CMS to Host 'Transitioning to ICD-10' Conference Call

The Centers for Medicare & Medicaid Services has announced it is hosting a conference call on transitioning to ICD-10.

Oct. 1, 2015, was recently confirmed as the new compliance date for healthcare providers to make the transition to ICD-10.

During this Medicare Learning Network Connects national provider call, scheduled for November 5 from 1:30-3:00 p.m. ET, CMS subject matter experts will discuss ICD-10 implementation issues, opportunities for testing and resources. A question and answer session will follow the presentations.

The agenda is listed as follows:

  • Final rule and national implementation
  • Medicare Fee-For-Service testing
  • Medicare Severity Diagnosis Related Grouper (MS-DRG) Conversion Project
  • Partial code freeze and annual code updates
  • Plans for National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs)
  • Home health conversions
  • Claims that span the implementation date

CMS says the target audience includes medical coders, physicians, physician office staff, nurses and other non-physician practitioners, provider billing staff, health records staff, vendors, educators, system maintainers, laboratories and all Medicare providers.

Space is limited, so it is advisable to register early. Register for the CMS conference call on the ICD-10 transition.

Free Mental Health Resource: Tips and Strategies for Billing From SPRC

The Suicide Prevention Resource Center (SPRC) provides numerous valuable and free primary care resources on its website.

Included in these resources is a five-page guide on "Tips and Strategies for Billing for Mental Health Services in a Primary Care Setting."

Topics covered in this guide include:

  • How to bill for diagnostic and treatment services
  • Tips for diagnostic and evaluation codes to use in billing for mental health services
  • CPT and HCPCS codes for Medicare and Medicaid payment for mental health services
  • Billing for actual time of service
  • Medical record documentation (recommended principles)

In addition to providing guidance to improve billing success, the guide also identifies a series of links to helpful, web-based information for primary care practices.

Access this guide on mental health billing strategies (pdf).

Note: The guide indicates the Department of Health and Human Services will replace the ICD-9-CM codes with ICD-10-CM (diagnosis) and ICD-10-PCS (hospital procedure) code sets effective Oct. 1, 2014. This date was recently changed and confirmed as Oct. 1, 2015.

While this guide provides some good tips and strategies, it just scratches the surface of what practices need to know to properly bill for mental health services. Mental health professionals provide one of the widest scopes of healthcare services, administering treatment to patients of all socioeconomic groups, and with all types of acute and chronic mental and social health issues. Patients receiving care are just as varied. Services are rendered in multiple facilities. Coverage for diagnosis and treatment undergoes frequent changes and varies widely by state and payor guidelines.

When taking all of these factors into consideration, it is not surprising to learn that many behavioral health professionals struggle to submit clean claims. This is why more practices are outsourcing their billing to a leading mental health billing service provider like PGM Billing. With PGM's mental health billing services, PGM manage all aspects of a practice's billing to help ensure proper, timely compensation is received for services rendered.

CMS Establishes Four New Modifiers to Define Subsets of -59 Modifier

The Centers for Medicare & Medicaid Services (CMS) has announced (pdf) it is establishing four new HCPCS modifiers to define specific subsets of the -59 modifier.

Modifier -59 is used to define a "distinct procedural service." It indicates that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled.

According to CMS, the -59 modifier is the most widely used HCPCS modifier. Modifier -59 can be broadly applied. Some providers incorrectly consider it to be the “modifier to use to bypass the Medicare National Correct Coding Initiative. As CMS notes, this modifier is associated with considerable abuse and high levels of manual audit activity, which leads to reviews, appeals and even civil fraud and abuse cases.

According to an AAPC report, the introduction by CMS of the four subset modifiers is intended to reduce improper use of modifier -59 while helping improve claims processing for providers.

CMS is establishing the following four new HCPCS modifiers (referred to collectively as -X{EPSU} modifiers) to define specific subsets of the -59 modifier:

  • XE Separate Encounter: A service that is distinct because it occurred during a separate encounter;
  • XS Separate Structure: A service that is distinct because it was performed on a separate organ/structure;
  • XP Separate Practitioner: A service that is distinct because it was performed by a different practitioner; and
  • XU Unusual Non-Overlapping Service: The use of a service that is distinct because it does not overlap usual components of the main service.

CMS states it will continue to recognize the -59 modifier, but notes that CPT instructions require the -59 modifier not be used when a more descriptive modifier is available. While CMS will continue to recognize the -59 modifier in many instances, it may selectively require a more specific - X{EPSU}modifier for billing certain codes at high risk for incorrect billing.

The implementation date for this change is January 5, 2015. At this time, CMS will initially accept either a -59 modifier or a more selective -X{EPSU} modifier as correct coding, although CMS encourages rapid migration of providers to the more selective modifiers. However, CMS indicates modifiers are valid modifiers even before national edits are in place, so contractors are not prohibited from requiring the use of selective modifiers in lieu of the general -59 modifier when necessitated by local program integrity and compliance needs.

View an MLN Matters article on the new HCPCS modifiers (pdf).

The frequent changes made to coding and billing rules create significant challenges for facilities working to collect what they deserve. Such challenges are just one of the many reasons more practices and ambulatory surgery centers (ASCs) are outsourcing their billing to a leading medical billing service provider such as PGM Billing. PGM has more than 30 years of practice and ASC medical billing experience. Contact PGM today to learn what they can do for your organization.

CMS Establishes New Physician Specialty Code for Interventional Cardiology

The Centers for Medicare & Medicaid Services has announced (pdf) the establishment of a new physician specialty code for interventional cardiology: C3.

According to an American College of Cardiology report, C3 "allows CMS to distinguish an interventional cardiologist from a clinical cardiologist when billing for Medicare services."

Previously, no such mechanism existed. As a result, ACC reports that some local Medicare carriers denied claims when a cardiologist and an interventionalist from the same group practice billed for patient evaluation services, citing duplicate billing.

C3 allows for the reporting of the involvement of two specialty physicians providing distinct services to an individual patient.

In addition to the establishment of the new C3 code, CMS also created a new non-physician specialty code for restricted use: C4.

Changes were also made to the description of specialty code 62, and the names associated to specialty codes 88 and 95 were updated.

The effective date for these changes in January 1, 2015, while the implementation date is January 5, 2015.

Access an MLN Matters Special Edition Article on these code changes detailed in Change Request 8812 (pdf).

Cardiology billing is complex, and requires extensive experience and knowledge to ensure proper reimbursement. With more than 30 years of experience in cardiology billing, PGM has become one of the nation's leading medical billing agencies. Contact PGM to learn how its team of certified medical billing and coding experts can help your practice submit clean claims in a timely fashion and receives proper compensation for services provided.

CMS Adds 3 New FAQs on Electronic Health Record Incentive Programs

The Centers for Medicare & Medicaid Services (CMS) has added three new FAQs related to the Medicare and Medicaid electronic health record (EHR) incentive programs.

The questions — and the answers provided by CMS — are as follows:

Q: For the certification criteria that providers must have in place to meet the Clinical Decision Support (CDS) objective, what type of interventions must the EHR technology trigger to meet the criteria? For this and for the Eligible Provider and Eligible Hospital Core Measures related to the Objective "use clinical decision support to improve performance on high-priority health conditions," are "pop-up" alerts the only type of intervention that a provider can use to meet the CDS objective?

CMS: The intention of the CDS intervention certification requirement is to ensure certified EHR technology helps providers make timely and informed decisions. The certification requirement that CDS interventions be 'triggered' means that a CDS intervention – which may come in many forms other than "pop-ups" – be based on relevant, timely patient and care process information and that it may appear in 'real time' when it is most relevant to improve care provision.

CDS is not simply an alert, notification, or explicit care suggestion. Providers can meet the objective by using other kinds of CDS, including, but not limited to clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support; and contextually relevant reference information. In addition, CDS interventions are not only for doctors or nurses, but also for support staff, patients, and other caregivers, and may be delivered outside of the examination room or treatment setting.

For more information on Clinical Decision Support, review the eligible professional and eligible hospital specification sheets, and the Clinical Decision Support tipsheet.

Q: I am an eligible professional. What should I do if my patients don't have broadband access?

CMS: Some meaningful use objectives require broadband access. The infrastructure required for the Secure Electronic Messaging objective is similar to the infrastructure required for the Patient Electronic Access objective's successful usage of an online patient portal, as required in the second measure.

Therefore, CMS finalized an exclusion for those two requirements:

An eligible professional that conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 3Mbps broadband availability, according to the latest information available from the FCC, on the first day of the EHR reporting period may exclude the second measure of the Patient Electronic Access objective and the Secure Electronic Messaging objective.
The FCC's National Broadband Map allows eligible professionals to search, analyze, and map broadband availability in their area:

Q: In the inpatient setting, when providing patient data to satisfy the Summary of Care and View Online, Download, and Transmit objectives, does a hospital have to provide two different documents for patients and providers?

CMS: Eligible hospitals may create one consolidated document for the download requirement of the View Online, Download, and Transmit objective and the Summary of Care objective, as long as it:

  • Has the required fields in it for both objectives
  • Meets the standards for structured data for both objectives



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