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: www.broadbandmap.gov.

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

Proper Modifier -59 Use for Postoperative Pain Management by Anesthesiologists

In a June blog post, we noted that CMS had updated an MLN Matters article to clarify the proper use of modifier -59.

When this MLN Matters article (SE1418) was released, the American Society of Anesthesiologists issued a Physician and Practice Management Memo to bring attention to the publication.

In this memo, ASA also provides guidance on when physician anesthesiologists may use modifier -59 when reporting a postoperative pain procedure separately from an anesthesia service.

If your facility conducts pain management billing associated with anesthesiologists delivering postoperative pain management, make sure to review the ASA's modifier -59 memo (pdf).

For more than 30 years, PGM Billing, one of the country's leading medical billing agencies, has provided anesthesiologist and pain management practices with billing solutions that ensure maximum reimbursement, reduced costs and streamline practice operations. Contact PGM to learn what its team of certified medical coders and billing experts can do for you.

Free Otolaryngology Coding Resource: Q&As on Flexible Laryngoscopic Procedures From AAO-HNS

The American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) provides numerous valuable, free and members-only resources on billing and coding on its website.

One free ENT resource that was approved earlier this year is three Q&As on flexible laryngoscopic procedures.

The questions AAO-HNS addresses are as follows:

  • How do I code for percutaneous laryngeal injections using flexible endoscopic guidance?
  • What if the laryngeal injection is done through the flexible scope?
  • Is flexible laryngoscopy using a distal chip scope also coded with 31575-31578?

Access these Q&As on flexible laryngoscopic procedures.

ENT, immunology and allergy billing and coding is extremely complex and challenging. Failing to properly code and bill for services in these specialties can not only result in money left on the table but also heavy fines from CMS.

Contact PGM Billing, one of the nation's leading providers of physician billing services, to find out how we can work with your allergy, immunology or ENT practice to help ensure you receive proper compensation for services provided and keep you out of legal hot water.

Same-Day Billing Guidelines for Mental Health Services

Last September, CMS published a Medicare Learning Network brochure on mental health services.

Included in this brochure is an informative section discussing same-day billing guidelines. Note: The information in this section, and publication, applies only to the Medicare Fee-For-Service Program, also known as Original Medicare.

According to CMS, integration of the following services is an approach to healthcare that can better address the needs of all individuals, including those with mental health and substance use conditions:

  • Mental healthcare services (which under the Medicare program includes treatment for substance abuse);
  • Alcohol and/or substance (other than tobacco) abuse structured assessment, and intervention services (SBIRT services) billed under Healthcare Common Procedure Coding System (HCPCS) codes G0396 and G0397; and
  • Primary healthcare services.

This is regardless of whether a patient is receiving care in a traditional primary care setting or a specialty mental or substance use healthcare setting.

CMS notes that Medicare Part B pays for reasonable and necessary integrated healthcare services when they are furnished on the same day, to the same patient, by the same professional or a different professional. This is regardless of whether the professionals are in the same or different locations.

The following are recognized as being eligible under Part B to provide diagnostic and/or therapeutic treatment for mental, psychoneurotic, and personality disorders as well as Medicare SBIRT services, to the extent permitted under state law:

  • Physicians (medical doctors and doctors of osteopathy), particularly psychiatrists;
  • Clinical psychologists;
  • Clinical social workers;
  • Clinical nurse specialists;
  • Nurse practitioners;
  • Physician assistants;
  • Certified nurse-midwives; and
  • Independently Practicing Psychologists.

In general, Medicare-covered services are those services that are considered medically reasonable and necessary to the overall diagnosis or treatment of the patient’s condition or to improve the functioning of a malformed body member. Services or supplies are considered medically necessary if they meet the standards of good medical practice and are:

  • Proper and needed for the diagnosis or treatment of the patient’s medical condition;
  • Furnished for the diagnosis, direct care, and treatment of the patient’s medical condition; and
  • Not mainly for the convenience of the patient, provider, or supplier.

Services must also meet specific medical necessity criteria defined by National Coverage Determinations and Local Coverage Determinations. For more information about the Medicare coverage determination process, visit the CMS website. For every service billed, CMS advises that you must indicate the specific sign, symptom or patient complaint necessitating the service. Although furnishing a service or test may be considered good medical practice, Medicare generally prohibits payment for services without patient symptoms or complaints or specific documentation.

Medicare also pays for multiple mental health services furnished to the same patient on the same day. However, the Medicare program prohibits inappropriate and/or duplicate payment for services furnished on the same day. In general, CMS advises you to consult with your local Medicare Administrative Contractor (MAC) to determine if local or national policies may prevent you from billing for certain services on the same day. To find MAC contact information, refer to the CMS website.

Mental health billing guidelines are complex. Services are often rendered in multiple facilities and locations, and coverage for diagnosis and treatment varies widely. It takes a significant amount of time to learn the guidelines — guidelines that are frequently updated and revised.

PGM Billing is a leading provider of mental health billing services. PGM has a core team of medical billing specialists that work closely with practices to identify problem areas and provide education on appropriate billing practices and procedures.

To learn more about our PGM's mental health medical billing services, request a free demo today.

Free Emergency Medicine Billing Resource: 'ICD-10 For the Busy Emergency Physician' Manual

The American College of Emergency Physicians provides a free, informative manual on ICD-10 you can access regardless of whether you are a member of ACEP.

Titled "ICD-10-CM For The Busy Emergency Physician" (pdf), ACEP says it was created by ED physicians for ED physicians to help provide an easy to read, clinically based reference. 

Sections in the manual include the following:

  • What is ICD-10-CM?
  • Comparison of ICD-9-CM to ICD-10-CM
  • Key ICD-10-CM Concepts Severity of Illness
  • Key ICD-10-CM Concepts First Listed (Principal) Diagnosis
  • Key ICD-10-CM Concepts: Signs and Symptoms/ Unspecified
  • Key ICD-10-CM Concepts: Episodes of Care for Injuries and Poisonings, Initial Encounter
  • Key ICD-10-CM Concepts: Enhanced Anatomic Specificity
  • Key ICD-10-CM Concepts: Sprains and Strains
  • Key ICD-10-CM Concepts: External Cause of Injury

Access the emergency medicine ICD-10 manual (pdf).

The transition to ICD-10 will create significant coding and billing challenges for emergency medicine. Providers are likely to face disruptions in their payments and will find submitting accurate, complete claims challenging due to the significantly more complex, detailed nature of the ICD-10 code set compared to ICD-9.

To reduce the negative impact of the transition while cutting the costs associated with employing medical billers, outsource your billing to an emergency medicine billing company such as PGM Billing. PGM is one of the nation's leading medical billing agencies, with more than 30 years experience of coding and billing experience. The PGM team of certified medical billing and coding experts will manage all aspects of your billing, ensuring you receive proper compensation for services provided.

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