Happy Halloween to all! This edition contains important updates from CMS, Palmetto  GBA, and other payers, as well as information about MACRA and Quality Reporting. You'll also find information about upcoming educational events.
ICD-10 Latest News
Here are some fun ICD-10 codes for Halloween:
E843            Fall from a broom
S11.95.X      Open Bite of Unspecified Part of the Neck, Initial encounter
Z72.820.      Sleep Deprivation (Zombie???)
Y93.D          Activities involving arts and handcrafts (making a costume!)
16. X99.2     Assault by sword or dagger
R46.1           Bizarre personal appearance
(information from Palmetto GBA)

Overpayment Demand Letters Added to eServices
Palmetto GBA is pleased to offer secure and fast delivery of HIGLAS (Healthcare Integrated General Ledger Accounting System) generated overpayment demand letters through Palmetto GBA’s eServices self-service portal! All providers who are enrolled in eServices will receive both hard copy demand letters and electronic copies through December 1, 2017. Providers have until December 1 to update their eServices profile if you choose to opt out of electronic delivery of these letters. After December 1, 2017, providers who have not opted out will receive only the electronic letter copy. Choose eDelivery instead of US Mail and save time and money.
Medicare covers annual screening for adults for depression in the primary care setting that has staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment and follow-up.
The CMS has posted the 2017-2018 season influenza vaccine payment limits on the CMS Seasonal Influenza Vaccines Pricing webpage, which will be applied retroactively for claims with dates of service August 1, 2017 – September 19, 2017. No action is required by providers. These instructions supersede instructions given in MLN Matters MM10224 regarding claim adjustments.
Physician Responsibilities When Using Outsourcers
As a reminder, the Centers for Medicare and Medicaid Services (CMS) requires providers, billing companies, and outsourced agencies to use the Interactive Voice Response (IVR) system or the Palmetto GBA eServices tool to verify eligibility and claim status. An increase in these inquiries from billing companies and outsourced agencies has been noted where some are failing and/or refusing to use the IVR or Palmetto GBA eServices. Additionally, some of these individuals are not familiar with basic Medicare coverage or billing requirements and explanations and guidance must be repeated on every call.

If you use a billing company or an outsourced agency to perform any of your Medicare work, please remember, these companies are representing your practice. When the PCC recognizes a pattern of calls where a vendor is not using the IVR or eServices for eligibility or claim status, Palmetto GBA may contact the billing provider to discuss their vendor’s activities that are unnecessarily and incorrectly tying up the PCC phone lines.

You can help by making sure that you are providing your vendor with access to the Medicare remittance and appeal notices for services/claims they will be working on and that your vendors:

  • Have knowledgeable staff:
  • Are aware of and following Medicare rules and regulations and are using resources available on the Palmetto GBA and CMS websites; and
  • Understand the requirement and will or are using the available IVR and eServices tools to verify eligibility and claims status

Providers are also cautioned to remember that the responsibility to guard Medicare beneficiary Protected Health Information (PHI) lies with the provider and not with the outsourcing agency or billing company. So if a PHI disclosure were to occur, the provider would be held liable for any financial penalties related to that disclosure. It is important that you verify adequate processes are in place to ensure PHI is protected.
A new Part B frequently asked question has been added to assist providers understanding of Claim Adjustment Reason Code (CARC) 209. This informational CARC allows providers to identify a beneficiary enrolled in the Medicaid/Qualified Medicare Beneficiary (QMB) program and that the patient has no Medicare cost-sharing liability. CARC 209 indicates amounts identified may be billed to subsequent payers. Some providers’ accounting systems or software protocol may be automatically writing off these amounts. Providers will need to research their individual write-off procedures and software protocols.
CMS employs several review contractors to measure, prevent and identify improper payments. These review contractors manually review claims against the submitted medical documentation to verify the providers' compliance with Medicare rules and regulations. These review contractors include: Palmetto GBA; Comprehensive Error Rate Testing Contractors (CERT), Recovery Auditor Contractor (RA) and Zone Program Integrity Contractors (ZPIC). With so many 'eyes' watching, be sure to ensure documentation is complete prior to submitting.
E/M Tip: 1995 Guideline
The levels of E/M services are based on four types of examination that are defined as follows: Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive.
E/M Tip: Combined Billing
Physicians in the same group practice, but who are in different specialties, may bill and be paid without regard to their membership in the same group. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.
MACRA Update

The CMS’ new service center for the Quality Payment Program under MACRA saw a spike in calls as the Oct. 2 deadline approached for those who wanted to submit 90 days of performance data. However, in the first year of MIPS, practices can also submit a single measure for a single patient as they test out the program, said Kate Goodrich, M.D., the CMS chief medical officer.  

Dr. Goodrich also stated that she wants to get the word out that the deadline was only around the 90-day reporting period. Time isn’t up for those who want to report a single measure. You won’t get a [payment] bonus, but you won’t get a penalty. 

CMS Releases PQRS and VM Reports
( information provided by the AMA)

Physicians who want to contest potential payment penalties associated with the 2018 Physician Quality Reporting System (PQRS) and/or the Value Modifier (VM) have until Dec. 1, 2017, to request an informal review of their data. The penalties in question stem from policies in effect prior to enactment of the Medicare Access and CHIP Reauthorization Act (MACRA). However, CMS has proposed some revisions intended to lessen the impact of prior policies and has based its calculation of related payment adjustments on these more lenient proposals.

Revisions in the prior VM and PQRS policies were laid out in the 2018 Medicare Physician Fee Schedule proposed rule issued last summer, and came about as the result of advocacy from the AMA and other medical organizations. They will reduce the number of PQRS and VM penalties as well as the severity of VM penalties that would otherwise have occurred in 2018 based on performance in 2016. 

If the proposals are finalized, a 2 percent PQRS penalty and a VM penalty could be avoided by having reported six measures in 2016, rather than complying with the previous reporting requirements of nine measures that crossed at least three domains and included one cross-cutting measure. The proposal would also halve VM penalties and bonuses, with penalties falling from a maximum of 4 percent to 2 percent for groups of 10 or more and from a maximum of 2 percent to 1 percent for smaller practices. In the unexpected event that these more lenient policies are overturned in the final Fee Schedule rule, penalties will be recalculated based on the prior policies. 

Physicians can determine whether they will be subject to PQRS and/or VM adjustments on their 2018 Medicare fee-for-service claims by examining their 2016 PQRS feedback reports for PQRS adjustments and their 2016 Quality and Resource Use Reports (QRURs) for VM adjustments. They will also receive letters stating whether they will or will not receive a 2 percent PQRS penalty in 2018. CMS has no plans to send a separate letter about the VM. Therefore,   the AMA highly encourages practices to download and review their QRURs and PQRS feedback reports to determine whether they are subject to potential PQRS and/or VM payment adjustments and ensure that such adjustments are based on the reduced requirements and penalties before filing for an Informal Review with CMS.

Those who have questions, even if they are uncertain about penalty status, are urged to submit a request for an informal review. CMS has said that it cannot guarantee that filing for an informal review in either PQRS or VM will automatically trigger an informal review in the other. Therefore, the safest course is to file requests for review of both PQRS and VM data. 

Filing an informal review and/or accessing PQRS reports and QRURs requires an Enterprise Identify Management Account (EIDM) with the appropriate role. Consequently, it will also be necessary to determine whether someone within the practice has such an account and to set one up if it does not already exist. 

For additional questions regarding the informal review process, contact the QualityNet Help Desk at 866-288-8912 (TTY 877-715-6222) or  Qnetsupport@hcqis.org. The help desk takes calls Monday–Friday, 7 a.m.–7 p.m. CDT. To avoid security violations, do not include personal identifying information, such as Social Security Number or TIN, in email inquiries to the QualityNet Help Desk.

For additional questions regarding EIDM, contact the QualityNet Help Desk at  qnetsupport@hcqis.org  or 866-288-8912 (TTY 877-715- 6222); For QRURs or the Value Modifier, contact the Physician Value Help Desk at  pvhelpdesk@cms.hhs.gov  or 888-734-6433 (select option 3).

Find Status by NPI
(information from CMS)
National Provider Identifier (NPI)

This is an interactive tool where many 2017 Advanced APM participants can look up their Qualifying APM Participant (QP) status based on calculations from claims with dates of service between 1/1/17 and 3/31/17 for the first QP snapshot. It will be updated soon with calculations from claims with dates of services between 1/1/17 and 6/30/17. The Methodology Fact Sheet is an excellent resource to understand how CMS  determines  QP Status.

There are approximately 75,000 National Provider Identifiers (NPI) included in this first QP analysis.
All statistics are based on the following:

  •      A clinician is defined by an NPI.
  •      Eligible clinicians in the Comprehensive Joint Replacement Model are not included.
  •       All eligible clinicians were assessed as part of an APM Entity group.

There are certain exceptions for which QP determinations are made at an individual clinician level:

  •  individuals participating in multiple Advanced APM Entities, none of which achieve QP  status as a group, and
  •  eligible clinicians on an Affiliated Practitioner List when that list is used for the QP determination because there are no eligible clinicians on a Participation List for the Advanced APM Entity. For example, Affiliated Practitioners in the CJR Track 1- CEHRT Model will be assessed individually.
Payer News

  Humana Update

Humana reminds physicians that the Charleston Area Medical Center Facilities are now all contracted with Humana as of April 1, 2017. Prior to this time, CAMC was only in-network for Humana PEIA retirees. 

Humana will also be managing TriCare as of January 1, 2018.  There will be some provider enrollment changes coming with the change. The WVSMA will notify physician practices when we receive the information. 
PEIA Update

West Virginia PEIA has announced that they have suspended their requirement that a modifier be included on the code for the delivery of a newborn.  The notice of required modifiers was sent to physicians on January 1, 2017 and effective as of April 1, 2017.  If Medicaid implements a policy, in the future, PEIA may reactivate the policy.

Devoted Health

Devoted Health is a new Medicare Advantage plan that plans to enter the West Virginia market for enrollment in the fall of 2018. The plan is currently contacting  physicians with participation agreements as they build a provider network.  As always, the WVSMA recommends that you review any agreements prior to signing. 

Other News  
EHR Cautions for Medical Records
(information from CMS.gov)

EHRs allow medical professionals a seamless approach for coordinating and managing their patient records. They can help reduce paperwork, eliminate duplicate tests, and facilitate code assignment for billing. However, it should be noted that recent reports indicate physicians are concerned about system interoperability, documentation overload, and untested billing systems. While EHRs can improve health care delivery and provider services, they can pose provider challenges. Challenges include, but are not limited to, privacy and security, author identification, altering entry dates, cloning, upcoding, and coding modifiers. Further details on each challenge are explained in the following points:

1. Security and Privacy—EHRs can offer multiple improvements over paper documentation. They can also pose security and privacy issues, such as allowing a malicious user to obtain patient information. Providers should be aware of security features offered and utilize them when using EHRs. Security features include secure networks, firewalls, encryption of data, and password protection that ensures only appropriate or authorized entities can access certain information. Sites where EHRs are maintained should be locked with facility access restricted. EHRs should be backed up to control the risk of data loss from natural disasters or system failure. In addition, edits, audits, and system logs should be enabled to track all persons accessing and editing EHR information. When using EHRs with mobile equipment, such as laptops and thumb drives, be sure to encrypt the information to prevent disclosure of personal health information.

 2. Author Identification—Different providers may add information to the same progress note. When this occurs, each provider should be allowed to sign his or her entry, allowing verification of the amount of work performed and which provider performed the work.

3. Altering Entry Dates—Be sure the EHR system has the capability to identify changes to an original entry, such as “addendums, corrections, deletions, and patient amendments.” When making changes, the date, the time, the author making the change, and the reason for the change should be included. Some systems automatically assign the date an entry was made. Others allow authorized users to change the entry date to the date of the visit or service. Some systems allow providers to make undated amendments without noting that an original entry was changed. If there is no date and time on the original entry or subsequent amendments, providers cannot determine the order of events, which can impact the quality of patient care provided.

4. Cloning—This practice involves copying and pasting previously recorded information from a prior note into a new note, and it is a problem in health care institutions that is not broadly addressed. For example, features like auto-fill and auto-prompts can facilitate and improve provider documentation, but they can also be misused. The medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter. Simply changing the date on the EHR without reflecting what occurred during the actual visit is not acceptable. Using electronic signatures or a personal identification number may help deter some of the possible fraud, waste, and abuse that can occur with increased use of EHRs. In its 2013 work plan, the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG) indicated that due to the growing problem of cloning, its staff would be paying close attention to EHR cloning.

5. Upcoding—Upcoding, sometimes known as “code creep,” occurs when a provider bills for a higher Current Procedural Terminology (CPT) code than the service actually furnished, resulting in higher payment. Again, auto-fill and auto-prompts can facilitate and improve documentation, coding, and billing, but if used inappropriately, these tools may suggest a higher billing code and payment than the actual services furnished warrant, resulting in an improper payment. Claims paid without the appropriate supporting documentation are improper payments, and providers must return them.
6. Code Modifier—A modifier is an extension of an assigned code, such as a CPT code. Two reasons for using procedure codes include communicating the professional medical services performed and billing for the services provided. Modifiers are used in conjunction with codes to complete the picture of the procedures and services provided. More complex services may require additional modifiers. When using modifiers, medical professionals should only use them to clarify the procedures and services performed and never for the purpose of increasing reimbursement.

 7. Transition from Paper to EHR—EHR users may continue to use paper records. Paper records are more permanent, and it is easy to discern if they have been altered in any way. Edits to an EHR may not always be obvious, so providers should establish safeguards to protect against fraud, abuse, and human error. Some of the safeguards for paper records can be applied to EHRs, like documenting who enters or edits data in an EHR, and, when creating backups (and, if paper records are retained), cross-checking the EHR with the paper record. Additionally, an EHR may lack the visual cues (for example, the colored letter tabs) that help a provider or staff member know they are working in the correct record. These potential issues require specific training in EHR data entry and management.

Educational Opportunities 
Huntington Area Medical Practice Consortium

The Huntington Area Medical Practice Consortium will meet on Thursday, November 9 th , 2017, beginning at 5:00 PM in the Dr. Charles “Skip” Turner Memorial Education Center at HIMG. 

The meeting will focus on MIPs: CoPs, and ACOs.  The evening is being sponsored by Valley Health Care and is open to all practice administrators.  

WVSMA/WVMGMA Spring  Conference
The WVSMA and the WVMGMA will again combine forces in 2018 to host a conference for physicians, management and staff. Mark your calendars now for  Friday, March 23, 2018 at the Embassy Suites in Charleston.  The groups are preparing a wide variety of programming to keep you apprised of all that is happening in the healthcare arena. Plan now to attend and watch both association websites for updates