News Flash – Medicare Fee-For-Service (FFS), and its business associates, will implement the ASC X12, version 5010, and NCPDP, version D.0, standards as of January 1, 2012 . To facilitate the implementation, Medicare has designated calendar year 2011 as the official 5010/D.0 transition year. As such Medicare Administrative Contractors (MACs) will be testing with their trading partners throughout calendar year 2011. Medicare encourages its providers, vendors, clearinghouses and billing services to schedule testing with their local MAC as soon as possible. Medicare also encourages you to stay current on 5010/D.0 news and helpful tools by visiting http://www.cms.gov/Versions5010andD0/ on its website. Test early, Test often!
Provider Types Affected
CAHs under the optional method who provide primary care services to Medicare beneficiaries and bill Medicare Administrative Contractors (A/B MACs) or Fiscal Intermediaries (FIs) are impacted by this issue.
Provider Action Needed
STOP – Impact to You
The Affordable Care Act provides for a 10% Medicare incentive payment for primary care services effective 2011 through 2015. Payments will be made on a quarterly basis.
CAUTION – What You Need to Know
The Affordable Care Act defines a primary care practitioner as: (1) a physician who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; or (2) a Nurse Practitioner, Clinical Nurse Specialist, or Physician Assistant, and in all cases, for whom primary care services accounted for at least 60 percent of the allowed charges under the Medicare Physician Fee Schedule (MPFS) for the practitioner in a prior period as determined appropriate by the Secretary.
GO – What You Need to Do
See the Background section below for specifics.
Background
Section 5501(a) of The Affordable Care Act revises section 1833 of The Social Security Act and will add a new paragraph “Incentive Payments for Primary Care Services”. The Social Security Act now states that in the case of primary care services furnished on or after January 1, 2011 and before January 1, 2016 by a primary care practitioner, there also shall be paid on a monthly or quarterly basis an amount equal to 10 percent of the payment amount for such services under the MPFS.
NOTE: The former “Quarterly Health Professional Shortage Area (HPSA) and Scarcity Report for Critical Access Hospital (CAHs)” is now known as the “Special Incentive Remittance for CAHs”. This change is necessary as Primary Care Incentive Program (PCIP) payments are made for all primary care services furnished by eligible primary care practitioners, regardless of the geographic location where the primary care services are furnished.
The PCIP payments will be based on 10 percent of 115 percent of the MPFS amount that the CAH was paid for the professional service.
Primary Care Services
The Affordable Care Act defines primary care services as those services identified by the following CPT codes:
99201 through 99215 for new and established patient office or other outpatient Evaluation and Management (E/M) visits;
99304 through 99340 for initial, subsequent, discharge, and other nursing facility E/M services; new and established patient domiciliary, rest home (eg, boarding home), or custodial care E/M services; and domiciliary, rest home (eg, assisted living facility), or home care plan oversight services; and
99341 through 99350 for new and established patient home E/M visits.
These codes are displayed in the table below. All of these codes remain active in Calendar Year (CY) 2011 and there are no other codes used to describe these services.
Primary Care Services Eligible for Primary Care Incentive Payments in CY 2011 CPT Code
Description
99201
Level 1 new patient office or other outpatient visit
99202
Level 2 new patient office or other outpatient visit
99203
Level 3 new patient office or other outpatient visit
99204
Level 4 new patient office or other outpatient visit
99205
Level 5 new patient office or other outpatient visit
99211
Level 1 established patient office or other outpatient visit
99212
Level 2 established patient office or other outpatient visit
99213
Level 3 established patient office or other outpatient visit
99214
Level 4 established patient office or other outpatient visit
99215
Level 5 established patient office or other outpatient visit
99304
Level 1 initial nursing facility care
99305
Level 2 initial nursing facility care
99306
Level 3 initial nursing facility care
99307
Level 1 subsequent nursing facility care
99308
Level 2 subsequent nursing facility care
99309
Level 3 subsequent nursing facility care
99310
Level 4 subsequent nursing facility care
99315
Nursing facility discharge day management; 30 minutes
99316
Nursing facility discharge day management; more than 30 minutes
99318
Other nursing facility services; evaluation and management of a patient involving an annual nursing facility assessment.
99324
Level 1 new patient domiciliary, rest home, or custodial care visit
99325
Level 2 new patient domiciliary, rest home, or custodial care visit
99326
Level 3 new patient domiciliary, rest home, or custodial care visit f
99327
Level 4 new patient domiciliary, rest home, or custodial care visit
99328
Level 5 new patient domiciliary, rest home, or custodial care visit
99334
Level 1 established patient domiciliary, rest home, or custodial care visit
99335
Level 2 established patient domiciliary, rest home, or custodial care visit
99336
Level 3 established patient domiciliary, rest home, or custodial care visit
99337
Level 4 established patient domiciliary, rest home, or custodial care visit
99339
Individual physician supervision of a patient in home, domiciliary or rest home recurring complex and multidisciplinary care modalities; 30 minutes
99340
Individual physician supervision of a patient in home, domiciliary or rest home recurring complex and multidisciplinary care modalities; 30 minutes or more
99341
Level 1 new patient home visit
99342
Level 2 new patient home visit
99343
Level 3 new patient home visit
99344
Level 4 new patient home visit
99345
Level 5 new patient home visit
99347
Level 1 established patient home visit
99348
Level 2 established patient home visit
99349
Level 3 established patient home visit
99350
Level 4 established patient home visit
Eligibility for Payment under the Primary Care Incentive Payment Program (PCIP)
For primary care services furnished on or after January 1, 2011 and before January 1, 2016, a 10 percent incentive payment will be provided to primary care practitioners, identified as: (1) in the case of physicians, enrolled in Medicare with a primary specialty designation of 08-family practice, 11-internal medicine, 37-pediatrics, or 38-geriatrics; or (2) in the case of non-physician practitioners, enrolled in Medicare with a primary care specialty designation of 50-Nurse Practitioner, 89-certified Clinical Nurse Specialist, or 97-Physician Assistant; and (3) for whom the primary care services displayed in the above table accounted for at least 60 percent of the allowed charges under the MPFS (excluding hospital inpatient care and emergency department visits) for such practitioner during the time period that has been specified by the Secretary of Health and Human Services.
If a claim for a primary care service is submitted by a CAH paid under the optional method for an eligible primary care physician’s or non-physician practitioner’s professional services, the “other provider” field on the claim must be populated by the eligible primary care practitioner’s National Provider Identifier (NPI) in order for the primary care service to qualify for the incentive payment. Primary care services potentially eligible for the incentive payment and furnished on different days must be submitted on separate CAH claims so a determination about the eligibility of the service based on the rendering practitioner can be made. If the CAH claim for a single date of service includes more than one primary care professional service, the incentive payment for all primary care services for that date, shall be made to the CAH on behalf of the eligible primary care practitioner based on the NPI in the “other provider” field. In addition to the CAH NPI, the “other provider” NPI shall be shown on the Special Incentive Remittance for CAHs.
PCIP Payments to Critical Access Hospitals
Physicians and non-physician practitioners billing on Type of Bill (TOB) 85X for professional services rendered in a CAH paid under the optional method have the option of reassigning their billing rights to the CAH. When the billing rights are reassigned to the CAH, payment is made to the CAH for professional services (Revenue Codes (RC) 96X, 97X or 98X).
The 10 percent PCIP payment is payable to a CAH billing under the optional method for the primary care professional services of eligible primary care physicians and non-physician practitioners who have reassigned their billing rights to CAH. The incentive payment is paid based on 10 percent of the 115 percent of the MPFS amount paid to the CAH for those professional services. PCIP payments are calculated by Medicare contractors and made quarterly on behalf of the eligible primary care physician or nonphysician practitioner to the CAH for the primary care services furnished by the practitioner in that quarter.
The Affordable Care Act authorizes payment under the PCIP beginning in CY 2011 as an additional payment amount for specified primary care services without regard to any additional payment for the service under the existing Health Professional Shortage Area (HPSA) physician bonus payment program. Therefore, eligible primary care physicians and non-physician practitioners furnishing a primary care service in a HPSA may receive both a HPSA physician bonus payment under the established program and a PCIP payment under the new program beginning in CY 2011.
Additional Information
The official instruction, CR7115 issued to your A/B MAC or FI regarding this change may be viewed at http://www.cms.gov/Transmittals/downloads/R2081CP.pdf on the Centers for Medicare & Medicaid Services (CMS) website.
If you have any questions, please contact your A/B MAC or FI at their toll-free number, which may be found at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS website.
News Flash - It’s a Busy Time of Year . Make each office visit an opportunity to talk with your patients about the importance of getting the seasonal flu vaccination and a one-time pneumococcal vaccination. Remember, Medicare pays for these vaccinations for all beneficiaries with no co-pay or deductible. The seasonal flu and invasive pneumococcal disease kill thousands of people in the United States each year, most of them 65 years of age or older. The Centers for Disease Control and Prevention (CDC) also recommends that health care workers and caregivers be vaccinated against the seasonal flu. Protect your patients. Protect your family. Protect yourself. Get Your Flu Vaccine - Not the Flu. Remember – Influenza vaccine plus its administration are covered Part B benefits. Note that influenza vaccine is NOT a Part D covered drug. For information about Medicare’s coverage of the influenza vaccine and its administration, as well as related educational resources for health care professionals and their staff, please visit http://www.cms.gov/MLNProducts/Downloads/Flu_Products.pdfand http://www.cms.gov/AdultImmunizations on the Centers for Medicare & Medicaid Services (CMS) website.
Dallas L Alford IV, CPA is a licensed Certified Public Accountant in the state of North Carolina and owner of Atlantic Financial Consulting, a consulting firm that provides comprehensive medical billing services, practice management consulting, coding audits, Medicare compliance, Medicare RAC support and other general medical practice consulting services.
To learn more about Atlantic Financial Consulting you may visit their website at http://atlanticfinancial.us or contact Dallas L Alford IV, CPA directly at 1 888-428-2555, Ext. 200.
No comments:
Post a Comment