medicaid (Medi-Cal in California) is exempt from the sequestration cuts.

Click here for more details on the sequestration cut as previously reported by SFMS.

Click here for our Sequestration FAQ.

FAQs: Affordable Care Act Primary Care Rate Increase & Medi-Cal State Plan Amendment

Fri, 12 Apr 2013 12:41:22 GMT

Under the provisions of the federal Affordable Care Act (ACA), Medi-Cal is required to pay primary care physicians at Medicare rates for primary care services for two years. The increase is fully funded by the federal government. The requirement began January 1, 2013 and ends December 31, 2014.

The California Department of Health Care Services (DHCS) submitted their state plan amendment (SPA) to implement the rate increase on March 29, 2013. Approval of the SPA is required by the Centers for Medicare and Medicaid Services (CMS) before the state can implement the rate adjustment. It is unclear when the rate adjustment will be approved by CMS and implemented by DHCS. In previous communications, DHCS has indicated that they expect implementation will begin in July 2013. However, the rate adjustment will be retroactive to the beginning of the year.

Below are answers to frequently asked questions about implementation of the rate adjustment as outlined in the SPA. Please note these provisions are subject to change pending approval by the CMS.

Why is the SPA just being filed now?

Federal guidance on the implementation of the rate increase was delayed until November 2012. The DHCS claims that the federal delay and the complications involved with applying the rate increase to managed care delayed the submission of the SPA.

Who qualifies as a “primary care physician”?

Any physician who is board-certified in internal medicine, family medicine, or pediatrics by the American Board of Physician Specialties, the American Board of Medical Specialties, or the American Osteopathic Association. This includes recognized physician subspecialties of the above board certified specialties.

Or, any physician who practices (but is not board certified) in a specialty or sub-specialty of internal medicine, family medicine, or pediatrics who also bills at least 60% of services rendered for qualifying codes. DHCS has indicated that billing 60% of services for qualifying codes alone does not qualify a physician unless they also can legitimately attest to practicing in internal medicine, family medicine or pediatric medicine or a subspecialty of internal medicine family medicine or pediatric medicine recognized by the ABMS, ABPS or AOA.

Click here to view the list of qualifying primary care providers (PCP).

How will physicians prove that they qualify?

Generally, physicians will self-attest that they qualify for the increased rates. DHCS is developing an online registry that physicians will use to register. However, managed care plans are allowed to choose to either use the DHCS attestation tool or develop their own.

What counts as a primary care service?

The rate increase applies to:

Evaluation and management codes 99201-99499
Vaccine administration codes 90460, 90461, and 90471-90474
Preventive care codes 99381-99387 and 99391-99397
Counseling risk/behavior intervention codes 99401, 99404, 99408-409, 99411, 99412, 99420 and 99429

The rate increase also applies to state-specific “Z” codes—Z0100, Z0102, Z0104, Z0106 and Z0108. These codes are relevant to some state-only programs, such as Family PACT, as well as many services provided in neonatal and prenatal intensive care units (NICU and PICU).

What Medicare rates will Medi-Cal use? Will they apply the GPCIs?

Per the SPA, rates will be based on the 2009 Medicare Fee Schedule. Geographic Payment Center Indices (GPCIs) will apply. SFMS/CMA urged the DHCS to adopt this approach based on our analysis that this approach would benefit California physicians.

Are clinics or physician employers eligible for the Medi-Cal reimbursement adjustment?

No, only the physician who is personally providing the service is eligible for the increase.

Does the increase apply to managed care?

Yes. Plans will be receiving increased payments, through the State of California, to pay providers at Medicare rates. The increase is fully funded by the federal government for 2 years beginning January 1, 2013 and ending December 31, 2014.

How will the state guarantee that the money actually makes it to the physician?

Plans will be contractually obligated to prove that they are paying primary care physicians at least the Medicare rates. The payments made to plans to cover the increased cost of higher rates will be separate from their general capitation payments, allowing for separate accounting. The SPA included plan reporting requirements to ensure the rate adjustment funding is going to the service providing physician.

Questions & Assistance

SFMS/CMA members with questions about Medi-Cal reimbursements can receive complimentary one-on-one assistance by contacting our Member Helpline at (800) 786-4262.

SFMS/CMA-Sponsored SB 640 Bill to Stop Implementation of Medi-Cal Cuts Introduced Today

Thu, 04 Apr 2013 15:13:07 GMT

Senator Ricardo Lara (D – Long Beach) introduced Senate Bill 640 today, which will stop the implementation of a 10% rate cut to Medi-Cal. The cut was part of the health services trailer bill (AB 97) to the 2011-12 state budget. SB 640 is co-sponsored by the SFMS and CMA.

“California has one of the lowest reimbursement rates for Medicaid in the nation,” said CMA President Paul Phinney, MD. “At a time when millions of new patients will be entering the program under health reform, the state should not be looking to rate cuts as a budget solution.”

SB 640 would block the 10% Medi-Cal provider rate cut and would stop the state from ‘clawing back’ rate cuts from providers dating back to 2011.

SFMS and CMA applaud Senator Lara for his commitment to ensure accessible health care for all. Cutting resources while adding patients to the Medi-Cal managed care system will make it hard for patients to find doctors and will delay much needed federal health reform in California. The cuts in trailer bill AB 97 were proposed when California was facing an enormous budget deficit. Those times have changed and there is no need to punish California’s poor and vulnerable patients any longer.

"This measure protects our most vulnerable communities from the devastating impacts of the cuts to Medi-Cal," stated Senator Lara. "I am proud to partner with CMA and the broad coalition of advocates to ensure that all of our communities have access to health care."

Following approval of the AB 97, CMA along with the California Dental Association, California Pharmacists Association, National Association of Chain Drug Stores, California Association of Medical Suppliers, Aids Healthcare Foundation and American Medical Response, filed suit against both the California Department of Health Care Services and the U.S. Department of Health and Human Services seeking to stop implementation of the cuts. That case is currently being considered by the 9^th Circuit Court of Appeals.

Click here for more information about the CMA lawsuit to stop the Medi-Cal cuts.

Medicare Claim Hold

Mon, 01 Apr 2013 18:03:21 GMT

The Centers for Medicare & Medicaid Services (CMS) has identified technical issues with certain parts of the April 2013 quarterly systems release. The problem impacts claims received by the Medicare contractors (Palmetto GBA for California) on or after April 1, 2013.

The issues affect:

1. All claims for assistant-at-surgery services

2. All Ambulatory Surgical Center claims

As a result of the system issues, CMS has instructed Medicare contractors to hold these types of claims until April 14, 2013, when system fixes are expected to be implemented.

Physicians should see minimal impact on the timeliness of these claims and their cash flow, as current law requires electronic claims to be held 14 calendar days, and paper claims for 29 days after the date of receipt.

Click here to view the official CMS notice.

Medicare Ordering/Referring Claims Denials to Take Effect May 1

Wed, 27 Mar 2013 15:33:01 GMT

Medicare will begin denying claims on May 1, 2013, if the ordering/referring provider listed on the claim is not in the Provider Enrollment, Chain and Ownership System (PECOS), the database Medicare uses to track physicians and other providers.

If you bill Medicare, you are encouraged to note any Medicare EOBs with the remittance code N264 and/or N265, which may indicate that the ordering/referring provider on the claim is not yet in PECOS. These providers must take action to enroll in PECOS or future claims that you submit with these providers listed for dates of service on or after May 1 will be rejected.

Physicians and other providers are not required to enroll with Medicare to provide services in order to be listed in PECOS. Physicians who wish to be listed in PECOS solely for ordering/referring purposes may submit an enrollment application online via the PECOS website or by completing a CMS-855o paper enrollment application.

Click here to access the PECOS system to determine if you or another physician is currently enrolled in PECOS.

Click here to download a paper CMS-855o application.

Click here for the MLN Matters article for details about the update on PECOS and ordering/referring.

Blue Shield Requires Physicians to Notify Patients Before Referring Out-of-Network

Wed, 27 Mar 2013 15:09:41 GMT

On March 15, Blue Shield announced that it would soon begin requiring contracted physicians to notify patients in writing before making out-of-network referrals. Effective May 15, physicians will be required to notify patients in writing using a form provided by the payor when referring a patient to an out-of-network provider. The policy does not apply to emergencies.

This change comes on the heels of a similar change recently implemented by Anthem Blue Cross.

While existing language in Blue Shield provider contracts had placed limitations on referrals to out of network providers for patients with HMOs, EPOs, and/or Medicare Advantage plans, those limitations did not apply to patients with PPOs. That will change effective May 15.

According to Blue Shield, the completed form must be filed in the patient’s medical record and be made available to Blue Shield within five business days if requested. The notice does not provide details on how Blue Shield intends to enforce this provision. The California Medical Association (CMA) has asked for clarification on this issue and will publish an update when available.

California law states that if a physician objects to a material contract change, such as this, he or she has the right to terminate the contract prior to implementation of the change. According to the Blue Shield contract, physicians who object to a material change may terminate the agreement with 60 days written notice. If a termination notice is submitted within 60 days of receipt of the notice, the proposed changes will not apply during the 60-day termination period.

Physicians with concerns are encouraged to contact the Blue Shield Provider Liaison Unit at (800) 258-3091.

Questions about managed care contracts and payor issues? SFMS members receive one-on-one assistance from the Center for Economic Services via CMA’s reimbursement helpline, (888) 401-5911 or economicservices@cmanet.org.

Update on Medicare MAC Contract Protest

Fri, 15 Mar 2013 11:47:36 GMT

The Centers for Medicare & Medicaid Services (CMS) announced in September 2012 that Noridian has been named the new Medicare Administrative Contractor (MAC) for Medicare Parts A and B in Jurisdiction E (previously called Jurisdiction 1). Two protests were filed challenging the award.

On January 18, 2013, the Government Accountability Office denied the two protests. As permitted by law, both protestors (Palmetto GBA and CGS) subsequently filed complaints with the U.S. Court of Federal Claims challenging the Jurisdiction E MAC contract award. The protests were filed on February 1, 2013. The Department of Justice is representing CMS before the court.

For at least the next several months, Medicare providers in Jurisdiction E (California, Hawaii, Nevada and the Pacific territories) will continue to file their Medicare claims with the incumbent Palmetto GBA.

CMS will notify affected Medicare providers about the situation, including any implementation dates, following the Court of Federal Claims review.

Jurisdiction E includes over 3.5 million Medicare fee-for-service beneficiaries, 500 Medicare hospitals and 86,500 physicians. MACs process Part A and Part B claims and perform other critical Medicare operational functions, including enrolling, educating and auditing Medicare providers.

Feds Allows States to Cut Medicaid Pay, Files Brief in CMA Court Battle

Fri, 08 Mar 2013 12:59:51 GMT

The U.S. Department of Justice filed a brief last Friday before the Ninth Circuit Court of Appeals arguing states can cut Medicaid (Medi-Cal in California) providers’ reimbursement as long as it does not harm access to care.

Earlier this year, SFMS/CMA have requested an en banc review from the Ninth Circuit as part of an effort to stop the State of California from implementing a 10% cut to Medi-Cal provider reimbursement rates.

In December 2012, a three judge panel of the Ninth Circuit ruled that the state could move forward with the rate cuts, passed by the Legislature in the spring of 2011, despite an earlier district court ruling that found that the cuts would irreparably harm the millions of patients who rely on Medi-Cal for health care. CMA and the other plaintiffs in the case are requesting a rehearing from the full Ninth Circuit Court of Appeals.

The justice department's brief urged the court to uphold the cuts and insisted that the Centers for Medicare and Medicaid Services (CMS) is not required to disapprove the plan amendments because they were motivated by “budgetary reasons.”

"It is entirely appropriate for a state to review its Medicaid plan to determine whether it can continue to satisfy its statutory obligations at lower payment rates," the justice department wrote in the brief.

CMA and the other plaintiffs in the case—California Dental Association, California Pharmacists Association , National Association of Chain Drug Stores, California Association of Medical Product Suppliers, AIDS Healthcare Foundation and American Medical Response—argue that reducing payments in the Medi-Cal system will force providers out of the program at a time when millions of new patients will be diverted into the Medi-Cal system.

If the state moves forward with these cuts, access to care will be devastated, not only for the existing Medi-Cal patients, but also the 900,000 kids moving from the Healthy Families program into Medi-Cal in 2013 and the millions of patients that will be newly eligible for Medi-Cal under the Affordable Care Act in 2014.

Sequestration Means 2% Medicare Cut to Health Care Providers Effective 4/1

Wed, 06 Mar 2013 10:50:25 GMT

Across-the-board federal budget cuts were triggered on March 1 because Congress failed to come to an agreement on how to reduce the federal deficit. Although it is still possible that Congress will reach some sort of a compromise before most of the cuts take effect on April 1, physicians should prepare for a 2% reduction in reimbursement from the Medicare program beginning in April.

The 2% Medicare "sequestration" cuts are part of the $1.2 trillion in cuts required by the Sequestration Transparency Act, part of a deal worked out to end last year's debt-ceiling crisis. The cuts are evenly split between defense spending and discretionary domestic spending. The mandatory Medicare cuts will result in a savings of $11 billion in 2013. Medicaid is exempt from the cuts.

The Medicare cut will impact physicians, hospitals, other health care providers, health plans, and prescription drug plans but will not directly impact beneficiaries.

Although the 2% cut is lower than the reductions in other federal agencies, physicians said it will still have a significant impact. Dr. Jeremy Lazarus, president of the American Medical Association, said that the cut comes at an especially bad time because physician payment rates have risen only about 4% over the last decade or so while the cost of caring for patients has climbed by more than 20%.

"A 2% cut erases half of what’s been gained over the past 12 years and continues to widen that gap between what Medicare pays and what it actually costs to care for patients," Dr. Lazarus said. "This is on top of the yearly concerns about even larger cuts that we’ve been going through over the last decade."

The cuts, and the back-and-forth in Washington over sequestration, add to physicians’ general concerns about the instability of Medicare payments, Dr. Lazarus said. That could lead some physicians to stop accepting Medicare patients.

"It’s a very difficult time to plan your practice and plan hiring new employees because you don’t understand what you’re going to be getting paid and what you can afford," said Dr. David L. Bronson, president of the American College of Physicians.

Click here to view the Sequestration FAQ and the impact on California physicians.

Source: Internal Medicine News, Mach 4, 2013.

Palmetto GBA Loses Protest for Medicare Contract

Tue, 22 Jan 2013 14:49:05 GMT

On January 18, 2013, the Government Accountability Office (GAO) announced that they denied Palmetto’s protest, awarding the Medicare contract for Jurisdiction E (previously referred to as J1) to Noridian Administrative Services. Noridian and Palmetto are awaiting further direction from CMS on the transition plan, including a transition date.

SFMS/CMA will work closely with them to help ensure a smooth transition. Until further direction is received, members should continue with business as usual.

Palmetto Posts New 2013 Medicare Fee Schedule

Wed, 16 Jan 2013 14:03:27 GMT

California’s Medicare contractor, Palmetto GBA, has now posted the new fee schedule on its website and has begun processing 2013 claims. The rates reflect a one-year Medicare fee-for-service physician payment freeze, approved by HR 8 (American Taxpayer Relief Act) recently passed by Congress. Although the Centers for Medicare and Medicaid Services gave contractors instructions to hold claims for up to 10 days to allow time to implement the new fee schedule, there shouldn't be any noticeable impact for California physicians.

Physicians should be aware that the 2013 fee schedule may not be exactly the same as the 2012 fee schedule. Although Congress stopped the 26.5 percent SGR cut, there were other components of the fee schedule formula that affect payment that may have changed, such as the relative value units (RVUs).

Click here to view the new fee schedule.

Anthem Blue Cross Delays Payment Policies Changes and Claims Editing Software Transition

Thu, 10 Jan 2013 16:05:24 GMT

As previously reported, Anthem Blue Cross notified physicians in August of upcoming changes to the insurer’s reimbursement policies and claims editing software, ClaimsXten. While the notice advised physicians that most changes would go into effect on December 8, 2012, Blue Cross announced in November that implementation of these changes has been delayed until early 2013.

Along with the August notice, Anthem provided a comprehensive grid outlining all new, revised and existing reimbursement policies and claims editing rules as well as copies of Anthem’s reimbursement policies.

Updates include: assistant surgeon and co-surgeon codes eligible for payment, frequency edits on certain codes, multiple surgery reductions for certain endoscopic procedures performed on the same day, application of multiple procedure reduction for the technical component of certain diagnostic imaging procedures performed on same day, restrictions on payment for prolonged services codes 99354 and 99355 and denial of certain screening services (e.g.,Q0091, G0101, G0102) when billed with preventive or problem focused evaluation and management codes.

Once these changes are implemented, physicians may notice a difference in how certain codes and code pairs are adjudicated. Physicians are encouraged to review the claims editing changes as well as the corresponding detailed payment policies to understand how the changes will affect their individual practices.

Physicians can also access the information in the mailer via the Blue Cross website, www.anthem.com/ca. (Log into the provider portal and select “Reimbursement Policies and McKesson ClaimsXten Rules” under the “What’s New” section.)

Questions about any of the claims editing rules or payment policies can be directed to Blue Cross Provider Care Department at (800) 677-6669.

SFMS members requiring assistance with billing and reimbursement issues can contact our member-only help line at (888) 401-5911 or economicservices@cmanet.org.

SGR Advocacy Alert

Wed, 19 Dec 2012 14:47:46 GMT

The negotiations between Speaker Boehner and President Obama on the Lame Duck tax and deficit reduction package are at an impasse. There is a very real threat of the 26.5 percent Medicare physician payment cut taking effect on January 1, 2013, at least temporarily.

If Congress does adjourn without addressing the payment cut being induced by the sustainable growth rate (SGR) formula, the Administration announced today that the Centers for Medicare and Medicaid Services will follow normal claims processing procedures. That is, claims will not be held and Medicare carriers will process payments for physician services provided after December 31 under the normal 14-day cycle required by law. Payment for these claims would be based on the new, lower fee schedule conversion factor of $25.0008, as opposed to the current rate of $34.0376.

At this time, it is impossible to predict whether the 112th Congress will find a way to pass a stop-gap measure before adjourning, how long such a measure would last, or how long payment cuts will be in effect before legislation can be passed after the 113th Congress convenes in January. It is highly unusual for a new Congress to enact significant legislation in the first month of its session, but the circumstances facing our nation today are far from typical.

It is inexcusable that Congress is once again putting the 47 million Medicare patients and the practices of physicians who provide them needed health care at significant risk. The Medicare program has become unreliable and its instability undermines efforts by physicians to implement new health care delivery models that stand to improve value for seniors and other beneficiaries through better care coordination, chronic disease management, and keeping patients healthy.

We believe that the financial disruption this situation will cause for physicians and their practices is unacceptable, and we will continue to fervently convey this message in the strongest possible terms to Congress and the Administration, as we have for the past several weeks. We are working with CMA and AMA physician grassroots networks, and are seeking your voices to tell Congress just how deeply its inaction will affect you.

Despite these efforts, at this time we feel compelled to advise physicians to start making plans for steps they can take to mitigate this disruption and meet their own financial obligations in January, in case the 26.5 percent cut actually takes effect. Given the potential impact on practice revenue in early January, physicians should be certain adequate arrangements are in place to sustain their practices. For those physicians who are forced into the untenable position of limiting their involvement with the Medicare program because it threatens the viability of their practices, we urge that patients be notified promptly so that they, too, can explore other options to seek health care and medical treatment.

We will remain engaged throughout the holidays and keep you informed of any new developments.

From CMS Region 9 (San Francisco Regional Office): Information Regarding the 2013 Medicare Physician Fee Schedule

Wed, 19 Dec 2012 14:20:03 GMT

The negative update of 27% under current law for the 2013 Medicare Physician Fee Schedule is scheduled to take effect on January 1, 2013.

Medicare Physician Fee Schedule claims for services rendered on or before December 31, 2012, are unaffected by the 2013 payment cut and will be processed and paid under normal procedures and time frames.

The Administration is disappointed that Congress has failed to pass a solution to eliminate the sustainable growth rate (SGR) formula-driven cuts, and has put payments for health care for Medicare beneficiaries at risk. We continue to urge Congress to take action to ensure these cuts do not take effect. Given the current progress with the legislation, CMS must take steps to implement the negative update.

Under current law, clean electronic claims are not paid sooner than 14 calendar days (29 days for paper claims) after the date of receipt. CMS will notify you on or before January 11, 2013, with more information about the status of Congressional action to avert the negative update and next steps.

Obama’s New Fiscal Cliff Offer Proposes Repeal of SGR

Tue, 18 Dec 2012 15:34:31 GMT

In the White House’s latest “fiscal cliff” offer to House Speaker John Boehner, President Obama proposed a permanent repeal of Medicare’s sustainable growth rate (SGR) alongside $400 billion health care savings, according to a source familiar with the talks.

A permanent fix would come with a $245 billion price tag and it’s still unclear how—or if—Congress would pay for a policy meant to stabilize doctor salaries.

SGR is the formula that determines how much Medicare providers get paid, by tethering their salaries to overall growth in the economy. This formula has, for a decade now, always fallen short of keeping doctor salaries stable. This year, if we stuck to what the sustainable growth rate says doctors should be paid, physicians would end up taking a 26.5% pay cut.

That has meant that, year after year, Congress has had to pass a “doc-fix:” A short term funding patch to make up the difference between what the formula says doctors should get paid, and what it would take to keep their salaries stable. It’s become somewhat of a tradition, where Congress scrapes together small cuts from other programs to pay for the fix.

If the White House does indeed succeed in eliminating the sustainable growth rate, it would presumably need to find $245 billion to pay for the provision. It would also need to settle on a new formula to calculate what Medicare ought to pay doctors for each surgery they perform and medication they prescribe.

MedPac, a non-partisan body that advises Congress on Medicare policy, has its own preferred option. It has recommended that if Congress repeals the sustainable growth rate, it should continue to hold primary care doctor payments steady. At the same time, specialty doctors would see a haircut in their services for three years, and then see their rates freeze as well.

Source: Washington Post, Wonkblog, December 18, 2012

ICD-10: Everything You Know Is About To Change

Mon, 12 Nov 2012 15:23:56 GMT

The transition to ICD-10 is one of the most daunting regulatory requirements ever imposed on physicians. Not only will the number of diagnosis codes dramatically increase from 16,000 ICD-9 codes to 68,000 ICD-10 codes, new formatting and documentation requirements will impact numerous medical office processes and personnel. While the compliance date for ICD-10 implementation of October 1, 2014 may seem far away, physicians are encouraged to start planning for ICD-10 and 5010 transition immediately.

About ICD-10

ICD-10-CM/PCS (International Classification of Diseases, 10^th Edition, Clinical Modification/Procedure Coding System) consists of two parts:

ICD-10-CM is for use in all U.S. health care settings. Diagnosis coding under ICD-10-CM uses 3 to 7 digits instead of the 3 to 5 digits used with ICD-9-CM, but the format of the code sets is similar.

ICD-10-PCS is only for use in all U.S. inpatient hospital settings. ICD-10-PCS uses 7 alphanumeric digits instead of the 3 or 4 numeric digits used under ICD-9-CM procedure coding. Coding under ICD-10-PCS is much more specific and substantially different from ICD-9-CM procedure coding.

Who Needs to Transition

ICD-10 will affect diagnosis and inpatient procedure coding for all health providers covered by HIPAA. Everyone covered by HIPAA who transmits electronic claims must also switch to version 5010 transaction standards. The change to ICD-10 does not affect CPT coding for outpatient procedures.

ICD-10 diagnosis codes must be used for all health care services provided in the U.S. on or after October 1, 2013. Claims with ICD-9 codes for services provided on or after October 1, 2014 cannot be paid.

Training

SFMS/CMA have partnered with AAPC, the nation’s largest medical training and credentialing association, to offer ICD-10 training to our members. Join us on December 5, from 12:15 pm to 1:45pm, for a free webinar about ICD-10 and how it will impact your practice. Topics covered include:

Key differences between ICD-9 and ICD-10
Scope of ICD-10 transition in a typical medical practice
Key steps in planning a successful transition
Resources to assist you

Click here to view the list of ICD-10 webinars/workshops available to members.

Additional Resources

General ICD-10 Information

CMS-0013-P—HIPAA Administrative Simplification: Modification to Medical Data Code Set Standards to Adopt ICD-10-CM and ICD-10-PMS

Transactions and Code Sets Regulations

ICD-10 Basics for Medical Practices

Talking To Your Vendors about ICD-10 and Version 5010 - Tips for Medical Practices

ICD-10 Transition FAQs

2013 Medicare Physician Fee Schedule Contains Good and Bad News

Wed, 07 Nov 2012 14:00:46 GMT

As SFMS reported last week, CMS released the final 2013 physician payment rule, which sets payment rates and related policies for next year.

Highlights from the 1,362-page ruling

Increase in payments for primary care—7% for family physicians and 3-5% for other primary care providers.
New “transitional care” CPT codes to reimburse physicians for coordinating patient care within 30 days following a discharge for a hospital or skilled nursing facility. Phone calls and other related care management activities can be billed for payment.
2-6% cut in Medicare fees for a number of specialties, including cardiology, nuclear medicine, ophthalmology, pathology, physical medicine, and vascular surgery.
Rules for value-based payment modifier to take effect in 2013 (using 2013 data) with groups of 100 or more physicians. The value modifier will reward physicians who successfully report on quality measures and spend less than the national average per Medicare patient, and penalize physicians with lower quality and higher costs.
Plans to streamline physician reporting programs (e.g., EHR meaningful use, Physician Quality Reporting System, eRx programs).

Click here to view the full ruling.

Looming Cuts

Physicians are still facing across the board Medicare payment cuts of nearly 30 percent, if Congress fails to act by the end of the year. The sustainable growth rate (SGR) is set to cut physician rates by 26.5 percent and the so-called “fiscal cliff” would drop payments another 2 percent under the sequestration agreement.

The sequestration cut is part of the part of the $1.2 trillion in cuts required by the Sequestration Transparency Act, part of a deal worked out in Congress to end last year’s debt-ceiling crisis. The SGR and sequestration cuts are both set to go into effect on January 1, 2013.

There is unanimous agreement in Congress that cuts of this magnitude would result in serious disruptions in care for the nation’s elderly and disabled populations, and cannot be allowed to occur. SFMS/CMA have been working with Congress to stop the SGR and the sequestration cuts during the lame duck session in December. We are also urging Congress to include a California Medicare locality update in the lame duck Medicare legislation.

Anthem Blue Cross Amends Physician Contracts to Include Individual/Exchange Product; Resources/Assistance Available to SFMS Members

Tue, 06 Nov 2012 13:28:21 GMT

On October 24, Anthem Blue Cross sent a notice to 8,345 physicians who are part of the Blue Cross Select PPO network announcing its intent to participate in the California Health Benefit Exchange, the state’s new insurance marketplace called for under the Affordable Care Act. Beginning in 2014, individuals and small business will be able to purchase health insurance using tax subsidies and credits from the exchange.

According to the notice, Blue Cross will be creating a new provider network called the “Anthem Individual/Exchange Network,” which will serve both individuals who purchase coverage through the exchange and individuals who purchase coverage from Anthem Blue Cross in the individual market outside of the exchange. In other words, the fee schedule would apply to all individual business, whether bought on or off of the exchange.

Blue Cross has clarified for the SFMS/CMA that this fee schedule change will not apply to Small Business Health Options Program (SHOP) business purchased through the exchange.

It’s important to note that Blue Cross is amending the physician’s Blue Cross Prudent Buyer Agreement to automatically include the new individual/exchange network, effective January 1, 2014. The new fee schedule associated with this product was included with the notice.

SFMS/CMA has been actively working with exchange stakeholders to address significant concerns regarding the exchange grace period, monitoring of network adequacy and clinician-level performance measurement in qualified health plans offered in the exchange. Click here for more information about contracting with exchange plans.

Individual/Exchange Network Opt-Out

Physicians can opt out of the individual/exchange network by notifying Blue Cross of their intent to opt out by December 31, 2012. Opt out notices should be in writing and sent via certified mail, return receipt to the address specified in Section VI of the amendment. Sections VI and VIII of the contract amendment provide instructions for physicians who wish to opt out of the individual/exchange network.

Please note that a small subset of Select PPO Network physicians did not receive the October 24 notice automatically opting them into the individual/exchange network. This subset of physicians received a notice from Blue Cross dated October 9 regarding fee schedule reductions. Physicians who choose to discontinue participation in the Select PPO network at the reduced rates have until December 14 to notify Blue Cross in writing.

Physician Status Inquiries

Physicians who did not receive a letter and are unsure whether they are affected by this change or those who have general questions about the amendment can contact Blue Cross’s Network Relations Department at (855) 238-0095 or networkrelations@wellpoint.com.

Assistance with Anthem Blue Cross Contracts

SFMS members can receive one-on-one assistance by contacting CMA staffers Mark Lane (916) 551-2865 or Jodi Black (916) 551-2863.

Health Plan Contract Analyses

As part of your member benefit, SFMS members enjoy free access to objective analyses of several health plan participating provider contracts. While these analyses are not intended to be exhaustive, they are designed to draw a physician's attention to issues which may warrant further inquiry or clarification.

Log into the SFMS website to view/download the Blue Shield Provider Agreement analysis, updated in September 2012. To access the member-only section for the first time, please use your license number as the username and the first name initial and full last name as the password. For example, Dr. John Doe’s password would be “JDoe.”

Click here to view analyses for Anthem Blue Cross of California Prudent Buyer Plan, Health Net, and United Healthcare. Please note SFMS/CMA is currently updating contract analyses for each of the California major health plans. Updated analyses will be posted on the SFMS website when they are available.

Step-by-Step Guide to Payor Contract Negotiation

SFMS/CMA have developed a step-by-step guide to assist physician members through the contract evaluation and negotiation/renegotiation process. Click here to view/download the free membership-only guide after logging into the SFMS website.

Member Helpline with Health Plan Contracting Issues

SFMS members are encouraged to contact our complimentary member reimbursement help line at (888) 401-5911 or economicservices@cmanet.org for personalized assistance with contracting issues.

Medicare Finalizes 2013 Physician Fee Schedule

Fri, 02 Nov 2012 14:39:24 GMT

Family physicians will receive up to a 7% boost in Medicare payments in 2013, and other primary care providers will receive 3% to 5% more, under a final rule announced yesterday by the Centers for Medicare and Medicaid Services (CMS).

Much of the increase in the physician fee schedule reimbursement will come from new added payments for coordinating a patient's care in the 30 days following a hospital or skilled nursing facility stay. Under the rule, providers will for the first time receive a separate payment to help a patient transition back to the community following a discharge.

Another final rule issued yesterday outlines how Medicaid reimbursements will be brought on par with those of Medicare for primary care providers in 2013 and 2014, as outlined in the Affordable Care Act.

The federal government will pay for 100% of the difference between the Medicaid state plan payment as of July 1, 2009 and the applicable Medicare rate, CMS said. The increase will impact family medicine physicians, general internists, pediatricians, and related subspecialists.

Payments go into effect January 1, 2013, and the final rule states how CMS and the states will work together to make the payments operational.

The 2013 fee schedule isn’t entirely set in stone. Physician payments are set to drop by 27% in 2013 under the sustainable growth rate reimbursement formula unless Congress acts to delay the cuts.

Medicare payments also could drop another 2% under the so-called “fiscal cliff” which again could be stalled depending on how lawmakers act following next week’s elections.

Click here to read the 1,362-page Final Medicare Fee Schedule Rule released by CMS. SFMS/CMA/AMA staff are reviewing the document and will provide more information shortly.