Dr. Joseph R. Maldonado
July 24, 2015
Volume 15, Number 28
Editor’s note: MSSNY President Dr. Maldonado is on vacation. This week’s Enews introduction is written by Michelle A. Leppert, CPC, a senior managing editor for JustCoding.com. And an editor for HCPro publication, Briefings on Coding Compliance Strategies.
Remember those friends and family cell phone plans where you didn’t use minutes if you called people in your circle? You had to pick who you wanted in your group and they had to pick you. It was very confusing trying to figure out who was in the family and who wasn’t.
CMS created the same kind of confusion last week when it basically cut a deal with the American Medical Association (AMA). The AMA, you may recall, has been very vocally opposed to ICD-10 being implemented in any way, shape, or form. To get AMA to cease and desist its defiance, CMS gave AMA something it wanted: no penalties for some coding errors and advanced payments if the technology goes kerflooey.
I can totally understand advancing payments if the system doesn’t work. That’s pretty straightforward. The physician gets paid on time and doesn’t have to worry about going under because of something he or she can’t control. The physicians will have to repay the advanced payment once the system is running smoothly, so they aren’t getting extra money. They just get a hedge against a Y2K meltdown.
Coding from the Right Family?
The confusing part of the pact is the hold harmless for miscoding. AMA initially wanted physicians to get a pass on coding errors for two years. I’m pretty sure AMA knew that wasn’t going to fly, but when you negotiate, you always start high. In the final deal, CMS stated auditors will not deny a claim “based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.”
CMS does not, however, define a family of codes. Is it a category of codes, such as S00, superficial injury of head? That could be interesting. S00 has nine subcategories of codes, each with their own subcategories. Or does CMS mean those subcategories, say S00.4, superficial injury of ear? Again, S00.4 includes eight subcategories with their own subcategories.
Maybe CMS considers a family to be the smallest group of subcategories. So under S00, we could go all the way down to S00.46-, insect bite (nonvenomous) of ear as a family. That would give us three codes in the family:
- 461, insect bite (nonvenomous) of right ear
- 462, insect bite (nonvenomous) of left ear
- 469, insect bite (nonvenomous) of unspecified ear
That seems reasonable. The only missing information is the laterality. Not a huge deal, but really the physician should be documenting it. Maybe the coder just couldn’t find it or was in a hurry and defaulted to unspecified.
Let’s consider open wounds of the eyelid and periocular area (S01.1). This is a subcategory under open wound of the head (S01). We’ve already narrowed it down to a specific area. The question becomes, is everything under S01.1- a family? I hope not. Here’s why. The first subcategory under S01.1- is S01.10- (unspecified open wound of eyelid and periocular area). S01.10- further specifies laterality:
- 101-, unspecified open wound of right eyelid and periocular area
- 102-, unspecified open wound of left eyelid and periocular area
- 109-, unspecified open wound of unspecified eyelid and periocular area
That last one’s a killer because it tells you nothing. No wound type, no laterality.
Additional subcategories under S01.1- specify the type of wound:
- Laceration with (S01.12-) and without foreign body (S01.111)
- Puncture wound with (S01.14-) and without (S01.131) foreign body
- Open bite (S01.15)
I can see not penalizing someone for failing to reporting the “without foreign body” code instead of requiring coders to query if the physician doesn’t document that no foreign body remained in the wound. The question of with or without foreign body becomes tricky when you start looking at subsequent encounters.
If S01.1- is a family, claims won’t be denied if you report S01.109- instead of S01.132- (puncture wound without foreign body of left eyelid and periocular area). Fractures will be even more confusing, largely because ICD-10 includes so many variations of fracture codes. What about specificity for diseases, such as diabetes? Where do you draw the family line? Is it the type of diabetes? So all codes under E11 (Type 2 diabetes mellitus) are one family?
Or do you go to the first subcategory and say all codes under E11.3- (Type 2 diabetes mellitus with ophthalmic complications) are the same family and therefore we won’t deny the claim if you have any E11.3- code. Maybe CMS goes one step further and really narrows down the family to E11.31- (Type 2 diabetes mellitus with unspecified diabetic retinopathy), which includes two codes:
- 311, Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
- 319, Type 2 diabetes mellitus with unspecified diabetic retinopathy without macularedema
We don’t know. I’m not convinced CMS knows at this point.
Something else we don’t know—how does this deal with AMA affect hospitals? CMS and AMA both only reference Part B physician fee schedule claims. What about Part A claims? Is CMS going to extend the same breaks to hospitals? Again, we don’t know.
CMS may have finally gotten the AMA on board with ICD-10, but it sure created a lot of additional confusion along the way.
Joseph Maldonado, M.D, MSc, MBA, DipEBHC
Please send your comments to email@example.com
Reminder: MSSNY General Counsel Develops Template Forms for Physicians To Comply With Out of Network Law Required Disclosures
As a reminder, MSSNY’s General Counsel Donald Moy, Esq. has developed model template disclosure forms that physicians can use in their practices to comply with the new “surprise medical bill” law which took effect on April 1, available from the MSSNY website (Members Only) here. These new requirements include:
Network and Hospital Affiliations
All physicians must provide to patients or prospective patients in writing or on the physicians’ website prior to the provision of non-emergency services:
- The health care plans with which the provider participates; and
- The hospitals with which the health care professional is affiliated
For the model form physicians can use in their practice, click here.
Model Form #1
In addition, this participation/affiliation information must be provided verbally at the time an appointment is scheduled.
Physicians who do not participate in the network of a patient’s or prospective patient’s health care plan must:
- Prior to the provision of non-emergency services, inform the patient or prospective patient that the amount or estimated amount the patient will be billed for health care services is available upon request;
- Upon receipt of a patient or prospective patient’s request, the amount or the estimated amount (in writing) the patient will be billed for health care services, absent unforeseen medical circumstances that may arise when the health care services are provided
For the model forms physicians can use in their practice, click here, Model Forms #2-A, 2-B and 3
Other Health Care Providers Involved in Providing Patient Care
Allphysicians who refer or coordinate services for patients with another provider must provide to their patients the name, practice name, mailing address, and telephone number of any health care provider scheduled to perform anesthesiology, laboratory, pathology; radiology; or assistant surgeon services, in connection with care to be provided
- in the physician’s office;
- as coordinated by the physician; or
- as referred by the physician.
For the model forms physicians can use in their practice, click here, Model Form, #4
Other Physicians Involved in Hospital Care
At the time of a patient’s pre-admission testing, registration or admission for scheduled hospital admission or outpatient hospital services, all physicians must provide their patients with the name, practice name, mailing address and telephone number of any other physician whose services will be arranged by the physician and are scheduled at the time non-emergency services are scheduled.
For the model forms physicians can use in their practice, click here, Model Form #5.
There are also numerous other provisions incorporated into this new law which took effect this past April 1. For a summary click here.
Residents Salary & Debt Report 2015: Are Residents Happy?
Medscape surveyed more than 1700 residents in 24 specialties to take part in an online survey from May 14, 2015, through June 22, 2015. All participants were enrolled in a US medical resident program. In 2015, the average resident salary—$55,400—was a slight increase over that reported in Medscape’s 2014 Residents Salary & Debt Report ($55,300). The figure averages higher earnings in such specialties as critical care and oncology and lower earnings in other specialties, such as primary care. Some 68% of residents have a considerable amount of medical school debt (exclusive of any other debt): $50,000 or more. Well over one third (37%) of residents have over $200,000 in debt, and over one fifth (22%) have $100,000-$200,000. Another 9% have $50,000-$99,999, and 10% have less than $50,000. A fortunate 22% of residents have no debt.
Nearly two thirds (62%) of the residents we surveyed reported that they considered their compensation fair. This is higher than what was reported by practicing physicians; almost one half (47%) of primary care physicians feel fairly compensated, and 50% of specialists feel fairly compensated. Medscape surveyed more than 1700 residents in 24 specialties to take part in an online survey from May 14, 2015, through June 22, 2015. All participants were enrolled in a US medical resident program.
Missed the Meaningful Use Town Hall Meeting? Watch a Re-Broadcast
This week the AMA hosted a special national “town hall” meeting in Atlanta to highlight physician concerns with electronic health record systems (EHRs). The forum gave physicians an opportunity, both in person and via Twitter, to express concerns with their efforts, often futile, to achieve meaningful use of EHR systems in order to avoid Medicare payment penalties. In many cases, physician speakers noted that they had been “early adopters of EHR technology, yet still could not achieve meaningful use Stage 2, and had simply chosen to accept penalties in lieu of the interference they were facing in trying to provide needed patient care. Moreover, physicians shared frustrations about the failure of EHR companies to assure that medical record systems become interoperable to better enable the sharing of treatment information when physicians treat the same patient. To watch a re-broadcast of the “Town Hall” event, click here: http://live.breaktheredtape.org/. To read more about this event, click here.
Your New Video – Countdown to ICD-10: 10 Facts about ICD-10
The Centers for Medicare & Medicaid Services (CMS) has released an exciting new video to help ease your transition as we count down to ICD-10 implementation. This animated video highlights ten facts of what to expect during the ICD-10 transition.
The following videos are currently available for viewing on CMS’s YouTube channel:
- Road to 10
- Introduction to ICD-10 Coding
- ICD-10 Coding and Diabetes
- Medicare’s Testing Plan for ICD-10 Success
- Converting the Home Health Prospective Payment System Grouper to ICD-10-CM
- ICD-10 Coding Basics 01/14/14
- Coding for ICD-10-CM: More of the Basics 12/02/14
- ICD-10 and Clinical Documentation
- Navigating ICD-10, the Provider Perspective
- ICD-10 Roadmap for Small Clinical Practices
- ICD-10 Rural or Urban; It Impacts All Providers
The 10/1/2015 implementation date is fast approaching and these 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. We hope you find these videos to be a valuable asset as we count down to ICD-10.
National Government Services Needs YOUR Help! Take Their Survey!
We know how busy you are but we urgently need our customers’ perspective. We are counting on you and your staff to complete the Medicare Satisfaction Indicator (MSI) and website ForeSee surveys. It takes time, but the benefit of taking these two surveys will help you as a Medicare Provider and us as a Medicare Contractor determine how we are performing. Are you happy with us? We hope you are, but if not, we need to know that too! Good, bad, or indifferent, your feedback is a necessity!
Both surveys are available on their website at www.NGSMedicare.com. The MSI survey banner is displayed on the home page. For the website ForeSee survey, you are randomly chosen to take it, so whenever you do get that option, please click “yes, I’ll give feedback.” As we work with your suggestions, you will be glad you took the 5-10 minutes to complete the survey.
This link will take you to the MSI survey for Part A and Part B providers.
As you should know, effective July 1, 2015 NYS Medicaid is no longer paying the 20% of the 20% coinsurance from the Medicare claim for Medicare/Medicaid dual eligible patients. The NYS budget did not include funding to maintain this benefit from the NYS Medicaid Program. The final budget, accepts in part, the Executive’s proposal to limit Medicaid payments for dual eligibles’ Medicare Part B coinsurance amounts so that the total Medicare/Medicaid payment to the provider does not exceed the amount that the provider would have received for a Medicaid-only patient. The final budget accepts this cut with respect to dual eligibles in fee-for-service Medicare, but rejects it for dual eligible beneficiaries who are enrolled in Medicare Advantage plans. This cut took effect on July 1, 2015.
The June 2015 Medicaid Update on this matter reads as follows:
Effective July 1, 2015 a change to New York State Social Services Law adjusts Medicare Part B coinsurances reimbursement methodology for practitioner claims: Medicaid presently pays practitioners the full Medicare Part B annual deductible and partial Medicare Part B coinsurance amounts (20 percent of the Part B coinsurance) for Medicaid covered services provided to Medicare/Medicaid dually eligible recipients. Pursuant to recent changes to Social Services Law, New York State Medicaid has revised the reimbursement methodology for practitioner claims effective July 1, 2015.
Beginning July 1, 2015, Medicaid is no longer reimbursing partial Medicare Part B coinsurance amounts. The total Medicare/Medicaid payment to the provider will not exceed the amount that the provider would have received for a Medicaid-only patient. If the Medicare payment is greater than the Medicaid fee, no additional payment will be made.
Note: The Medicare and Medicaid payment (if any) must be accepted as payment in full. Per State regulation 18 NYCRR Section 360- 7.7, a provider of a Medicare Part B benefit cannot seek to recover any Medicare Part B deductible or coinsurance amounts from Medicare/Medicaid Dually Eligible Individuals.
There is no change to the current reimbursement methodology of Medicare Part B coinsurance for the following: Ambulance providers; Psychologists; Article 16 clinics; Article 31 clinics; and Article 32 clinics. Medicaid will continue to reimburse these providers the full Medicare Part B coinsurance.
Reminder: If a patient is dually eligible, private practitioners must bill Medicare prior to billing Medicaid for the Part B co-insurance. Most claims are submitted to Medicare and are automatically crossed over to Medicaid for processing.
If a medical practice is enrolled with a Medicare Managed Care (MMC) (Medicare Part C), when the MMC pays the practice the payment is expected to be considered as payment in full. The medical practice should review its MMC contract.
Regrettably, this goes back to the federal Balanced Budget Act of 1997. The BBA included a clause that stated the states no longer had to pay the coinsurance amounts for “dual eligible.” The BBA was passed at the time when MSSNY had just won the Medicare/Medicare Crossover lawsuit. Therefore, NYS had decided to continue paying a small portion of the Medicare Coinsurance amount. However, it just so happens that this year, the state decided to no longer include payment for this in the state budget. The state will still cover the Medicare Part B deductible, though.
The statute §1902(n)(3) of the Social Security Act) says that, where the State Medicaid program limits the amount it will pay for deductibles and coinsurance for QMBs, “for the purposes of applying any limitation under title XVIII [Medicare] on the amount that the beneficiary may be billed or charged for the service, the amount of payment made under title XVIII [Medicare] plus the amount of payment (if any) under the State plan [Medicaid] shall be considered to be payment in full for the service…”
Therefore, under Medicare rules, the provider has been paid in full if it receives the normal Medicare payment amount for the service plus any amount that Medicaid pays, even if Medicaid pays nothing. It doesn’t matter that the provider is not enrolled in Medicaid, billing beyond what Medicare and Medicaid pays would be a violation of Medicare rules.
When treating a dual eligible, there is mandatory assignment for the Medicare claim. This is not a new rule.
Can a physician who is not enrolled in Medicaid bill a Medicaid recipient for the Medicare deductible?
The answer is no. Under no circumstance can a provider balance bill dual eligible. The provider needs to enroll in the Medicaid program as a non-participating provider for Medicaid to cover the Medicare deductible. Being enrolled in Medicare, you need to be cautious about not treating dual eligibles in your medical practice. Any patient should not be discriminated against because of the health insurance they have or don’t have.
Since a medical practice should not discriminate against any patient based on the type of payer/insurance/plan by which the patient is covered, a practice can make a business decision to limit the amount of patients it can handle from a particular plan. So, the practice can say it can’t take any more patients from “X” plan.
Questions Regarding Out of Network Telephone Audits
Question: I am an out of network physician, but a health plan wants to audit me. What are my obligations?
Being out of network, physicians would be non-participating and therefore have NO contract with a health plan. To par or not to par with a health plan must be an individual business decision by any physician/practice.
A physician without a contract with a health plan who is asked to go through an audit process, should tell the health plan that a patient authorization is required before an audit can be conducted. Without a contract, physicians have no obligation to a health plan but do have a privacy obligation to their patient. If the patient is covered by a health plan, the link is between the health plan and the patient. If the health plan wants the patient’s medical record, the health plan needs to obtain the patient’s authorization for disclosure of his/her medical information by the physician.
Physicians without contract with a health plan have no obligation to the plan. The physician’s only obligation is to the patient. Physicians should not leave themselves open to violations of their patients’ privacy. Without the patient’s authorization to disclose their medical record, the physician has no authority to disclose the information.
Question: What if I have a contract with the plan?
If the health plan takes a negative position and wants the call to proceed without the benefit of recording and the physician has a contract, then the physician would need to make a business decision about the possibility of putting his/her contract at risk of termination.
Question: I am out of network. What if I receive a check from the plan?
When a physician has no contract with a health plan and the health plan inadvertently sends the physician a check, if the physician cashes the check, there could be an implied assignment of benefit whereby the physician is expected to “stand in the shoes of the patient.” If the physician does not want an implied assignment of benefits, the word “VOID” should be written across the face of the check and the check should be returned to the health plan with the instruction to reissue the check to the health plan’s insured/patient.
Question: Can I record a telephone audit?
It would be a good idea and a professional courtesy to inform the auditor that the telephone call will be recorded. If the health plan representative chooses not to be recorded, then the audit would not need to proceed for a physician who has no contract.
In reference to recording a telephone audit, the law on this is as follows:
NYS Penal § 250.00 Eavesdropping; definitions of terms.
The following definitions are applicable to this article:
- “Wiretapping” means…
- “Mechanical overhearing of a conversation” means the intentional overhearing or recording of a conversation or discussion, without the consent of at least one party thereto, by a person not present there at, by means of any instrument, device or equipment…..
–From Regina McNally
Comprehensive Care for Joint Replacement (CCJR) Model Webinar Materials Posted
In follow-up to the July 9, 2015 announcement of the Comprehensive Care for Joint Replacement (CCJR) Model, the CMS Innovation Center hosted two webinars on July 15 and July 16, 2015. These webinars focused on providing an overview of the Model and provided an opportunity for attendees to ask questions.
The materials from these overview webinars are now available on the CCJR Overview webinar page. To access the audio recordings of both webinars, an email address is required. If already registered, please use the same email address used at the time of registration. Additional information on the CCJR Model can be accessed through the CCJR Model web page
Calling All Amateur Photogs for MSSNY’s Social Media Feeds
We’d like to include more happenings from around the state in our Twitter, Facebook and Instagram feeds. If you’re at an event that you think might be of interest to our followers, please snap a picture with your phone and send to firstname.lastname@example.org with your name. Be sure to include a caption or some identifying words. If you’re traveling around our beautiful state this summer, send us a photo!
Doctors Digital Agency
When you understand your practice is an online business, tell us where it hurts. Whether your website needs a simple refresh or serious surgery, our digital doctors heal what hurts. Doctors Digital Agency will improve your site’s front-end user experience and back-end functionality. That means more patients, more phone calls, more patient time, more profitability. We use responsive design to build mobile and search-engine friendly custom websites. Leverage electrons! Visit http://www.doctorsdigital.agency Email: email@example.com, or call 786-529-2025. Doctors Digital Agency, Inc. Since 1996.