August 2016

Welcome to the Wesgram Online!  


This edition of the Wesgram contains information about upcoming classes and events, as well as payor news.  You'll also find an update on the ransomware information that was provided previously. 

story1ICD-10 Latest News

MACRA, MIPS, APMS--What Do They Mean For My Practice?

Every practice needs to know about these new payment models. WVSMA is ready to help you!

Now is the time to begin taking steps toward becoming a more data driven practice. Good data and metrics will drive these new payment models in healthcare. Quality-based measurements are no longer optional. Under MIPS, practices will be reimbursed in 2019 based on quality metrics reporting in 2017. Act now to prepare your practice and set the stage for future financial success!

The WVSMA is offering two courses to help you prepare, both by learning about the new payment methods, and by learning the updated ICD-10 codes for 2017 and beyond. Classes will be offered on Monday, September 12, or Tuesday, September 13, 2016, at the WVSMA in Charleston, WV. You may choose which courses to take and which day to take the class. 
ICD-10-CM Coding - Bad Habits Revealed
(This class will address the New Payment Methods and Preparations Needed to Become a Data Driven Practice)

Time:   9am-Noon
CEUs: 3 Hours
ICD-10 Coding Update 2017

Time:   1pm - 4pm
CEUs: 3 Hours 
Full day, both courses

Time:   9am- 4pm
CEUs: 6 Hours

Register today at the WVSMA website,   

The WVSMA is also offering the Certified Medical Coder certification class beginning on Friday, October 21, 2016. This 5 day class will provide nationally recognized certification for coders. Registration information is available on the WVSMA website,

Finally, here are some ICD-10 fun codes for summer:

T67.0XXD - Heatstroke and sunstroke, subsequent encounter

Y93.02 - Activity, running

Y92.414 - local residential or Business Street as the place of occurrence of the external cause

S62.035A - Non-displaced fracture of proximal third of navicular [scaphoid] bone of left wrist, initial encounter for closed fracture
Y93.18 - Activity, surfing, windsurfing and boogie boarding
Y92.832 - Beach as the place of occurrence of the external cause

Palmetto GBA News
(information from Palmetto GBA)

New Call Back Assist Program Eliminates Wasted Time

Palmetto GBA now offers a new option that you can choose when you call into the Provider Contact Center (PCC) and call wait times are long. This feature will allow you to choose to leave a message with your name and contact number in order to get a callback as opposed to waiting on the phone line. This callback will occur within the same day, and sometimes within the hour.

eServices: Claim Status
To check on a particular claim status, please enter the HICN and other required beneficiary information, as well as the date(s) of service. Should you not know the exact date of service, you are able to enter a span or range of up to 45 days.
eServices: How Often is Patient Eligibility Updated?
The eServices application is required to use CMS' HETS 270/271 system for all eligibility inquiries. Although eServices pulls data from HETS in real time, the data available in the HETS 270/271 system is only updated at certain times. CMS currently pulls the updated data Tuesday through Saturday during the hours of 6 p.m. and 8 p.m. This data is then uploaded into HETS during the hours of 9 p.m. to 6 a.m. As soon as updated data is available in the HETS 270/271 system, providers will be able to view it in eServices.
eServices Password Login Recommendation
Palmetto GBA recommends logging in to eServices every 30 days to ensure your user ID is not disabled. CMS system security requirements require your password to be changed every 60 days. This is especially important if you are a provider administrator, as this could also impact those account user IDs who are signed up under your ID.

Medicare Secondary Payer (MSP) eServices Tab
eServices allows users to identify when a patient has coverage primary to Medicare under the Medicare Secondary Payer (MSP) tab. The MSP tab will display active MSP data based on the dates you request if they are within the past 12 months.
Protecting Patient Personal Health Information

MLN Matters Number: SE1616 reminds physicians of the HIPAA requirement to protect the confidentiality of the PHI of their patients. Recently, the Centers for Medicare & Medicaid Services (CMS) learned of a potential security breach in which someone was offering for sale over 650,000 records of orthopedic patients. Remember that a covered entity must notify the Secretary of Health and Human Services if it discovers a breach of unsecured protected health information. They are required to report any actual or potential security breaches to you, especially threats that compromise patient PHI.
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.
Timely Reporting of Provider Enrollment Information Changes
The timely reporting of changes in your Medicare enrollment information helps you avoid disruption of your Medicare claims payments. All physicians and other healthcare providers must report changes in their enrollment information to their MAC (Palmetto GBA) via the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) or the CMS 855 paper enrollment application within 30 days of the change.

E/M Tips

E/M Tip: Hospital Visit and Critical Care on Same Day

If a hospital inpatient or office/outpatient evaluation and management service (E/M) is furnished on a calendar date at which time the patient did not require critical care and the patient subsequently requires critical care, both the critical care services (CPT codes 99291 and 99292) and the previous E/M service may be paid on the same date of service.

E/M Tip: Double Dipping

Documentation cannot be used twice under the History Component. This is referred to as 'double dipping.' Example: Allergies may be used under the ROS (Allergic/Immunologic) or under past history.

E/M Tip: Prolonged Care Time Requirement

The start and end times of the visit shall be documented in the medical record along with the date of service.
E/M Tip: Risk of Significant Complications, Morbidity and/or Mortality (Risk Assessment)
The risk of significant complications, morbidity, and/or mortality is based on the risks associated with the following categories: presenting problem(s), diagnostic procedure(s), and possible management options. The highest level of risk in any one category determines the overall risk. The level of risk of significant complications, morbidity and/or mortality can be: minimal, low, moderate or high.
Know the Purpose of the CERT Contractor
Do you know the purpose of the CERT contractor?
The CERT contractor checks to see that providers are billing correctly and contractors are paying correctly. They select and review claims, assign improper payment categories, calculate improper payment rates and provide education to change behaviors.

Requested CERT Documentation Located at Another Facility
If the requested CERT documentation is located at another facility (ex. hospital, nursing home, referring physician's office, etc.) as the billing provider, it is your responsibility to obtain the medical records to support services billed to Medicare, regardless of where the records are housed. The CERT contractor should not be referred to a third party to obtain medical records.
Setting up a CERT Point of Contact

Palmetto GBA encourages providers to set up a CERT point of contact (POC). This person will be responsible for receiving all correspondence regarding the CERT program. Some facilities designate the compliance officer, Health Information Management, facility practice manager, etc. To supply or update the CERT contractor with a new POC, access

The Centers for Medicare & Medicaid Services (CMS) recently issued a proposed rule that updates payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2017. This year, CMS is proposing a number of new physician fee schedule policies that will improve Medicare payment for those services provided by primary care physicians for patients with multiple chronic conditions, mental and behavioral health issues, and cognitive impairment or mobility-related disabilities.
CMS will accept comments on the proposed rule until September 6, 2016, and will respond to comments in a final rule.  The final rule is expected to be released by
November 1, 2016. The proposed rule appeared in the July 15, 2016, Federal Register and can be downloaded from the Federal Register at: 
Payor News and Other News 
Highmark Update (information provided by Highmark) 
Highmark recently announced a change in their credentialing processes. This information has been provided by Highmark and will also appear in their most recent
Provider News.
Effective Aug. 15, 2016, all network providers will be credentialed and recredentialed based on several changes to the Highmark Credentialing Policies and Procedures regarding board certification. These new requirements will be added to the Highmark Blue Shield Office Manual, Chapter 2, Unit 2.
What Processes Will Be Discontinued?
Initial applicants: Effective Aug. 15, 2016, the following exceptions to board certification will no longer be applicable and will be replaced by the new Geo Access exception (defined below).
50 percent rule
Fifty percent or more of the organizational-credentialed practice's associates are board certified in the same specialty, and the practitioner has completed an approved, applicable residency or fellowship in the specialty in which the practitioner is requesting to be credentialed.
Rural rule
Practitioners located in a rural location must have greater than five years of experience in the specialty in which they practice and have completed an approved, applicable residency or fellowship in the specialty of practice.
Recredentialing applicants
Effective Aug. 15, 2016, the 50 percent and rural exceptions to board certification will be replaced by the new Geo Access exception at the time of the provider's next recredentialing cycle.
New Highmark Credentialing Policies and Procedures
Highmark credentialing requirements that are new to all providers are listed below and will be effective on Aug. 15, 2016.
NEW - All applicable West Virginia practitioners will be required to be board certified or meet one of the lack of board certification exceptions.
NEW - Geo Access exception to board certification
An annual Geo Access report will be generated, and practitioners who are not board certified will be evaluated using network access requirements for specialty and practice location(s).
Initial applicants:
If there is an access deficiency for any location, the practitioner's file will meet the exception.
If there are no access deficiencies in any location, the practitioner's file will not meet the exception and will be finalized as "Process Discontinued."
Recredentialing applications:
If there is an access deficiency for any location, the practitioner's file will meet the exception.
If there are no access deficiencies in any location, the practitioner's file will not meet the exception and will be reviewed for board eligibility status of the practitioner.

If board eligible, the practitioner will be given a one-year approval with the expectation that he or she becomes board certified.

If not board eligible, the practitioner's file will be reviewed by the Credentials Committee for decision.
NEW - Dual Credentialing criteria:
Initial applicants requesting to be dual credentialed must be board certified or meet one of the board certification exceptions for each specialty requested. Each specialty not boarded/meets exception will be finalized as "Process Discontinued."
Recredentialing applicants requesting to add dual credentialing after the effective date of Aug. 15, 2016, must be board certified or meet one of the board certification exceptions in each additional specialty requested. If the applicant is not board certified or does not meet one of the board certification exceptions in the additional specialty requested, the file will be finalized as "Process Discontinued" for that specialty only.
Recredentialing applicants approved for dual credentialing prior to the effective date of Aug. 15, 2016, will be "grandfathered" into the network for lack of board certification.
UniCare Update
UniCare is currently seeking a medical director. Details may be found below.
Unicare also reminds providers that the plan recently introduced the Availity Web Portal, a tool that helps reduce costs and administrative burdens for physicians and hospitals. You may register at If you currently use Availity, no additional registration is needed. UniCare will appear as one of the options in the payor drop down menus.
With Availity, you may:
  • Get current patient insurance coverage information (including eligibility and benefits)
  • Submit medical claims online
  • Monitor the status of claims submissions
  • View reports, including panel listings
  • Link to the UniCare AccessPoint website for any remaining transactions
WV PEIA Update
PEIA has authorized HealthSmart and SMS to authorize replacement of DME lost in the flood.
WV Medicaid Update
Reminder: Providers Should Submit Revalidation Applications to Meet the September 24, 2016, Deadline
As a requirement of the Patient Protection and Affordable Care Act (PPACA), state Medicaid agencies must revalidate the enrollment of all providers by September 24, 2016. West Virginia Medicaid has established an application submission deadline of August 31, 2016 to enhance the chance providers will meet the federal revalidation deadline of September 24, 2016. While there is no guarantee that an application submitted by August 31 will complete the revalidation process by the September 24 deadline it provides the best possible chance of continued enrollment.
If a revalidation application has not completed the approval process by September 24, 2016, the provider will be not be reimbursed by West Virginia Medicaid for dates of service on and after September 25, 2016.
The Molina Medicaid Solutions provider enrollment web page contains helpful information and documents related to re-enrolling/revalidation in WV Medicaid.
To avoid possible disruption in claims payment for dates of service on and after September 25, 2016, providers should submit a revalidation application to Molina's Provider Enrollment Unit today.
For more information, please call the Molina Provider Enrollment Unit at 1-888-483-0793.
story6Other News
Ransomware Update
Last month's Wesgram contained an article about ransomware and the threat it has become to practices. As a refresher, 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.  
The OCR (HHS Office for Civil Rights) has just issued guidance that when a covered entity or business associate is hit by ransomware, the incident is presumed to be a reportable breach unless the entity can prove otherwise.
If your practice is a victim of a ransomware attack, the way to determine if it reportable is to conduct the HIPAA "4-factor" risk analysis:
            1. The nature and extent of the PHI involved
            2. The unauthorized person who used the PHI or to whom the disclosure was made
            3. Whether the PHI was just viewed or actually used
            4. The extent to which the risk to the PHI has been mitigated
The only way to avoid going through the 4 factor process is to show that your data was encrypted.
HIPAA's breach notification rule requires more than a simple reporting the beach to affected individuals, HHS and the media if 500 or more records have been compromised. You must also determine the scope of the incident, its impact, and conduct measures to ensure it doesn't occur again.
According to the OCR, there have been 4000 daily ransomware attacks since early 2016. If you've not had an attack, you should protect your practice by encrypting your data to meet specifications from the National Institute of Standards and Technology (NIST).  
The WVSMA has a partnership with ASP in South Charleston. If you need advice about ransomware, ASP has answers.   Please contact the WVSMA if you need additional information and we will provide ASP contact information for you.

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