Welcome to the April 2016 Wesgram Online!
This Wesgram contains news and updates that are important to your practice. You'll also find several opportunities for additional education for physician and staff.
The WVSMA has advocated tirelessly for clarity with the TCM (Transitional Care Management) CPT codes. As many of you know, some plans were not paying the codes, while others have paid them with different guidance as to the billing dates. After discussions with several insurers, changes have been made for TCM. Additional information is included on the TCM billing changes that have been made by Medicare, PEIA and Humana as a result of WVSMA advocacy
ICD-10 Code Changes are Coming
The United States began using ICD-10 codes officially on October 1, 2015. There are already new codes coming. As of now, there are 2,670 proposed ICD-10-CM code changes that
take effect Oct. 1, 2016. These are new codes which were issued by the Centers for Disease Control and Prevention (CDC). The final code changes will be posted on the CDC's website this June.
This is the first update since transitioning to the new code set after a five-year code freeze and will greatly impact your practice this year. Specifically, there are 1,943 new, 422 revised and 305 deleted codes.
Some of the changes include:
260 new diabetes combination codes for reporting manifestations
152 new codes added to the already dense musculoskeletal chapter including bunions,
temporomandibular joint conditions (adhesions, arthralgia), cervical spine disorders and atypical femoral fractures
885 new codes in Chapter 19, the majority of which are fracture codes including neck, base of skull, facial bones, Salter-Harris calcaneal fractures as well as other physeal fractures.
The WVSMA will keep you updated of code changes in order to help you bill correctly and accurately, helping to ensure that you receive maximum reimbursement.
You are also reminded that the CMS "grace" period for ICD-10 billing ends as of October 1, 2016. If you're not currently billing the most specific codes, it would be a good idea to begin doing so now, so that you are ready when the "grace" period ends
(information from Palmetto GBA)
Many questions have arisen lately about the billing for TCM (Transitional Care Management). The Federal Register had included language
that would change the date of service to be used when billing for TCM but, until recently, CMS had not provided direction to the Medicare Administrative Contractors (ours is Palmetto GBA) regarding how the guidance change was to be implemented in the system of edits used to process these claims.
The WVSMA worked closely with Palmetto's Medical Directors and management to obtain and clarify information for you.
There have been new instructions on the date of service that should be used. Previously CMS instruction was to bill on the 30th day since the transitional care management code describes 30 days of service. The new CMS direction is that the date of service be the date of the required face-to-face visit.
CMS has updated a question and answer document on their website but other questions that center around the date of service to be billed have not been updated in the same document and contractors have not received guidance on how to implement the change. Additionally, CMS has a TCM Service Fact Sheet that has not been updated with the new information.
eServices-Check that Claim Status!
To check on a particular claim status, please enter the HICN and other required beneficiary information, as well as the date(s) of service. Should you not know the exact date of service, you are able to enter a span or range of up to 45 days. Please keep in mind, retrieving claims older than six months takes a little longer than something more current. Claims older than three years may not be searchable.
Additional Documentation Narrative Fax Cover Sheet
When submitting required additional documentation to support a service billed using the Additional Documentation Narrative Fax Cover Sheet, be sure that the patient?s name and Medicare (Health Insurance Claim, (HIC)) number is entered correctly on the fax coversheet and that it matches the patient name and HIC number submitted on the claim. Additionally, follow all instructions found on the coversheet form. Failure to do so can result in claim rejections or denials.
Medicare Does Not Accept Retroactive Orders
Providers may not add late signatures to medical records. Medicare does not accept retroactive orders. In the event a signature is missing, the record cannot be changed. If the signature cannot be read or is missing, a signature log or attestation statement should be included.
Please be sure to use the correct address if you are mailing a redetermination request, Palmetto GBA Part B - MAC, AG-655, P.O. Box 100190, Columbia, SC 29202-3190. You may also submit a redetermination request using the eServices portal or by fax.
E/M Tip: Medical Necessity
Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation must support the level of service reported.
Save Time and Assure Accuracy: Use the Most current Redetermination Request Form
Palmetto GBA is committed to making it easier to submit requests for a redetermination. They have improved our Redetermination: First Level Appeal form (AP-JM-B-1000) to allow the information you type onto this form to be captured automatically by our system. This allows your request to process more quickly and accurately. Once you have entered all of the information onto the form, print the form for submission. A new blank form should be used for each appeal request so that all appropriate information specific to that request is read by the Palmetto Workflow System. Avoid entering spaces before or after your entries.
ADR Response Calculator
If you have received an Additional Documentation Request (ADR) for one or more claims, you will have 45 days from the date of the letter to submit supporting records. If Palmetto does not receive your documentation within 46 days, your claim will be denied for lack of a response. Palmetto has placed an ADR calculator on their website to assist you in determining the 45-day period for your response.
Medicare Advantage payments to rise by 0.85 percent in 2017, CMS says
from the AMA)
The Wall Street Journal (4/4, Radnofsky, Armour, Subscription Publication) reports that Sean Cavanaugh, deputy administrator at CMS, said payments for Medicare Advantage would rise by an average of 0.85 percent in 2017, and that on the whole, insurers' revenue would probably rise by about 3.05 percent.
The Washington Times (4/4, Howell) quotes acting CMS Administrator Andy Slavitt as saying, "With these policies, we will continue to see improvements in growth, affordability, benefits and quality for millions of seniors and people living with disabilities." The article says the release of CMS' final rule for payments to Medicare Advantage plans "caps an intense lobbying campaign by insurers and some in Congress, who urged" the Obama Administration not to cut payments to these plans.
Mid-year QRURs Available
CMS has released the 2015 Mid-Year Quality and Resource Use Reports (QRURs) to groups and solo practitioners nationwide, including those who participated in the Shared Savings Program, the Pioneer Accountable Care Organization (ACO) model, or the Comprehensive Primary Care (CPC) initiative in 2015.
The 2015 Mid-Year QRURs were made available for informational purposes only and will not affect a group or solo practitioner's payments under the Medicare Physician Fee Schedule. The Mid-Year QRUR contains information on a subset of the measures used to calculate the 2017 Value Modifier. The Mid-Year QRUR provides interim information about performance on the six cost and three quality outcomes measures that CMS calculates from Medicare claims. These are some of the measures used in the calculation of the Value Modifier. The information in the MYQRUR is based on care provided from July 1, 2014, through June 30, 2015, a period that precedes the actual calendar year 2015 performance period for the 2017 Value Modifier. More information about the Mid-Year QRUR can be found on the 2015 QRUR and 2017 Value Modifier webpage.
BMS Schedules Provider Workshops
The West Virginia Bureau for Medical Services (BMS) has set the dates, times and places for the 2016 Spring Provider Workshops. Presenters will include BMS, Molina Medicaid Solutions, Medicaid's Managed Care Organizations, CHIP and Medicaid contractors. These workshops give providers and their staff a chance to learn about upcoming changes. The workshops will be from 8 a.m. to 4 p.m. To register for the workshop of your choice please go to:
For more information contact BMS at 304-558-1700.
Highmark West Virginia News
Physicians were recently sent a communication from Highmark regarding a change in reimbursement for their ACA product. Highmark West Virginia has taken a measured approach to managing ACA fees with an aggregate adjustment (reduction) of 0.6 percent for ACA direct-pay products.
Effective May 1, 2016, Highmark will adjust the provider fee schedule to implement new fees for their ACA individual (direct-pay) products.
Current fees are available in NaviNet®, and the ACA fees became viewable in the system this week. (For more information on accessing current fees in NaviNet, please see "Fees Available via NaviNet" below. If you don't yet have NaviNet, visit navinet.net to get access to the system.)
The Highmark mailing also included an addendum to memorialize the fee changes and other agreements relevant to Highmark West Virginia's ACA network and products. Physicians should retain this document with their contract records.
On or before May 1, 2016, practices will be able to access all applicable payment information online. Visit the Provider Resource Center (via NaviNet) and select Administrative Reference Materials, and then Fee Schedule Information. Please note that fees are not published on the public Provider Resource Center.
Questions regarding the new fees should be addressed to Highmark's Provider Resource Center.
Highmark West Virginia has also announced that the plan is doing business differently in 2016. You will no longer have an assigned Provider Relations representative, but are instead encouraged to utilize the plan's self-service options. Highmark encourages you to take advantage of the online and telephonic tools that the plan offers.
NaviNet should be utilized as the primary resource for inquiries related to West Virginia Family Health members. Questions that cannot be resolved through NaviNet functionality for these members should be directed to West Virginia Family Health Provider Services at 1-855-412-8002.
Providers who have had issues with Humana regarding their TCM billing will be glad to know that Humana will now permit TCM claims to process on the face to face visit date.
Previous denied claims may be resubmitted to Humana for processing.
PEIA to Reprocess TCM Claims
Perhaps your practice had noticed that PEIA had been denying the TCM claims until recently. The plan was delayed in loading the codes/reimbursement in their system so they are now asking that provider submit denied claims for reprocessing.
As a review, The Centers for Medicare & Medicaid Services (CMS) recently announced an update to the way transitional care management (TCM) is billed. Although TCM is an important tool in reducing unnecessary hospital readmission rates, many physician practices who were utilizing TCM commented that the requirements were confusing. As a result, CMS changed the date of service (DOS) requirement starting on January 1, 2016.
Previously, practices had to use the 30th calendar day after the patient's discharge as the date of service to ensure the patient wasn't readmitted within that 30-day window. This meant they usually had to wait several weeks after the face-to-face visit to submit the bill for TCM. As of January 1, 2016, the DOS will reflect the date of the face-to-face visit, which allows practices to bill for TCM much sooner.
PEIA also plans to
lower reimbursement by 3% as of July 1, 2016. The WVSMA will update you as soon as more information becomes available.
UniCare reminds physicians that your Network Education Representative should not be your first point of contact for billing/claims issues and cannot accept inquiries that have not gone through the following escalation process.
Claims and billing inquiries must be handled in the Provider Services Call Center at 1-800-782-0095, select provider, then follow the prompts. In the event the Call Center Representative does not sufficiently address your issue, please request that you be escalated to a manager. (Remember to please get the name of the person(s) with whom you spoke with and the inquiry number.)
Plans State Education Meeting
The West Virginia Office Managers Association has scheduled an Education Day on Friday, May 20, 2016, from 9:00 AM-4:00 PM, at the Day Hotel and Conference Center, Flatwoods, West Virginia. The theme for the day is "Hot Topics in the Medical Office". Registration begins at 8:30 AM. Lunch will be provided.
You may register online at the OMA website,
. OMA members may attend at no charge. Non-members may attend for a $25.00 charge by sending a check to:
Huntington OMA Chapter
PO Box 1672
Huntington, WV 25717
Please indicate your name with the check if it is a business check.
Registration Deadline is
May 13th, 2016
WVMGMA Regional Meetings
The West Virginia Medical Group Management Association (WVMGMA) has planned a series of statewide regional meetings in May. Ken T. Hertz, Principal Consultant with MGMA will be speaking on the topics of
Trends in Practice Management and
Setting a Vision for Your Practice. The meetings are free but
registration is necessary.
Below are the dates and locations for the regional meetings.
Please register with the contact person at least ten (10) days prior to the meeting you would like to attend.
Monday, May 23rd---Morgantown
Holiday Inn Morgantown - University Area
9:00am - 11:15am
Tuesday, May 24th---Parkersburg
Camden Clark Hospital
10:30am - 2:00pm
Wednesday, May 25th----Beckley
Mountain State Co-op
10:00am - 2:00pm
Thursday, May 26th-----Teays Valley
9:00am - 11:15am
WVSMA to Offer CMIS Certification in August
The WVSMA will offer the CMIS (Certified Medical Insurance Specialist) course
beginning on Thursday, August 4, 2016. This PMI (Practice Management Institute) nationally recognized certification class explores the current landscape of third party reimbursement. Detailed lectures, course materials and examples will teach participants how to effectively expedite claims, secure timely, correct reimbursement, and protect the financial interest of the practice.
This class has not been offered in West Virginia since 2014 and will not be offered again in 2016.
Watch for more details and registration information!
The WVSMA is the exclusive WV partner with PMI.
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©2015, West Virginia State Medical Association
WESGRAM is solely intended for members of the West Virginia State Medical Association (WVSMA) and PMI certified professionals.To join WVSMA, go to our website.