January 2016


Welcome to the Wesgram Online!  

Welcome to the January 2016 Wesgram. This edition contains important information about the rescheduled Physican Practice Conference.  You'll also find information about some recent coding changes and changes with insurers. You can check out upcoming educational opportunities for physicians/staff and even register online for events. 

The West Virginia State Medical Association and West Virginia Medical Group Managers Association invite you to attend the 2016 Physician Practice Conference on Friday, February 26, at Embassy Suites in Charleston! The conference, which was postponed due to the massive snowfall from snowstorm Jonas, will feature excellent speakers, one on one time with speakers/insurance payors, CEU credits, and great networking. You can even win free tuition for the PMI certification course of your choice (up to $1250.00 in value!)

Register today at the WVSMA website by clicking here. You may also download a registration form from the WVSMA website, www.wvsma.org.

story1ICD-10 Latest News
CPT Changes for 2016

The past several editions of the Wesgram have featured changes in the 2016 CPT codes. Below are the remainder of the changes. Make sure that you are using the 2016 CPT codes when you are billing; otherwise your claims may be denied.

Mediastinum: Two new codes are added (39401 and 39402) and one code is deleted (39400) to separate reporting of biopsies of lymph nodes and mediastinal masses.
Digestive: There are 10 deleted, 16 new codes. Among the changes: New codes that describe percutaneous biliary procedures with bundled imaging (47533-47544).
Urological: There are 14 new, one revised, four deleted codes overhaul genitourinary catheter procedures (50387-50706) and add a code for penile trauma repair (54438).
Nervous: There 6 new and one deleted code. Changes include new codes for intracranial endovascular intervention (61645-61651) and paravertebral block injections and infusions for post-operative pain management (64461-64463).
Ocular: One new code, eight revised, one deleted. Among the changes: Revised coding for intrastromal corneal ring implant (65785) and retinal detachment repair (67101-67108).
Auditory: One new code for cerumen removal by lavage (69209).
Radiology: 21 new, 14 revised, 25 deleted. Changes include overhaul of radiological exam codes for spine, hip and pelvis (deleted: 72010, 72069, 72090, 73500, 73510, 73520, 73530-73550 and added: 72080-72084, 73501-73503, 73521-73523 and 73551-73552) as well as deletion of intravascular ultrasound codes (75945 and 75946).
Path/Lab: 28 new, 50 revised, 11 deleted. Changes include revision of codes to reflect full gene names and update the number of variants tested and movement of certain molecular pathology tests between Tier 1 and Tier 2. In addition, certain chemistry lab codes will undergo another round of revisions, including 86708, 86709, 87301-87503.
Winter ICD-10 Codes

Did the recent snowstorm cause you to use any of these codes?

T33.5      Superficial Frostbite of Wrist and Hand
M54.5      Low Back Pain (maybe from shoveling snow??)
V00.211   Fall from ice skates
V00.221   Fall from sled
V00.32     Snow Ski Accident
V98.3       Accident Involving a Ski Lift

Palmetto GBA News
(information from Palmetto GBA)

2016 Medicare Physician Fee Schedules Available
On January 20, 2016, Palmetto GBA posted the updated 2016 Medicare Part B Physician Fee Schedules (MPFS) on their webiste, www.palmettogba.com. under the Medicare Physician Fee Schedule tool. The files can also be downloaded in Excel or a CSV format.

The previously posted codes were incorrect, which caused CMS to remove all fee schedules from their MACs' websites.  This caused an emergency update to the CY 2016 Medicare Physician Fee Schedule Database (MPFSDB)

MLN Change Request (CR) 9495 amends payment files that were issued to contractors based on the CY 2016 Medicare Physician Fee Schedule (MPFS) Final Rule. The Centers for Medicare & Medicaid Services (CMS) amended these payment files in order to correct technical errors to the MPFS update files, and to include corrections described in the CY 2016 MPFS Final Rule Correction Notice.

New Place Of Services Codes
Effective January 1, 2016, there are  two possible place of service codes to choose from for outpatient hospital settings: new place of service code 19 and revised place of service code 22.

Place of Service 19
Off Campus-Outpatient Hospital

A portion of an off-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

Place of Service 22
On Campus-Outpatient Hospital

A portion of a hospital's main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

Reporting outpatient hospital POS code 19 or 22 is a minimum requirement to trigger the facility payment amount under the Physician Fee Schedule (PFS) when services are provided to a registered outpatient. Therefore, you should use POS code 19 or POS code 22 when you furnish services to a hospital outpatient regardless of where the face-to-face encounter occurs.

The payment policies that currently apply to POS 22 will continue to apply to this POS, and will now also apply to POS 19 unless otherwise stated in Change Request (CR) 9231.

Clarifying the Medical Necessity Component for Critical Care Services
Critical care services must be medically necessary and reasonable. Critical care is defined as a physician's direct delivery of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition. In some instances, the patient may require critical care for the first day, but not on subsequent days as their condition has stabilized.

Save Time and Assure Accuracy: Use the Most current Redetermination Request Form
Palmetto GBA is committed to making it easy for you to submit requests for a redetermination. They have changed the Redetermination First Level Appeal form to allow the information you type onto this form to be captured automatically by their system. This allows your request to process more quickly and accurately. The form can be completed online and printed and signed for submission. The most current Redetermination 1st Level Appeal form includes the form number, Revision Date of 11/2105 and a Barcode date of 12/15/2015.

eServices: Fast and Secure Medicare Information
Palmetto GBA offers secure and fast access to your Medicare information through their eServices. Through this system, you can securely submit forms, documents and payments, receive print material/letters electronically via eDelivery, view beneficiary eligibility, claims status, online remittances and financial information and much more.  For more information, visit Palmettogba.com.

The CERT Contractor Differs from the Medicare Contractor
Palmetto GBA is the Jurisdiction M contractor who CMS employs to provide claims processing for the states of SC, NC, VA and WV. Services provided by Palmetto GBA include processing claims for Medicare Part A, Part B and sixteen states that provide Home Health and Hospice (HHH) services. The CERT contractor is a totally separate contractor who contracts with CMS.

Compliance officers at each medical practice are encouraged to ensure that the CERT contractor's database stays updated with the correct contact information.

Please verify or change the CERT contact information for your facility at the CERT Provider website.  You will need your Contractor ID, so please select the line of business and the number by your state.  The West Virginia number is 11402.

Palmetto GBA continues to see a problem regarding the absence of a physician signature on medical records reviewed by the CERT contractor. Once the provider receives a response from CERT, the provider will then submit an appeal to Palmetto and will send a copy of the record that has been signed after the CERT review. The important tip here is to ensure medical records are signed prior to submitting the records to the CERT contractor.

Submitting Complete and Legible Medical Records is Key!

When submitting medical records to the CERT contractor, be sure the medical record submitted is complete and legible. Documentation must support the level of care and treatment and must be reasonable and necessary. Codes documented on the claim must be reflected in the medical record. Coders should ensure they use the correct code when coding services on the claim.

E/M Tip: Discharge Services-Patient Expired

Only the physician who personally performs the pronouncement of death may bill for the face-to-face hospital discharge service. The date of the pronouncement must reflect the calendar date of service on the day it was performed even if the paperwork is delayed to a subsequent date.

E/M Tip: Documentation Requirements for Teaching Physicians
E/M services billed by teaching physicians require that they personally document at least the following:
    That they performed the service or were physically present during the key or critical portions of the   service when performed by the resident
    The participation of the teaching physician in the management of the patient

When assigning codes to services billed by teaching physicians, reviewers will combine the documentation of both the resident and the teaching physician.

Automated Calls to Physicians with Eligible Overpayments
Effective Monday, January 11, 2016, Jurisdiction M Medicare implemented automated calls to providers with eligible overpayments in an effort to increase timely responses to eligible outstanding overpayments.

An automated courtesy call will be made when the debt remains open in a collections status and ages to at least 67 days old. This call will be a reminder to any provider who has not responded to a first demand letter either with payment in full, by submitting an appeal, or by submitting an acceptable request for an extended repayment schedule. 

These calls will provide basic information about the pending overpayment, including the date of the first demand letter and the outstanding balance. 

To avoid further collection action, providers can submit payment electronically using the Palmetto GBA eServices link at www.PalmettoGBA.comeServices , submit a check to the address listed on the demand letter, submit a request for an extended repayment schedule, or file an appeal in accordance with the rights provided to you in the demand letter.

Medicare Secondary Payer Inquiry Form
Palmetto GBA has added a Medicare Secondary Payer Inquiry Form in the Finance forms section of our website. This form should be used for any Medicare Secondary Payer (MSP) request pertaining to Primary or Secondary payment of claims.

Helpful Hints
    Please forward all inquiries for MSP Recovery to the Benefits Coordination & Recovery Center (BCRC)
    Do not include a refund check with the new form
    If you are sending a refund check, please use the Medicare Secondary Payer Refund Overpayment       Check Enclosed form
    Do not use this form if you are requesting a Redetermination on a MSP claim that is not MSP related
    Do not use this form for new claim submissions
    Do not use this form for situations that involve the Veteran's Administration. Use the Reopening      form instead.
CMS Says that Meaningful Use Will End in 2016
CMS Acting Administrator Andy Slavitt announced on Tuesday, January 19, that CMS will
be ending the "meaningful use" EHR Incentive Program in 2016.
CMS had announced stage 3 meaningful use guidelines in October which followed a series
of proposed changes to the program, including payment adjustments and the creation of hardship exemptions.
In his remarks at a JP Morgan Healthcare Conference, Administrator Slavitt said that further specifics on how meaningful use will be replaced will be announced later, although it will be tied to the implementation of Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and include streamlining various quality reporting programs.
The WVSMA will keep you updated on these changes as they are announced.
Payor News and Other News 
Aetna Market Fee Schedule Being Adjusted
( information from Aetna)
Physicians may have recently received a letter from Aetna, stating that the Aetna Market Free Schedule (AMFS) for all West Virginia market plans would be adjusted.
The letter sent is Aetna's 90 day notification to providers of the adjustments to its standard fee schedule (aka the Aetna Market Fee Schedule or AMFS). The new fee schedule is effective March 1, 2016 and does not impact providers with negotiated agreements.
You may view your current fee schedule on Aetna's secure provider website www.aetna.com.
If you have questions, please contact Aetna at (800) 624-0756 for HMO-based and Medicare Advantage plans, or call (888) MDAetna for all other plans.
Humana Update
(information supplied by Humana)
 The PEIA Humana Medicare Advantage members have a $100 deductible for the 2016 plan year.   Historically, this has been a $25 deductible.   This can be confirmed by checking a member's eligibility on Humana.com or calling customer service.     Also, the PEIA members received new cards for 2016.   Please make note in your patient records.
Humana reminds physicians, that due to this increase of deductible, there may be claims that will process uniquely in comparison to prior plan years.   For example, a total E&M line could be applied to member responsibility until the member's deductible has been met.
There is one exclusion of this increase in deductible.   Members that are under the PEIA assistance program have retained benefit very similar to 2015.   Below is a brief example of benefit costs.
Plan Element                                                 Humana/PEIA Plan1       Humana/PEIA Plan 1
Medical Deductible                                         $100                                                   $25
Medical Out-of-Pocket Maximum                   $850                                                   $325
Primary Care Copay                                       $20                                                      $2
 Specialist Copay                                            $40                                                    $5
Inpatient Hospital Copay                                $100 per admission                          $100 per admission

Skilled Nursing Facility                                   $0 up to 100 days                              $0 up to 100 days $0
 Emergency Room                                         $50                                                     $50
 Ambulance                                                     $0                                                      $0
 Outpatient Surgery Copay                           $100                                                     $50
Important News from Molina!
Molina implemented a new Medicaid Management Information Service (MMIS) for West Virginia Medicaid, effective January 18, 2016. This new MMIS is for fee for service only and does not impact the claims you submit to the MCOs
In addition, the new WVMMIS will soon begin processing WVCHIP claims. You will use the same applications that you now use to submit WV Medicaid claims, using your provider ID and the WVCHIP member ID on the claims.   Prior Authorizations still need to be obtained from HealthSmart.
If you are currently enrolled with WV Medicaid, you still need to complete an abbreviated enrollment form for WVCHIP. You may complete the form at www.wvmmis.com, or contact Molina Provider Enrollment to request an enrollment form.   New WVCHIP providers will need to complete a new application for CHIP.
Payors will present more information in detail at the WVSMA's Physician Practice Conference on Friday, February 26, 2016, at the Embassy Suites. Register here to attend!
story6Other News
Certified Medical Office Manager (CMOM) Class Scheduled
The WVSMA will host the next CMOM class in February, 2016 at the WVSMA in Charleston. The course will begin on Thursday/Friday, February 11/12 and continue the next week on Thursday/Friday, February 18/19.
This is an excellent class for both beginning and experienced managers. Don't miss the opportunity to obtain a national certification in practice management.   Registration information will be coming soon on the WVSMA website, www.wvsma.org.   If you attend the January Physician Practice conference, you might win a free registration for this great class!
WVMGMA Schedules Regional Meetings
The West Virginia Medical Group Management Association (WVMGMA) has scheduled a series of regional meetings during the week of May 23, 2016. The meetings will be held on these dates in these areas:

Monday, May 23               Morgantown
Tuesday, May 24             Parkersburg
Wednesday, May 25        Beckey
Thursday, May 26            Teays Valley
Additional information will be coming soon. Mark the dates and plan to attend the event in your area!

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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.