July 11, 2016

Welcome to the Wesgram Online!  


This edition of the Wesgram contains the latest information about proposed Medicare payment changes, as well as information about upcoming educational events. You'll also find information about the WVSMA's Disaster Relief Fund that has been established to aid in flood relief.   


Physicians--Remember to nominate your Practice Administrator/Manager for the annual "Practice Administrator/Manager of the Year" award.  You can do so directly by using the information found in the Wesgram.  

story1ICD-10 Latest News
Summertime, Summertime....

Here are some common ICD-10 codes for conditions you may be encountering in July:

T75.1XXA - Swimmer's cramp
H60.331 - Swimmer's ear,right ear
B65.3 - Swimmer's itch
W3.9xxA---Discharge of firework as the external cause of injury, initial encounter
W42.9xxA---Exposure to loud noise as the external cause of Injury, initial encounter
X04.xxA---Exposure to ignition of highly flammable material (while attempting to light the    barbecue grill), initial encounter
Palmetto GBA News
(info from Palmetto GBA)

ICD-10: 2017 ICD-10-CM and ICD-10-PCS Files Available
The 2017 ICD-10-CM and ICD-10-PCS code updates, including a complete list of code titles, are available on the 2017 ICD-10-CM and GEMs and 2017 ICD-10-PCS and GEMs webpages. The posted files contain the complete versions of both ICD-10-CM (diagnoses) and ICD-10-PCS (procedures).
Recovering Overpayments from Providers Who Share Tax Identification Numbers
Section 1866j(6) of the Social Security Act authorizes the Secretary to make any necessary adjustments to the payments of a provider of services or supplier who shares a TIN with a provider of services or supplier that has an outstanding Medicare overpayment. The Secretary of Health and Human Services is authorized to adjust the payments of such a provider of services or supplier regardless of whether it has been assigned a different billing number or NPI from that of the provider of services or supplier with the outstanding Medicare overpayment.
CMS' Open Payments Program Posts 2015 Financial Data
The Centers for Medicare & Medicaid Services (CMS) published 2015 Open Payments data, along with newly submitted and updated payment records for the 2013 and 2014 reporting periods. The Open Payments program (sometimes called the "Sunshine Act") requires that transfers of value by manufacturers of drugs, devices, biologicals, and medical supplies that are paid to physicians and teaching hospitals will be published on a public website.
Now You Can Access Your Personal Data to See Who Has Been Using Your NPI
Electronic Utilization (eUtilization) reports are now available in the eServices online provider portal. eUtilization reports provide rendering providers and ordering and referring providers access to their personal data. This data can be reviewed to ensure providers are aware of when and by whom their NPI is being used for billing Medicare services and when their NPI is entered on a Medicare claim as the ordering referring physician. This will provide providers with the ability to identify possible misuse of their NPI. Providers will be able to select a period from 1-12 months for the previous 12 months of data. This data will be updated monthly so that providers can trend their data over time.
Ordering and Referring
This function enables an individual physician to view all Medicare claims billed where their NPI was entered as the ordering and referring provider for a beneficiary. The report will also allow providers to click and see a summary by the type of code for the services billed.
This will allow an individual provider who is part of a group practice or multiple groups to pull a data report for their NPI, which will enable them to view their utilization for each associated provider ID for a specified time period.
How to Sign Up to Receive This Data:
In order to access your data, you will need to have an eServices account. You can sign up at www.palmettogba.com/eservices external link .
Submitting First Level Appeals Through the eServices Portal
Submitting your first level appeals through Palmetto GBA's eServices is fast and free! For current eServices users, if you notice the 'Messages' and 'Forms' tabs are grayed out, ask your practice's eServices administrator to use the 'Admin' tab to edit your user profile and give you access to these functions. Using eServices for the submission of first level appeals saves time and money!
CERT TIP---Ask Questions, Be Informed
Questions Regarding CERT should be directed to the Palmetto GBA website and/or to the Provider Contact Center. Palmetto GBA supports a collaborative partnership between us as your contractor and you as the provider. Filing the claim right the first time is the key to reducing the CERT error rate.
CERT TIP--- Follow-up Record Requests
The CERT Contractor sends follow-up record requests when a response was received to the initial request, but certain required elements of the documentation are still missing. Be sure to closely review the CERT letter for details regarding what documentation is still needed.
Revised CMS-855R Application - Reassignment of Medicare Benefits
Physicians and non-physician practitioners must use the revised CMS-855R (Reassignment of Benefits) application beginning January 1, 2017. The revised application will be posted on the CMS Forms List by mid-summer. Medicare Administrative Contractors (MACs) will accept both the current and revised versions of the CMS-855R through December 31, 2016.
Billing Tests for Zika Virus
The Centers for Medicare & Medicaid Services (CMS) issued MLN Matters SE1615 reminding providers that Medicare covers Zika virus testing under Medicare Part B as long as the clinical diagnostic laboratory test is reasonable and necessary for the diagnosis or treatment of a person's illness or injury. Presently there are no specific HCPCS codes for testing of the Zika virus. This article contains the code to use to billing and a reminder that medical documentation must support the services billed. Clinical laboratories may be asked by Medicare administrative contractors to provide resources and cost information to establish appropriate payment amounts for the tests.
E/M Tips
Review of Systems and Past/Family/Social History Recorded by Patient
The review of systems (ROS) and past, family and social history (PFSH) may be recorded on a form completed by the patient.
Review of Systems - 'All others Negative'
It is acceptable to use the statement 'All others Negative' or 'No other complaints' as long as the pertinent systems/symptoms/problems were addressed and documente

Medicare Proposes Substantial Improvements to Paying for Care Coordination and Planning, Primary Care, and Mental Health in Doctor Payment Rule
Medicare also expands the Diabetes Prevention Program

(info from CMS)

On July 7th, the Centers for Medicare & Medicaid Services (CMS) proposed changes to the Physician Fee Schedule to transform how Medicare pays for primary care through a new focus on care management and behavioral health designed to recognize the importance of the primary care work physicians perform. The rule also proposes policies to expand the Diabetes Prevention Program within Medicare starting January 1, 2018. This is the first time a preventive service model from the CMS Innovation Center would be expanded into the Medicare program.

The rule's primary care proposals improve how Medicare pays for services provided by primary care physicians and other practitioners for patients with multiple chronic conditions, mental and behavioral health issues, as well as cognitive impairment or mobility-related impairments.
These changes will improve payment for clinicians who are making investments of time and resources to provide more coordinated and patient-centered care. These proposed coding and payment changes will better reflect the resources involved in furnishing contemporary primary care, care coordination and planning, mental health care, and care for cognitive impairment, such as Alzheimer's disease. In addition, these proposed changes further reinforce Medicare's transformation to better align priorities and reward physicians for quality care through the Quality Payment Program.

To learn more about these efforts to support and improve access to primary care, please visit the CMS Blog at https://blog.cms.gov/2016/07/07/focusing-on-primary-care-for-better-health/.

In March 2016, CMS announced that the Diabetes Prevention Program met the statutory eligibility criteria for expansion into Medicare. Today, CMS is proposing to expand the Diabetes Prevention Program into Medicare beginning January 1, 2018. The new proposal would allow Medicare Diabetes Prevention Program suppliers, recognized by the Centers for Disease Control and Prevention, to submit claims to Medicare for providing diabetes prevention services. CMS is proposing a process for suppliers to enroll in the program so they can furnish services and bill Medicare as soon as possible after the program becomes effective. 

CMS hopes that the expansion of the Diabetes Prevention Program into Medicare can serve as a model for employers and insurers who may want to initiate diabetes prevention programs in their populations as well.

The annual Physician Fee Schedule updates payment policies, payment rates, and quality provisions for services provided in calendar year 2017. These services include, but are not limited to visits, surgical procedures, diagnostic tests, therapy services, and specified preventive services. In addition to physicians, the fee schedule pays a variety of practitioners and entities, including nurse practitioners, physician assistants, physical therapists, as well as radiation therapy centers and independent diagnostic testing facilities. Additional policies proposed in the 2017 payment rule include:
  • Primary Care and Care Coordination: The rule proposes revisions to payment for chronic care management, including payment for new codes and for extra care management furnished by a physician or practitioner following the initiating visit for patients with multiple chronic conditions. This proposed change is a significant update to the Physician Fee Schedule and will support primary care when and where patients need it most.
  • Mental and Behavioral Health: CMS is proposing to pay for specific behavioral health services furnished using the Collaborative Care Model, which has demonstrated benefits in a variety of settings. In this model, patients are cared for through a team approach, involving a primary care practitioner, behavioral health care manager, and psychiatric consultant. CMS is also proposing to pay more broadly for other approaches to behavioral health integration services.
  • Cognitive Impairment Care Assessment and Planning: CMS is proposing a new code to pay for cognitive and functional assessment and care planning for patients with cognitive impairment (e.g., for patients with Alzheimer's). This is a major step forward for care planning for these populations.
  • Care for Patients with Mobility-Related Impairments: CMS is proposing to pay physicians more accurately for furnishing services to beneficiaries with mobility-related impairments. This increase in payment will improve quality and access for this vulnerable population.  
In addition, CMS evaluated concerns about payment adjustments to Puerto Rican clinicians based on local costs and is proposing a change that would more accurately reflect these costs and significantly increase payments in the Commonwealth. Other changes in the proposed regulation would enhance program integrity and data transparency in the Medicare Advantage program.
For more information, please click here.

CMS will accept comments on the proposed rule until September 6, 2016, and will respond to comments in a final rule. The proposed rule will appear in the July 15, 2016, Federal Register and can be downloaded from the Federal Register at: h ttps://www.federalregister.gov/public-inspection.
Important Reminder about Billing Requirements for Certain Dual-Eligibles
(information from the American Medical Association)
As part of the AMA's ongoing work with the Centers for Medicare & Medicaid Services on issues affecting Medicare providers and beneficiaries, the AMA would like to remind physicians that balance billing is prohibited for Medicare beneficiaries enrolled in the Qualified Medicare Beneficiary (QMB) program. CMS has conveyed their concern that some physicians are still billing QMB beneficiaries, despite the existing prohibition.
The QMB program is a Medicaid program that helps very low-income dual eligible beneficiaries-e.g., individuals who are enrolled in both Medicare and Medicaid-with Medicare cost-sharing. Beneficiaries in the QMB program have annual incomes of less than $12,000. Federal law protects QMBs from any cost-sharing liability and prohibits all original Medicare and Medicare Advantage providers-even those who do not accept Medicaid-from billing QMB individuals for Medicare deductibles, coinsurance, or copayments. All Medicare and Medicaid payments that physicians receive for furnishing services to a QMB individual are considered payment in full. It is important to note that these billing restrictions apply regardless of whether the state Medicaid agency is liable to pay the full Medicare cost-sharing amounts (federal law allows state Medicaid programs to reduce or negate Medicare cost-sharing reimbursements for QMBs in certain circumstances). Physicians may be subject to sanctions for failing to follow these billing requirements, and CMS has indicated that they may start conducting more frequent audits to address this practice.
Payor News and Other News 
Aetna/CoventryCares Announces Medicaid Provider Forums
CoventryCares of West Virginia will be hosting provider forums across the state in July in anticipation of the transition from CoventryCares to Aetna Better Health on September 26, 2016. All CoventryCares of West Virginia providers are encouraged to attend. Representatives will review the upcoming transition and changes.
Sessions will include:
*            Overview of changes to claims billing (address, electronic payer ID, etc)
*            Updates to procedures for disputes and appeals
*            New Provider Portal registration and demo
*            Review of case management, utilization management and pre-authorization
*            Q & A Session with Provider Relations and Operations
Breakfast will be provided. Registration opens at 8 a.m. and the presentation will begin promptly at 9 a.m.   The sessions will end at Noon.
The dates and locations for each session are listed below:
Beckley, WV   07/19/16         
Location: Tamarack Conference Center
Huntington, WV   07/20/16  
Location: Pullman Plaza Hotel
Charleston, WV  07/21/16    
Location: Embassy Suites
Martinsburg, WV   07/25/16 
Location: Holiday Inn
Wheeling, WV   07/26/16     
Location: Oglebay Resort - Wilson Lodge (Glessner)
Parkersburg, WV     07/27/16
Location: The Blennerhasset Hotel
Clarksburg, WV   07/28/16  
Location: Village Square Conference Center
Please RSVP to ABH_WV_ProviderRelations@aetna.com including the office name, number of people planning to attend, and the session you will be attending.
story6Other News
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.
The CMIS (Certified Medical Insurance Specialist) class has a recently added benefit!   A new incentive, The Coding Basics Package, is designed to help those who lack coding experience or want to gain foundational knowledge prior to taking the class.
The FREE package consists of four pre-recorded webinar courses that can be downloaded and reviewed at your convenience. Each presentation includes a 90-minute lecture, presentation PDF, and a quiz that will help participants better prepare for the class. You will receive the Coding Basics Package when you register for the CMIS class.  
This class has not been offered in West Virginia since 2014 and will not be offered again in 2016.
Register now at the WVSMA's website, www.wvsma.org.   
The WVSMA is the exclusive WV partner with PMI.  
Practice Administrator of the Year Award

Nominations are now being accepted for the WVSMA's annual Practice Administrator/Manager of the Year.

The award is presented to an individual recognized as a dynamic medical practice leader and advocate for patient care. The nominee must meet the following criteria:
  • Must be from a WVSMA Member's practice and nominated by a physician member of WVSMA.
  • A dynamic leader is someone who inspires others to be their best, to think about solutions, and can adapt to changing situations and environments.
  • A strong advocate who thinks about the needs of the patient and the patient experience and consistently works to build cohesion among practice staff and the patients they serve. 
The recipient will be recognized at the 2016 WVSMA Healthcare Summit during the Friday evening, August 26 Inaugural Celebration and Gala Dinner at The Greenbrier. 
Nomination deadline is July 31, 2016. To nominate your Practice Manager today click  here and return the completed form to 4307 MacCorkle Avenue SE, Charleston, WV 25304 (attn: Karie Sharp) or fax to (304) 925-0345. 
Questions: Contact Barbara Good  or  Karie Sharp

WVSMA Establishes Disaster Relief Fund to Aid Flood Relief Efforts

(A Message from Paula F. Taylor, MD, President)

In the wake of the tragic and devastating floods that hit West Virginia late last week, the West Virginia State Medical Association (WVSMA), through its West Virginia Medical Foundation (WVMF), has established a special disaster relief fund to collect donations to support the ongoing relief efforts throughout the state. The WVMF is a 501 C(3) not-for-profit charitable foundation under IRS law.
The flooding in central and southeastern West Virginia is historic. The recovery for thousands of West Virginians and dozens of counties and towns across this state is going to be a long, difficult process that requires a multitude of needs. Many of these needs can be anticipated, such as vaccines, first aid supplies, flashlights, batteries, and cleaning supplies and equipment. However, there will be just as many needs that are not anticipated or will not be fulfilled by governmental agencies or local organizations in the affected communities. These can include but are not limited to crisis intervention, mental health services, housing, water, food, clothing and other such services.
The WVMF Disaster Relief Fund will enable Medical Associations, both local societies and state associations from around the nation, as well as pharmaceutical and medical device corporations and other strategic partners from within and outside the state to donate monies that can be utilized to provide basic medical relief efforts and to fill the gaps unexpectedly discovered in the recovery effort.
All donations to the WVMF Disaster Relief Fund will be tax deductible, and all donations will be used to support flood relief efforts as approved by the WVMF Board of Directors. Checks should be made payable to the
                         West Virginia Medical Foundation
                         Attn: Karen Foy
                         4307 MacCorkle Ave., SE
                         Charleston, WV 25304

Please write "WVMF Disaster Relief Fund" on your check.
If you would like to make a donation by credit card, please call the
WVSMA offices at 304-925-0342.

Important Notice about Ransomware
Department of Health and Human Services Secretary, Sylvia Burwell, recently sent a letter to many physician groups regarding ransomware. Several healthcare organizations have recently fallen victim to ransomware, where an attacker gains access to your system, encrypts your data, and holds it hostage until payment is received. This disruptive and debilitating crime can be prevented.
Ransomware has become a real threat to medical practices.   This is when an attacker gains access to your system, encrypts your data, and holds it hostage until payment is received. Unlike many cyber threats like stolen data or compromised health information, ransomware is immediately disruptive for your day to day business functions, making it virtually impossible to provide high quality health care.  
If your practice is the victim of a ransomware attack, you should contact law enforcement immediately. The DHHS recommends that organizations contact a FBI Field Office Cyber Task Force ( www.fbi.gov/contact-us/field/field-offices) or local U.S. Secret Service field office ( www.secretservice.gov/contact/field-offices) immediately to report the event and request assistance.

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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.