Influenza Vaccine Payment Allowances - Annual Update for 2016-2017 Season

 

Each year, CMS updates the Medicare Healthcare Common Procedure Coding System

(HCPCS) and Current Procedure Terminology (CPT) codes and payment rates for personal influenza (flu) and pneumococcal vaccines. Payment allowance limits for such vaccines are 95 percent of the Average Wholesale Price (AWP), except where the vaccine is furnished in a hospital outpatient department, Rural Health Clinic (RHC), or Federally Qualified Health Center (FQHC). In these cases, the payment for the vaccine is based on reasonable cost.

 

Annual Part B deductible and coinsurance amounts do not apply. All physicians, non-

physician practitioners and suppliers who administer the influenza virus vaccination and the pneumococcal vaccination must take assignment on the claim for the vaccine.

Medicare Part B has released the HCPCS and CPT codes effective for services provided on August 1, 2016, through those provided on July 31, 2017; however, the allowances have not yet been released, with the exception of Q2039 (Flu Vaccine Adult - Not Otherwise Classified: Payment allowance is to be determined by the local claims

processing contractor ---Palmetto GBA).

 

Change Request (CR) 9758 informs MACs about the payment allowances for seasonal influenza virus vaccines. These payment allowances are updated on August 1 of each year. The Centers for Medicare & Medicaid Services (CMS) will post the payment allowances for influenza vaccines that are approved after the release of CR9758. You'll want to ensure that your billing staffs are aware that the payment allowances are being updated.

 

Documenting Specific Services in the Medical Record

 

Providers should document specific services in the medical record. All services require the basic information in the medical record.

 

Can a service be billed as 'incident to' if the auxiliary staff performing the service, where there is no face-to-face encounter with the billing provider, changes a patient's treatment plan based on protocol or the results of laboratory tests?

 

No. This does not mean that each occasion of an incidental service performed by a nonphysician practitioner must always be the occasion of a service actually rendered by the physician. It does mean that there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the nonphysician practitioner is an incidental part, and there must be subsequent services by the physician of a frequency that reflects the physician's continuing active participation in and management of the course of treatment.

 

Documenting the Patient's Progress in the Medical Record

 

Always document in the medical record the patient's progress. Document the patient's response to treatment. Document the change (if any) in the diagnosis or treatment and always document the patient's non-compliance (if applicable).

 

eServices: Fast and Secure Medicare Information

 

Palmetto GBA is pleased to offer secure and fast access to your Medicare information through our eServices. Through this system, you can securely submit forms, documents and payments, receive print material/letters electronically via eDelivery, view beneficiary eligibility, claims status, online remittances and financial information and much more.

 

 eServices Makes Asking a Medicare Question Easier

 

Palmetto GBA is pleased to announce the newest addition to our eService options - Secure eChat! This innovative feature allows providers to interact with designated Palmetto GBA staff so they can receive real-time assistance locating information on any topics or specialties they are searching for on the Palmetto GBA website or within the eServices online portal. The Secure eChat feature also allows users to dialogue with an online operator who can assist with patient or provider specific inquires or address questions that require the sharing of PHI information!

 

 E/M Tip: Review of Systems - "All others Negative"

 

It is acceptable to use the statement 'All others Negative' and 'No other complaints' as long as the pertinent systems/symptoms/problems were addressed and documented.

 

E/M Tip: General Principles

 

There are general principles of medical record documentation that are applicable to all types of medical and surgical services in all settings. While E/M services vary in several ways, such as the nature and amount of physician work required, general principles help ensure that medical record documentation for all E/M services is appropriate

 

E/M Tip: Acuity Caveat (Examination)

 

The acuity caveat (unable to obtain) does not apply to the Examination component; it only applies to the History component.

MACRA Update

 

CMS announced recently that the final MACRA regulation will exempt physicians from any risk of penalties if they choose one of multiple MIPS reporting options in 2017, in addition to the option of participating in an advanced APM.   These options and other supporting details will be described fully in the final rule. Below are brief summaries of the options:

 

First Option: Test the Quality Payment Program

 

With this option, as long as physicians submit some data to the Quality Payment Program, including data from after January 1, 2017, you will avoid a negative payment adjustment. This first option is designed to ensure that your system is working and that you are prepared for broader participation in 2018 and 2019 as you learn more.

 

Second Option: Participate for Part of the Calendar Year

 

Physicians may choose to submit Quality Payment Program information for a reduced number of days. This means your first performance period could begin later than January 1, 2017, and your practice could still qualify for a small positive payment adjustment. For example, if you submit information for part of the calendar year for quality measures, how your practice uses technology, and what improvement activities your practice is undertaking, you could qualify for a small positive payment adjustment. You could select from the list of quality measures and improvement activities available under the Quality Payment Program.

 

Third Option: Participate for the Full Calendar Year

 

For practices that are ready to go on January 1, 2017, you may choose to submit Quality Payment Program information for a full calendar year. This means your first performance period would begin on January 1, 2017. For example, if you submit information for the entire year on quality measures, how your practice uses technology, and what improvement activities your practice is undertaking, you could qualify for a modest positive payment adjustment. We've seen physician practices of all sizes successfully submit a full year's quality data, and expect many will be ready to do so. 

Fourth Option: Participate in an Advanced Alternative Payment Model in 2017

 

Instead of reporting quality data and other information, the law allows you to participate in the Quality Payment Program by joining an Advanced Alternative Payment Model, such as Medicare Shared Savings Track 2 or 3 in 2017. If you receive enough of your Medicare payments or see enough of your Medicare patients through the Advanced Alternative Payment Model in 2017, then you would qualify for a 5 percent incentive payment in 2019.

 

However, if you choose to participate in 2017, CMS will have resources available to assist you and walk you through what needs to be done. And however you choose to participate, your feedback will be invaluable to building this program for the long term to achieve outcomes that matter to your patients.

 

Physicians who report in 2017 may be eligible for bonus payments in 2019, depending on which option they choose. Those who opt for full-year reporting will be eligible to receive a "modest positive payment adjustment;" those who choose partial year reporting will be eligible for a "small positive payment adjustment." Physicians who choose the "test" option will not be subject to any payment adjustments. Qualified participants in advanced APMs will be eligible for 5 percent incentive payments in 2019.

BrickStreet Acquires Pennsylvania Workers' Compensation Business

 

BrickStreet has announced the recent expansion of its book of business. In July 2016, BrickStreet acquired the workers' compensation block of business of Pittsburgh-based HM Insurance Group, a Highmark Company.

 

This acquisition will further expand BrickStreet's presence in Pennsylvania and involves workers' compensation policies totaling approximately $120 million in premium.

All of HM's current workers' compensation employees became BrickStreet employees August 1 and will remain in Pennsylvania.

BrickStreet is now writing business in 12 states and the District of Columbia and is one of the largest writers of workers' compensation coverage in the region. In addition, with this acquisition, BrickStreet will be the third largest writer of workers' compensation insurance in Pennsylvania.