March 2016
Welcome to the Wesgram Online!  
This edition of the Wesgram Online contains information intended to help you with your practice management issues.  Please feel free to contact the WVSMA for practice assistance and concerns.

The recent MidWinter Conference was a terrific success! The combined effort by the WVSMA and WVMGMA provided several diverse educational sessions. Palmetto GBA representatives started the morning off with information about recent Medicare updates and motivational speaker Keith Matheny's presentation both wowed and moved attendees.
The afternoon included payor updates from 12 payors, as well as presentations by Huntington Internal Medicine Group (Chronic Care Management) and a 2016 Update by Highmark West Virginia.
Attendees gave great reviews about the conference for both the presentations and networking opportunities. We hope to see you next year!

Certified Medical Office Manager (CMOM) Class Scheduled
The WVSMA will host the next CMOM class beginning next week at the WVSMA in Charleston. The course will begin on Thursday/Friday, March 10/11, and continue the next week on Thursday/Friday, March 17/18.
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 is available on the WVSMA website, or by clicking here.

story1ICD-10 Latest News
Coding Update

Have you taken your ICD-10 Proficiency Exam?

If you are one who must take the proficiency exam before March 31, 2016, you may need to review. Here are some sample ICD-10 codes for you:

E66.01   Other obesity due to excess calories
Z68.38   Body mass index (BMI) 38.0-38.9, adult
Z72.3     Lack of physical exercise
Z72.4     Inappropriate diet and eating habits
Z57.8     Occupational exposure to other risk factors
Z56.6     Other physical and mental strain related to work
Y92.531 Health care provider office as the place of occurrence of the external

Palmetto GBA News
(information from Palmetto GBA)

Palmetto Provider Contact Center Update
If you have been experiencing long call wait times when you call the Palmetto GBA provider contact center, you now have an alternative. If you leave a message with your name and contact number, you should receive a callback within an hour. This is a great alternative to waiting on "hold".
CERT Tip----Documenting Specific Services in the Medical Record
Providers should document specific services in the medical record. All services require the basic information in the medical record.
CERT TIP---Documenting the Patient's Progress in the Medical Record
Always document in the medical record the patient's progress. Document the patient's response to treatment. Document the change (if any) in the diagnosis or treatment and always document the patient's non-compliance (if applicable).
CERT TIP---Lack of Documentation is the #1 reason for Claims Denial!
Lack of documentation in the medical record is the #1 reason for claims being denied for payment. Providers can fix this by documenting the information in this article.
CERT TIP---Signatures Are Important
CMS mandates the presence of signatures for medical review purposes. Signature requirements are applicable to all Medical claims and medical records submitted for medical review purposes.
E/M Tip: Documentation of Prolonged Care
Documentation is required in the medical record about the duration and content of the medically necessary evaluation and management service and prolonged services billed.
E/M Tip: Diagnosis/Management Options-New Problem
In most instances, a new problem is one that is new to the provider and being addressed at that visit. There are two exceptions to this general rule:
   The initial visit of an established beneficiary in a single specialty group practice setting with a new provider
   A visit by an 'on call' or covering provider. In these instances, the established problems are treated as if the beneficiary was seen by the unavailable provider
E/M Tip: Review of Systems; and Past, Family and Social History - Obtained During an Earlier Encounter
A review of systems (ROS) and/or a past, family and social history (PFSH) obtained during an earlier encounter do not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:
   Describing any new ROS and/or PFSH information or noting there has been no change in the information
   Noting the date and location of the earlier ROS and/or PFSH
E/M Tip: Discharge Services-Date of Service
A hospital discharge service must be reported for the date of the actual visit by the physician or qualified non-physician practitioner even if the patient is discharged from the facility on a different calendar date.
E/M Tip: Completing Documentation
Providers are encouraged to enter all relevant documents and entries into the medical record at the time they are rendering the service. Occasionally, upon review a provider may discover that certain entries, related to actions that were actually performed at the time of service but not properly documented, need to be amended, corrected, or entered after rendering the service.
E/M Tip: History of Present Illness (HPI) - Negative Findings/Complaints
If a physician documents negative findings for the history of present illness, for example (subsequent hospital visit for chronic heart failure), provider states, 'Denies any SOB,' he/she may use this information under 'Associated Signs/Symptoms.'
Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program
The QMB program is a State Medicaid benefit that covers Medicare deductibles, coinsurance, and copayments, subject to State payment limits. (States may limit their liability to providers for Medicare deductibles, coinsurance and copayments under certain circumstances.)
Medicare providers may not balance bill QMB individuals for Medicare cost-sharing, regardless of whether the State reimburses providers for the full Medicare cost-sharing amounts. Further, all original Medicare and MA providers --not only those that accept Medicaid--must refrain from charging QMB individuals for Medicare cost-sharing. Providers who inappropriately balance bill QMB individuals are subject to sanctions.
Influenza and Pneumococcal Vaccines and Administration Reimbursement
These immunizations are paid at 100 percent of the established fee schedule amount. Coinsurance and the annual deductible do not apply.

CMS News
The Centers for Medicare & Medicaid Services (CMS) has published a final rule that requires Medicare Parts A and B health care providers and suppliers to report and return overpayments by the later of the date that is 60 days after the date an overpayment was identified, or the due date of any corresponding cost report, if applicable.
The requirements in this rule are meant to support compliance with applicable statutes, promote the furnishing of high quality care, and to protect the Medicare Trust Funds against improper payments, including fraudulent payment.  This rule clarifies requirements for the reporting and returning of self-identified overpayments.  Health care providers and suppliers have been and will remain subject to the statutory requirements found in section 1128J(d) of the Social Security Act (the Act) and could face potential False Claims Act (FCA) liability, Civil Monetary Penalties Law (CMPL) liability, and exclusion from federal health care programs for failure to report and return an overpayment. 
Section 6402(a) of the Affordable Care Act established a new section 1128J(d) of the Act.  Section 1128J(d)(1) of the Act requires a person who has received an overpayment to report and return the overpayment to the Secretary, the state, an intermediary, a carrier, or a contractor, as appropriate, at the correct address, and to notify the Secretary, state, intermediary, carrier, or contractor to whom the overpayment was returned in writing of the reason for the overpayment.  Section 1128J(d)(2) of the Act requires that an overpayment be reported and returned by the later of: (A) the date which is 60 days after the date on which the overpayment was identified; or (B) the date any corresponding cost report is due, if applicable
This final rule states that a person has identified an overpayment when the person has or should have, through the exercise of reasonable diligence, determined that the person has received an overpayment and quantified the amount of the overpayment.  Creating this standard for identification provides needed clarity and consistency for health care providers and suppliers regarding the actions they need to take to comply with requirements for reporting and returning of self-identified overpayments.
Under this final rule, overpayments must be reported and returned only if a person identifies the overpayment within six years of the date the overpayment was received.  Specifying the length and other parameters of the look back period provides additional clarity for providers and suppliers who have identified an overpayment that is covered by the provisions of 1128J(d).
This final rule provides that providers and suppliers must use an applicable claims adjustment, credit balance, self-reported refund, or another appropriate process to satisfy the obligation to report and return overpayments.  This approach for returning overpayments provides an array of familiar options from which providers and suppliers can select.
 This rule also provides that if a health care provider or supplier has reported a self-identified overpayment to either the Self-Referral Disclosure Protocol managed by CMS or the Self-Disclosure Protocol managed by the Office of the Inspector General (OIG), the provider or supplier is considered to be in compliance with the provisions of this rule as long as they are actively engaged in the respective protocol.
Apply for Hardship Exemption to Avoid Meaningful Use Penalties
(Info from the AMA)
Physicians have until March 15 to apply for a hardship exemption from the electronic health record (EHR) meaningful use financial penalties for the 2015 program year. Those who don't apply could face up to a 3% cut in their Medicare payments in 2017 since the meaningful use program operates on a two-year look-back period. New this year for physicians, individuals can apply on behalf of a group of physicians.
The Centers for Medicare & Medicaid Services (CMS) has stated that it will broadly grant hardship exemptions as a result of the delayed publication of the Stage 2 meaningful use modifications rule, which left physicians with insufficient time to report under the modified program requirements issued in late 2015.
All physicians should apply for the exemption since there isn't a downside to doing so. Even physicians who believe they met the requirements of the meaningful use program in 2015 can apply. Submitting an application for a hardship exemption will not prevent those who qualify from receiving an incentive payment.
How to apply: Physicians should be sure to submit their applications before midnight Eastern Time on March 15, 2016. Physicians can download an application from CMS.
While CMS has given a deadline for applications, it has not yet indicated when physicians will receive confirmation of their exemption status.
In response to requests from the AMA, the Centers for Medicare & Medicaid Services (CMS) has issued
FAQ #14357 clarifying that applying for a hardship exemption from the 2017 meaningful use payment penalty will not preclude physicians from receiving the incentive if they successfully attest to meaningful use in 2015. In essence, the hardship exemption will act as a safety net. As a reminder, the AMA is encouraging all physicians to apply for a hardship exemption as a result of the delay of the 2015 meaningful use modification rule.
Submission of a hardship exception application does not prevent a provider from attesting and receiving an incentive payment if meaningful use requirements are met.
Attestation for the 2015 EHR reporting periods is currently open. The AMA urges providers to try to attest by the March 11, 2016 attestation deadline. If they successfully attest, they will avoid the payment adjustment in 2017 and may also be eligible to receive an EHR Incentive payment.
However, if a provider cannot attest for a 2015 reporting period or believes their attestation may be unsuccessful, the provider can apply for a hardship exception to avoid the payment adjustment in 2017. The application will not prevent a provider from earning an incentive if their attestation is in fact successful. The deadline to submit a hardship exception application is March 15, 2016 for eligible professionals and April 1, 2016 for eligible hospitals.
Payor News and Other News

WV Medicaid Update

Update on Drug Testing Procedures

Beginning January 1, 2016, the Centers for Medicare and Medicaid Services (CMS) deleted all 2015 drug testing  G codes and will continue to not recognize the AMA CPT codes for drug testing.

BMS will follow the CMS coding guidelines for reporting drug testing procedures:
  • Submit drug testing services to BMS using CMS codes G0477-G0483
  • Only one of the three presumptive codes (G0477, G0478, G0479) may be billed per day.
  • Only one of the four definitive codes (G0480, G0481, G0482, G0483) may be billed per day.
  • Only one service unit per procedure code per date of service may be billed when submitting G0477-G0483
  • Drug confirmation tests are no longer eligible to be separately reported under any procedure code, unlisted or otherwise.  This service is considered included in the presumptive or definitive drug testing procedure codes (G0477-G0483)
  • Specimen validity testing is not eligible to be separately billed under any procedure code.  The code description for G0477-G0483 indicates that this testing is included if it was performed.
BMS policy will continue to require a prior authorization for drug screenings performed for over the limit of 30 per calendar year.  The HF modifier must continue to be included on all claims for these codes when related to substance abuse treatment. (e.g. Suboxone).
Under the 2011 federal regulations, WV Medicaid providers are required to revalidate their enrollment in order to be reimbursed for services provided for WV Medicaid members.  This notice is to reach providers from Phases 1 through 10 who have not initiated re-enrollment/revalidation or who started but have not completed the process.
For more information contact Molina Provider Enrollment at 888-483-0793.

Highmark Update

Highmark has expanded the professional and facility manuals that have been available to participating providers in Pennsylvania and Delaware to now include West Virginia. These consolidated manuals will now be a valuable resource applicable to all Highmark participating providers in all of our service areas. If information differs by service area, both manuals will have either separate links within the text or the information will be designated for a specific service area by an icon indicating the state to which the information applies.
In some instances, information may apply to only two states. The information applies to all service areas when no icon appears. A key to the state icons appears on the first page of each unit.
In addition to the new professional and facility manuals, the information participating providers need for servicing West Virginia Medicaid recipients with coverage through West Virginia Family Health (WVFH) is now provided in a separate manual. Previously a chapter in the Provider Manual, the new WVFH Provider Manualis organized by chapters/units on specific topics to help you quickly find the information you need.
Highmark Blue Shield Office Manual

The Highmark Blue Shield Office Manual contains information specific to procedures required of Highmark network participating professional providers. To access the manual from the Highmark West Virginia Provider Resource Center, select Administrative Reference Materials from the main menu. Highmark Facility Manual
The Highmark Facility Manual has new and/or expanded information and adds
to the many resources regarding Highmark West Virginia's policies, procedures
and processes available to providers. The manual is located on the Provider Resource Center under Facility Information.
West Virginia
Family Health Provider Manual
The new West Virginia Family Health Provider Manual is available on the Provider Resource Center under West Virginia Family Health.
story6Other News
WVMGMA Regional Meetings

T he West Virginia Medical Group Management Association invites you to attend one of their upcoming regional meetings. The meetings will be held in four locations and will feature speaker Ken T. Hertz, principal consultant with MGMA.
The meetings will be held in the following locations:
Morgantown-Monday, May 23
Parkersburg----Tuesday, May 24
Beckley---------Wednesday, May 25
Teays Valley---Thursday, May 26
Watch for more information and plan to attend the meeting near you . For additional information, see the WVMGMA website, .

Wesgram Online Copyright   

  ©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.