Welcome to the Wesgram Online!
Welcome to the May 2016 Wesgram. This edition contains many updates that are important for you and your practice. You can also check out upcoming educational opportunities for physicians and staff. As always, if you have questions, please contact WVSMA Physician Advocate, Barbara Good.
As all know well, the United States finally began using ICD-10 codes officially on October 1, 2015. The Centers for Disease Control has announced approximately
2600 new ICD-10 CM code changes that take effect on October 1, 2016.
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.
For the benefit of our physician practices who want to ensure proper coding and billing, the WVSMA has scheduled a Certified Medical Coder class for this fall. We will also keep you updated of code changes in order to help you keep receiving maximum reimbursement.
Physician practices 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" or "soft" denials period ends.
(information from Palmetto GBA)
E/M Tip: Initial Preventative Physical Examination (IPPE) and Annual Wellness Visit (AWV)
When the physician or qualified non-physician practitioner (NPP) provides a significant, separately identifiable medically necessary E/M service in addition to the Initial Preventative Physical Examination (IPPE) or an Annual Wellness Visit (AWV), CPT codes may be reported depending on the clinical appropriateness of the circumstances.
Note: Some of the components of a medically necessary E/M service (e.g., a portion of history or physical exam portion) may have been part of the IPPE or AWV and should not be included when determining the most appropriate level of E/M service to be submitted for the
medically necessary, separately identifiable, E/M service.
Orders For Tests Must Be Signed
If an order for tests is unsigned, you may submit progress notes showing intent to order the tests. The progress notes must specify what tests were ordered. A note stating "Ordering Lab" is NOT sufficient. If the orders and the progress notes are unsigned, your facility will be assessed an error, which may involve recoupment of an overpayment.
Create a Signature Log
If a provider does not have a signature log currently in place, he/she may create a signature log at any time. Medicare contractors will accept all submitted signature logs, regardless of the date on which they were created.
For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or electronic signature.
Stamped signatures are not acceptable.
eServices: Preventive Services Eligibility
Do you want to check when your Medicare patient is eligible for his or her next preventive service? The preventive sub-tab in eServices identifies the HCPCS code noted as a preventive service.
Lack of Signature Could Affect Provider Reimbursement
If a signature is missing from an order, claims reviewers will disregard the order during the initial review of the claim which results in a claim denial and no reimbursement to the provider.
E/M Tip: Examination
A brief statement or notation indicating 'negative' or 'normal' is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s
Provider Enrollment Requirements for Writing Prescriptions for Medicare Part D Drugs
All physicians and other eligible professionals who write prescriptions for Part D drugs must be enrolled in an approved status or to have a valid opt-out affidavit on file for their prescriptions to be coverable under Part D, except in very limited circumstances. The enrollment must be completed through Palmetto GBA. CMS recently revised a previously published article to show the delayed enforcement of the Part D prescriber enrollment requirement until February 1, 2017. All other information remains the same.
The purpose of these rules are to ensure that Part D drugs are prescribed only by physicians and eligible professionals who are qualified to do so under state law and under the requirements of the Medicare program and who do not pose a risk to patient safety. By implementing these rules, CMS is improving the integrity of the Part D prescription drug program by using additional tools to reduce fraud, waste, and abuse in the Medicare
program. Prescribers who are determined to have a pattern or practice of prescribing Part D drugs that are abusive and represents a threat to the health and safety of Medicare enrollees or fails to meet Medicare requirements will have their billing privileges revoked.
If you write prescriptions for covered Part D drugs and you are not already enrolled in
Medicare in an approved status or have a valid record of opting out, you should submit an enrollment application or an opt-out affidavit to Palmetto GBA by August 1, 2016, or earlier, so that the prescriptions you write for Part D beneficiaries are coverable on and after February 1, 2017.
JW Modifier: Drug Amount Discarded/Not Administered to any Patient
The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 9603 of the change in policy regarding the use of the JW modifier for discarded Part B drugs and biologicals.
Effective July 1, 2016, providers are required to use the JW modifier for claims with unused drugs or biologicals from single use vials or single use packages that are appropriately discarded (except those provided under the Competitive Acquisition Program (CAP) for Part B drugs and biologicals) and document the discarded drug or biological in the patient's medical record when submitting claims with unused Part B drugs or biologicals from single use vials or single use packages that are appropriately discarded.
Remember that the JW modifier is not used on claims for CAP drugs and biologicals.
Medicare Coverage of Substance Abuse Services
While there is no distinct Medicare benefit category for substance abuse treatment, such services are covered by Medicare when reasonable and necessary. The Centers for Medicare & Medicaid Services (CMS) provides a full range of services, including those services provided for substance abuse disorders. MLN Matters Publication #1604
summarizes the available services and provides reference links to other online Medicare information with further details about these services.
Influenza Vaccine: Reminder
It is important to bill using the correct HCPCS code for the influenza vaccine administered. To assist you with selecting the correct HCPCS code for your vaccine, use the CMS ASP NDC-HCPCS Crosswalk for Medicare Part B Drugs available on the CMS website.
Review Your Data Before it Becomes Available to the Public
Review and dispute for the June 30, 2016 Open Payments data publication opened on Friday, April 1, 2016, and will last for 45 days. CMS will publish the 2015 payment data and updates to the 2013 and 2014 data on June 30, 2016. In order for any disputes to be addressed before the June 30th publication, physicians and teaching hospitals must initiate their disputes during the 45-day review period, and industry must resolve the dispute before the publication deadline. Review and dispute is voluntary, but strongly encouraged. The opportunity for physicians and teaching hospitals to review and dispute the data submitted about them expires at the end of the year that the record is first published.
If You Have Never Registered with Open Payments Before:
Make sure you have your National Provider Identifier (NPI) number, Drug Enforcement Agency (DEA) number, and State license number (SLN). Initial registration is a two-step process and should only take 30 minutes:
For Users That Registered Last Year and Have Used Their Accounts in the Last 60 Days:
Physicians who registered last year do not need to reregister in the EIDM or the Open Payments system. If the account has been accessed within the last 60 days, go to the CMS Enterprise Porta, llog in using your user ID and password, and navigate to the Open Payments system home page.
For Users That Registered Last Year but Have Been Inactive for More than 60 Days:
The EIDM locks accounts if there is no activity for 60 days or more. To unlock an account, access the CMS Enterprise Portal,enter your user ID and correctly answer all challenge questions; you'll then be prompted to enter a new password.
For Users That Registered Last Year but Have Been Inactive for More than 180 Days:
The EIDM deactivates accounts if there is no activity for 180 days or more. To reinstate an account that has been deactivated, contact the Open Payments Help Desk.
For assistance with the registration process, please call the CMS live Help Desk at 1-855-326-8366, Monday through Friday, from 8:30 a.m. to 7:30 p.m. (ET), excluding Federal holidays. Questions can also be submitted to the Help Desk via email, at
Questions-Contact Live Help Desk
Submit questions to the Help Desk via email at
or by calling 1-855-326-8366, Monday through Friday, from 8:30 a.m. to 7:30 p.m. (ET), excluding Federal holidays.
The Help Desk refers media inquiries to CMS' Press Office for response.
CMS Revalidation Update
The Centers for Medicare & Medicaid Services (CMS) has established due dates by which the provider/supplier's revalidation application must reach the Medicare Administrative Contractor (MAC) in order for them to remain in compliance with Medicare's provider enrollment requirements. The due dates will generally be on the last day of a month (for example, June 30, July 31 or August 31). Please submit your revalidation application to Palmetto GBA by the established due date to avoid a hold on your Medicare payments and possible deactivation of your Medicare billing privileges.
The list is available at
external link and includes all enrolled providers/suppliers. Those due for revalidation will display a revalidation due date, all other providers/suppliers not up for revalidation will display a 'TBD' (To Be Determined) in the due date field. This means that you do not yet have a due date for revalidation. Please do not submit a revalidation application if there is not a listed due date. All unsolicited revalidation applications will be returned without processing. An unsolicited revalidation application is an application submitted from providers or suppliers who are not due to revalidate (i.e., display a TBD on the Revalidation Lookup Tool, a revalidation notice has not been received from their MAC requesting them to revalidate or the application is submitted more than six months in advance of the due date).
CMS recently released a Notice of Proposed Rulemaking (NPRM) for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Supported by a bipartisan majority and stakeholders, such as patient and medical associations, the MACRA legislation ended more than a decade of last-minute fixes and potential payment cliffs for Medicare doctors and clinicians. It also made numerous improvements to America's health care system.
Here are the new proposed MACRA Requirements:
Currently, Medicare measures the value and quality that physicians and other clinicians provide through a patchwork of programs. In the MACRA legislation, Congress streamlined these programs into a single framework to help clinicians transition to payments based on value from payments based on volume. The proposed rule would implement changes through this unified framework known as the Quality Payment Program, which includes two paths (The Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).
Most Medicare clinicians will initially participate in the Quality Payment Program through MIPS. MIPS allows Medicare clinicians to be paid for providing high value care through success in four performance categories:
1. Quality (50 percent of total score in year 1)
2. Advancing Care Information (25 percent of
total score in year 1)
3. Clinical Practice Improvement Activities (15
percent of total score in year 1)
4. Resource Use (10 percent of total score in
Another option are the Advanced Alternative Payment Models (APMs). Clinicians who take a further step toward care transformation would be exempt from MIPS reporting requirements and qualify for financial bonuses.
These models include:
1. Comprehensive ESRD Care Model (Large
Dialysis Organization arrangement)
2. Comprehensive Primary Care Plus (CPC+)
3. Medicare Shared Savings Program - Track 2
4. Medicare Shared Savings Program - Track 3
5. Next Generation Accountable Care
6. Oncology Care Model Two-Sided Risk
Arrangement (available in 2018)
You can submit comments using one of the four methods in the rule until June 27. 2016.
For More Information, you may contact:
HHS MACRA NPRM Press Release Quality Payment Program Fact Sheet Advancing Care Information
150 S. Independence Mall West
The Public Ledger Building, Suite 216
Philadelphia, PA 19106
Phone: (215) 861-4154
Fax: (215) 861-4243
The WVSMA is committed to keeping you up to date about MACRA.
West Virginia Medicaid recently announced that physicians who provide services to Medicaid patients in West Virginia will now be seeing payment delays, further cuts in reimbursement, or possibly both. A letter was sent by the WVDHHR, Bureau of Medical Services (BMS), to all Medicaid Providers alerting them that, "absent an upward trend in revenues or a funding solution identified, the BMS will be unable to continue to process claims at the same consistent level that has been maintained." In other words, physicians and other providers can expect to see payment delays while the BMS attempts to address its budgetary shortfalls. In the meantime, physicians will be expected to continue caring for the more than 550,000 Medicaid patients who rely on their services without expectation for compensation in a reasonable time frame.
Medicaid has confirmed that this reimbursement delay does NOT apply to WVCHIPs payments.
At this time, the four WV MCOs have also confirmed that they are reimbursing timely, per contract.
CoventryCares has announced that in September 2016 they will be transitioning to Aetna Better Health of WV. The plan will have be "rebranding" at that time and all website/provider manuals will be update.
Also, the plan's pre-authorization unit is moving to the Charleston office. The new pre-authorization phone number is 1-844-835-4930.
PEIA has announced a number of plan benefit changes that will be effective July 1, 2016. Medical home office visit copays will increase to $20.00 per visit for PEIA PPB Plans A, B, and D for members in these West Virginia plans. Non-state members will continue to pay $10.00 copay. State/non-State will be noted on the ID card. The Urgentcare copay will also increase to $50.
Out of state, non-network services are no longer covered in any of the PEIA PPB Plans. Patients will be responsible for 100% of billed charges from non-network providers outside West Virginia, except in a medical emergency or when approved in advance by HealthSmart.
Additional emergency room copays of $500.00 will be required for high risk behaviors, such as:
- Accidents while driving motorcycles/UTV/ATV without a helmet
- DUI/DWI or drug related accident
- Failure to wear a seatbelt
Opiod pain medications will have quantity limits for all medications in the opiod class. Additional quantities will require Prior Authorizations.
There will be a new Pharmacy Benefit Manager (PBM) as of July 1, when the plan switches from Express Scripts to CVS Caremark. HealthSmart will continue to be the TPA for PEIA.
Provider reimbursement will be reduced to100% of Medicare allowance over the next 3 years. In year 1 (2017) there will be a 3% decrease. Although this change goes into effect with the new benefit plan on July 1, PEIA has said that the plan will not implement the reduction until January 2017.
UniCare Health Plan Update
UniCare now has a new benefit for members that gives patients access to immediate postpartum placement of long-acting reversible contraception: intrauterine devices (IUDs) and etonogestrel implants.
During an inpatient facility admission, physicians will have the ability to implant the device of your patient's choice and receive the same reimbursement as if the device were implanted on an outpatient basis. The inpatient facility will provide the device. Please work closely with your obstetrical unit to understand the logistics of obtaining the devices.
UniCare requests that physicians discuss with patients the option for immediate postpartum placement of long-acting reversible contraception during the third trimester of pregnancy. The plan requests that physicians provide additional counseling and support to your teenage and young patients (ages 13-19) as this group is at the greatest risk for early discontinuation of these methods. It appears that there is lower discontinuation at two years of IUDs as compared to the etonogestrel implant. When clinically appropriate, IUDs should be considered over the implant.
According to UniCare, unintended pregnancies are associated with higher rates of maternal and neonatal complications of pregnancy and continue to be a concerning health problem in the United States. Long-acting methods are more effective at preventing unintended pregnancies, have significantly greater continuation rates than oral contraceptives, the vaginal contraceptive ring or the contraceptive patch. These methods also have very low rates of serious side effects.
The West Virginia Section Chair of the American Congress of Obstetrics and Gynecology (ACOG) has issued a statement endorsing postpartum long-acting reversible contraception. The National American Congress of Obstetrics and Gynecology has also promoted postpartum long-acting, reversible contraception, and this is outlined extensively in several documents. The most notable of these is committee opinion number 642, October 2015, Increasing Access to Contraceptive Implants and Intrauterine Devices to Reduce Unintended Pregnancy. Additional information, including a complete list of all documents and training videos are available on the ACOG website,
If you have questions about information or need assistance with any other item, please contact UniCare Customer Care Center toll free at
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.
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 for each meeting.
Monday, May 23
Holiday Inn Morgantown - University Area
9:00am - 11:15am
Tuesday, May 24
Camden Clark Hospital
10:30am - 2:00pm
Wednesday, May 25
Mountain State Co-op
10:00am - 2:00pm
Thursday, May 26
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.
You may register for the CMIS on the WVSMA's website
The WVSMA is the exclusive WV partner with PMI.
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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.