Welcome to the Wesgram Online!
Welcome to the November 2016 Wesgram. This edition contains important information from CMS and Palmetto regarding Medicare changes and updates, as well as some fun ICD-10 codes to celebrate the Thanksgiving holiday.
Happy Thanksgiving from the WVSMA staff!
Thanksgiving "Fun" ICD-10 Codes
Y93.63 Activity, Cooking and Baking
W61.42 Struck by Turkey
W71.43 Pecked by Turkey
W61.49 Other Contact with Turkey
W21.01 Struck by Football
R63.2 Polyphagia (Overeating)
W21.01 Lack of Adequate Sleep
(information from Palmetto GBA)
2017 Medicare Physician Fee Schedules Available
Palmetto GBA has posted the 2017 Medicare Part B Physician Fee Schedules (MPFS) on their website, w
, under the Medicare Physician Fee Schedule tool. The files can also be downloaded in Excel or a CSV format.
The 2017 MPFS conversion factor is $35.8887 (up slightly from the 2016 $35.8279), which accounts for the budget neutrality adjustment required by MACRA (0.5%). There is also a slight downward change due to the non-budget neutral 5% Multiple Procedure Payment Reduction for the professional component of imaging services.
Influenza, Pneumococcal and Hepatitis B Vaccines and Administration Reimbursement
These immunizations are paid at 100 percent of the established fee schedule amount.
Coinsurance and the annual deductibles do not apply. The American Medical Association issued a new CPT code for influenza vaccine Flucelvax effective August 1, 2016 for Medicare claims. However, Medicare claims processing systems will not be able to accept the new code until January 1, 2017.
Effective immediately, please hold your claims for the Flucelvax vaccine for dates of service August 1, 2016 - December 31, 2016 following code implementation on January 1, 2017.
Appeals Forms Available in eServices
eServices users can request a first level redetermination, a reopening (simple claim correction) or an overpayment appeal through the eServices portal. Submitting these requests through eServices gets your form to Medicare more quickly than mailing or faxing a paper form and eServices allows you track your form from submission through completion.
New Physician Specialty Code for Hospitalist
The Centers for Medicare & Medicaid Services (CMS) has established a new physician specialty code for Hospitalist. The new code for Hospitalist is C6.
Medicare Secondary Payer Inquiry Form
Palmetto GBA added a Medicare Secondary Payer Inquiry Form in the Finance forms section of our website earlier this year. To ensure timely processing of your request, this form should be used for any Medicare Secondary Payer (MSP) request pertaining to Primary or Secondary payment of claims.
Signatures, Credentials and Dates: All Are Important
Each entry in the patient's medical record requires the acceptable signature of the person writing the note along with the date. Palmetto GBA also recommends the inclusion of the applicable credentials (e.g. P.A., D.O. or M.D.), especially when the services being billed are only coverable when performed by certain credentialed professionals.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate formula, which threatened clinicians participating in Medicare with potential payment cliffs for 13 years. As physician practices are aware, there are many changes coming with the Medicare reimbursement methodology. The following information is from recent CMS calls and discussions.
If a physician participates in Medicare Part B, he/she is a part of the clinicians who serve more than 55 million of Americans. The Quality Payment Program's purpose is to provide new tools and resources to help the physician give patients the best possible care. A physician may choose how he/she wishes to participate based on practice size, specialty, location, or patient population.
The Quality Payment Program has two tracks a provider can choose: (quality measures specifications are not finalized but will be published)
Advanced Alternative Payment Models (APMs) or
The Merit-based Incentive Payment System (MIPS)
If physicians decide to participate in Advanced APM, through Medicare Part B they may earn an incentive payment for participating in an innovative payment model.
If physicians decide to participate in traditional Medicare Part B, they will participate in MIPS where they may earn a performance-based payment adjustment.
The Merit based Incentive Payment System officially begins (performance)
January 1, 2017 and closes December 31, 2017.
Physicians should then submit their performance data by
March 31, 2018. Medicare will then provide feedback to physicians regarding the data submitted.
Physicians may earn a positive MIPS payment adjustment beginning January 1, 2019 if they submit 2017 data by March 31, 2018. If physicians participate in an Advanced APM in 2017, they could earn 5% incentive payment in 2019.
If physicians are not utilizing Electronic Health Records they can still participate and earn in MIPS during the transitional year, but to earn maximum incentive in years 2 and forward they must focus on Electronic Health Records.
Chronic Care Management
If you are not billing for chronic care management (CCM) services that you and your staff are providing, you are leaving revenue on the table. CMS has new CCM codes that will reimburse physicians for the work they are already performing. Reimbursement for current CCM codes is also increasing, as the value of the program is becoming more recognized.
Several changes have been made for 2017, including doing away with the separate benefit consent form for CCM (although physicians must still have a patient's consent for CCM). Also, as of January 1, 2017, CMS no longer requires access to the electronic care plan outside of normal business hours to those providing CCM services.
There is also a new G code (G0506) that may be billed if a face-to-face initiating visit is required before CCM services can be provided. If the patient hasn't been seen during the past calendar year, this code may be utilized. Current patients would not require a separate initiating visit.
2017 Medicare Premiums
The Centers for Medicare & Medicaid Services (CMS) have announced the 2017 premiums for the Medicare inpatient hospital (Part A) and physician and outpatient hospital services (Part B) programs.
Medicare Part B Premiums and Deductibles
Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and other items.
On October 18, 2016, the Social Security Administration announced that the cost-of-living adjustment (COLA) for Social Security benefits will be 0.3 percent for 2017. Because of the low Social Security COLA, a statutory "hold harmless" provision designed to protect seniors, will largely prevent Part B premiums from increasing for about 70 percent of beneficiaries. Among this group, the average 2017 premium will be about $109.00, compared to $104.90 for the past four years.
For the remaining roughly 30 percent of beneficiaries, the standard monthly premium for Medicare Part B will be $134.00 for 2017, a 10 percent increase from the 2016 premium of $121.80. Because of the "hold harmless" provision covering the other 70 percent of beneficiaries, premiums for the remaining 30 percent must cover most of the increase in Medicare costs for 2017 for all beneficiaries. This year, as in the past, the Secretary has exercised her statutory authority to mitigate projected premium increases for these beneficiaries, while continuing to maintain a prudent level of reserves to protect against unexpected costs. The Department of Health and Human Services (HHS) will work with Congress as it explores budget-neutral solutions to challenges created by the "hold harmless" provision.
Medicare Part B beneficiaries not subject to the "hold harmless" provision include beneficiaries who do not receive Social Security benefits, those who enroll in Part B for the first time in 2017, those who are directly billed for their Part B premium, those who are dually eligible for Medicaid and have their premium paid by state Medicaid agencies, and those who pay an income-related premium. These groups represent approximately 30 percent of total Part B beneficiaries.
CMS also announced that the annual deductible for all Medicare Part B beneficiaries will be $183 in 2017 (compared to $166 in 2016). Premiums and deductibles for Medicare Advantage and prescription drug plans are already finalized and are unaffected by this announcement.
2017 Participating Provider Guidelines
Every year physicians have the opportunity to become a participating provider. The open enrollment period begins November 14 and ends on December 31, 2016. A participating provider enters into an agreement to accept the Medicare-approved amount as full payment for services and supplies covered under Part B. A participating provider receives five percent more reimbursement than a non-participating provider. The participation agreement will automatically renew each year. However, if there is a name or EIN (tax identification number) change, you will need to complete a new participation agreement.
UnitedHealthcare has been sending out the results of the Physician Premium Designation assessments.
Physicians who are in geographic areas where the UnitedHealth Premium Designation Program is available and practice in one of the Premium-eligible medical specialties will soon receive their Premium designation. The physician notification letter includes your Premium Designation along with instructions on how to access your Premium assessment reports.
Practice administrators for these physicians will also receive a group-level assessment letter that includes summary information by medical specialty.
Designations will be publicly displayed on Jan. 4, 2017. Prior to public display of your designation, the plan will provide time for physicians to review their assessment reports and request reconsideration, if applicable. Submit your request on or before Dec. 5, 2016 so UnitedHealthcare can make any applicable changes to your designation before it is publicly displayed.
Mark Your Calendars Now!
The WVSMA and the WVMGMA will again combine forces this year to host a conference for physicians, management and staff. Mark your calendars now for
Friday, March 24th 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!
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