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Medicare: 2015 PQRS and Fee Schedule

The Patient Protection and Affordable Care Act (PPACA) mandated that non-participation or unsuccessful/unsatisfactory reporting in Medicare’s Physician Quality Reporting System (PQRS), formerly referred to as PQRI, will result in negative payment adjustments to Medicare reimbursement beginning in 2015. In the 2012 Medicare Physician Fee Schedule Final Rule, the Centers for Medicare and Medicaid Services (CMS) ruled that providers who did not successfully/satisfactorily participate in PQRS by the 2013 reporting period will have their Medicare reimbursement decreased by 1.5 percent beginning on January 1, 2015. Non-participation or unsuccessful/ unsatisfactory reporting during the 2014 performance period will result in a 2% reduction in a provider's 2016 Medicare reimbursement, and further non-participation or unsuccessful/unsatisfactory reporting this year (Jan. 1 -  Dec. 31, 2015) will affect a provider's 2017 Medicare reimbursement by applying a payment reduction of 2%.

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Revalidation of Chiropractic Provider Enrollment in the State Medicaid Program

 

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Medicare 2015 Physician Fee Schedule

The 2015 Medicare fee schedule has not yet been finalized. Once it is finalized, there will be a number of different fee schedules depending on your practice’s location, PQRS participation, and EHR/Meaningful Use participation. We will keep you informed as updates become available.

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Medicare Update December 2014

If you have received a letter from Medicare stating that you will have your fee reduced due to failure to certify with meaningful use through Electronic Health Records you can visit http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/paymentadj_hardship.html.
  • Eligible Professional Payment Adjustment Reconsideration Instructions
  • Eligible Professional Payment Adjustment Reconsideration Application
Although the categories may not fit your situation, there is a tab for other where you can explain your reason for not meeting the EHR/Meaningful use requirement. As many of us have small practices that this may pose a financial hardship for it is worth a try. The application is simple to fill out and can be emailed. This is only for those doctors who have received the payment adjustment letter for meaningful use. The deadline is February 28, 2015.

 

Non-Acute Pain MTGs and Revised MTGs Became Effective December 15, 2014

The new Non-Acute Pain Medical Treatment Guidelines (NAP MTG), as well as the revisions to the existing Medical Treatment Guidelines (MTGs), went into effect on December 15, 2014.

The Chair began the formal adoption process in June 2014, with the publication of a proposed regulation in the New York State Register. The process amends 12 NYCRR 324.2 to incorporate the Non-Acute Pain MTG as well as revisions to the third editions of the Mid and Low Back, Neck, Shoulder, and Knee MTGs and the second edition of the Carpal Tunnel Syndrome MTG. Additionally, Intrathecal Drug Delivery (Pain Pumps) have been added to the list of procedures requiring prior authorization. For your review, complete copies of the new NAP MTG, revised MTGs and the Amendment of 12 NYCRR 324.2 are available on the Board’s website.

The new NAP MTG presents a comprehensive approach to the management of patients with chronic pain, including best practice recommendations for the appropriate use of narcotics. This is a particularly important topic in light of the opioid epidemic facing the nation, including New York’s injured workers.

As was announced last month, e-learning training programs have been developed to facilitate compliance with both the new NAP MTG and revised MTGs recommendations. The training consists of medical courses that enable providers to earn CME credits, as well as courses for non-medical professionals. These programs are free and have been available on the Board’s website since November 12, 2014. In addition, the Non-Acute Pain Medical Treatment Guidelines training is available with free CME credits on MSSNY’s website. Please take advantage of the training, if you have not already done so. The Board will make an official announcement when the training is available for physical therapists and chiropractors.

If you have any questions concerning the Guidelines, please contact the Board’s Medical Director’s Office at (800) 781-2362.

Robert E. Beloten
Chair

 

Optum Physical Health announces the STarT Back Screening Tool

As referenced in the 2014 third quarter Optum newsletter, effective in the fourth quarter of 2014, Optum Physical Health (OptumTM) will include reporting of the STarT Back Screening Tool (SBST) as part of the electronic clinical submissions for those providers who are required to submit.

For your information, I have attached the letter that has been sent to Optum providers detailing the inclusion of the SBST in the “Patient Completes this Section” of the electronic Patient Summary Form (PSF). The PSF incorporates a version of the SBST that should be used for most adult patients with musculoskeletal disorders.

There will be a slight delay in the deployment of this tool. The SBST will be visible to providers logging on to the portal on December 7, 2014 rather than the November 23, 2014 date noted in the letter.

If your members have questions, please direct them to Optum’s Member Provider Services (MPS) at (800) 873-4575 or their support clinician.

 

ACA Releases 2nd Edition ICD-10 Toolkit Featuring Updated Resources

Arlington, Va. -- The American Chiropractic Association (ACA) has released a 2nd edition ICD-10 Toolkit to prepare doctors of chiropractic for a seamless transition to ICD-10 coding beginning Oct. 1, 2015.

Beginning Oct. 1, 2015, the ICD-9 codes currently used to describe diagnoses and treatment plans can no longer be used by HIPAA covered entities. The conversion to ICD-10 will enable U.S. health care providers to report greater specificity and clinical information. The new coding system includes updated health care terminology and provides higher quality data for processing claims and making clinical decisions. It may also enhance the ability to provide data that proves the effectiveness and positive outcomes achieved by chiropractic services.

To ensure that the chiropractic profession is prepared for and understands ICD-10, ACA has updated its online ICD-10 resources, featuring a 2nd edition ICD-10 Toolkit with a Mapping Tool that simplifies the conversion of diagnosis codes from ICD-9 to ICD-10. If you have previously purchased the Toolkit or the Mapping Tool, you will now receive both as part of this update. Check lists, printable worksheets and an introductory training webinar are available to ACA members. An intermediate training webinar will soon be available for purchase.

"ACA will work to ensure that the chiropractic profession is well-prepared for the ICD-10 transition," says ACA President Anthony Hamm, DC. "Beginning Oct. 1, 2015, all claims submitted to HIPAA covered entities will be rejected unless they contain the proper ICD-10 code. With this in mind, ACA will continue to provide the needed resources for DCs to efficiently and confidently transition to ICD-10 compliance."

ACA will provide the chiropractic profession with up-to-date information and resources in its publications and online at www.acatoday.org/ICD-10. Visit the FAQs page for more information or call the ACA at 703-276-8800.



About ACA

The American Chiropractic Association (ACA), based in Arlington, Va., is the largest professional association in the United States advocating for more than 130,000 doctors of chiropractic (DCs), chiropractic assistants (CAs) and chiropractic doctoral students. ACA promotes the highest standards of ethics and patient care, contributing to the health and well-being of millions of chiropractic patients. Visit us at www.acatoday.org.

 

Medicare Prepayment Review Results for CPT Codes 98940 & 98941 for June-Aug'14

Providers in Connecticut (98941), Queens, NY (98940), Downstate NY (98941) and Upstate NY (98941)

National Government Services’ Medical Review Department is currently conducting a prepayment review on JK Part B chiropractic services in the states of CT and NY. This article includes the results of these reviews for June, July and August 2014.

Background

During these reviews, documentation is reviewed to adjudicate claims for payment based on the LCD and Medicare coverage guidelines.

Findings

The following results are based upon the completion of the reviews for JK Part B chiropractic providers in CT and NY.
  • Connecticut
    • June 2014 - of 23 services billed; 22 (95.7%) were reduced or denied
    • July 2014 - of 161 services billed; 133 (82.6%) were reduced or denied
    • August 2014 – of 221services billed; 188 (85.1%) were reduced or denied
  • Queens, NY
    • June 2014 – of 242 services billed; 240 (99.2%) were reduced or denied/li>
    • July 2014 – of 1,401 services billed; 1,246 (88.9%) were reduced or denied/li>
    • August 2014 – of 2,383 services billed; 2,181 (91.5%) were reduced or denied
  • Downstate NY
    • June 2014 – of 74 services billed; 72 (97.3%) were reduced or denied
    • July 2014 – of 371 services billed; 339 (91.4%) were reduced or denied
    • August 2014 – of 576 services billed; 461 (80%) were reduced or denied
  • Upstate NY
    • June 2014 – of 136 services billed; 124 (91.2%) were reduced or denied
    • July 2014 – of 357 services billed; 313 (87.7%) were reduced or denied
    • August 2014 – of 641 services billed; 588 (91.7%) were reduced or denied

Claims were reduced and/or denied for the following reasons:

  • Lack of patient’s specific subjective complaint – A relevant medical history in a patient’s record must indicate a beneficiary subjective complaint(s) and the area(s) of complaint(s) should correlate to the area(s) of subluxation(s) cited and/or treated.
  • Lack of functional status – Documentation does not describe a patient’s current level of functioning and activities of daily living, nor treatment goals related to functional levels.
  • Lack of objective documentation of specific level(s) of subluxation in the exam – The precise level(s) of subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine. The level(s) of spinal subluxation must bear a direct causal relationship to the patient's symptom(s), and the symptom(s) must be directly related to the level(s) of the subluxation that has been diagnosed. Documentation needs to be clearly legible without the use of abbreviations, checks or circles that provide minimal and unclear information. If using P.A.R.T exam, the documentation requirement must be fully met per policy. Policy requires documentation of two of the four criteria, one of which must be asymmetry/misalignment or range of motion abnormality.
  • Lack of area(s) of chiropractic manipulative treatment (CMT)that corresponds to subjective complaint(s) – The specific spinal area(s) that was treated on the day of the visit must be clearly documented and the area(s) treated must correspond to patient’s subjective compliant(s). Documentation needs to be clearly legible without the use of abbreviations, checks or circles that provide minimal and unclear information.
  • Treatment plan and goals not documented/not addressed – Documentation of a treatment plan must include the recommended level of care (duration and frequency of visits); specific treatment goals and objective measures to evaluate the treatment effectiveness. The patient’s progress or lack thereof related to the established treatment plan and goals should be addressed on subsequent visits. If treatment continues on without evidence of improvement or the clinical status has remained stable for a given condition, further manipulative treatment is considered maintenance therapy and is a non-covered benefit.
  • Documentation supporting maintenance – Maintenance therapy is a noncovered benefit. Examples of maintenance therapy would include long term treatment per history without the documentation supporting exacerbation, subjective complaint of “minimal pain” on multiple visits without showing improvements or no positive response; documentation remains the same or template for multiple visits. Also, documentation of “chronic” condition with no documentation to support an exacerbation and/or improvement.

Other issues that resulted in claim denials include:

  • Nonresponse to development letters – When an ADR letter is received, submitting information and appropriate documentation suggested in the ADR letter is required to consider payment of the claim in question. If the requested medical record is not submitted in a timely manner, the services will be systematically denied.
  • Illegible Documentation – Medical record must be legible. If the reviewer cannot decipher the documentation, it may result in the denial of a claim.
  • Missing or illegible provider signature - Documentation must be legible and include a provider’s signature. The method used can either be electronic or handwritten, stamp signatures are not acceptable. A signature key or signature log can be included with the documentation to identify the author associated to the illegible signature.
  • Incorrect rendering physician – The rendering physician on the documentation did not correspond with the rendering physician submitted on the claim form.
  • Incomplete or missing beneficiary information – A patient’s medical record must include a legible beneficiary name for identification. Also, the medical record should be clearly dated and correspond to the date of service billed. If this information is missing or incomplete, it may result in denial of a claim.

Recommendations

We recommend that you perform random sample claim audits within your practice to ensure that these errors do not exist. You may also use the errors identified in the prepay audit as a checklist before submitting future claims. Please also take time to review the chiropractic services LCD (L27350) and SIA (A47385) posted on our website under Medical Policy & Review > Medical Policy Center.

The National Government Services Provider Outreach and Education Department can assist with Medicare coverage, medical policy, medical necessity, and documentation questions through the JK Provider Contact Center at 866-837-0241.

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MLN Connects Upcoming Calls: Transitioning to ICD-10

Wednesday, November 5; 1:30-3pm ET

To Register: Visit MLN Connects™ Upcoming Calls. Space may be limited, register early.
HHS has issued a rule finalizing October 1, 2015 as the new compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10. During this MLN Connects National Provider Call, CMS subject matter experts will discuss ICD-10 implementation issues, opportunities for testing, and resources. A question and answer session will follow the presentations.

Agenda:
  • 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
Target Audience: 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.

Continuing education credit may be awarded for participation in certain MLN Connects Calls. Visit the Continuing Education Credit Information web page to learn more.

 

"Medicare Appeals Process" Fact Sheet — Revised

The “Medicare Appeals Process” Fact Sheet (ICN 006562) was revised and is now available in a downloadable format. This fact sheet is designed to provide education on the five levels of claim appeals in Original Medicare (Medicare Part A and Part B). It includes details explaining how the Medicare appeals process applies to providers, participating physicians, and participating suppliers, in addition to including more information on available appeals-related resources.

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CMS Announces 2013 PQRS Incentive Payments are Now Available

 

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Court Rules in Favor of Class Standing in United Healthcare/Optum Lawsuit

 

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Workers Compensation Update: Form HP-1 Revised

As part of the Workers' Compensation Board’s effort to improve service and increase efficiency in the unpaid medical bill(s) process, Form HP-1, Health Provider's Request for Decision on Unpaid Medical Bills(s), has been revised. Form HP-1 now directs that the form is sent to the following addresses as appropriate.

When requesting an Administrative Award, Form HP-1 should be sent to the Board’s Centralized Mailing Address:
New York State Workers' Compensation Board
PO Box 5205
Binghamton, NY 13902-5205
When requesting Arbitration, Form HP-1 and a check for the processing fee should be sent to:
New York State Workers' Compensation Board
Medical Director's Office/Finance
328 State Street
Schenectady, NY 12305
The revised Form HP-1 with the new addresses may be obtained at the Board's website here or by following the link "Forms" at the top of the home page.

Please contact the Board at 1-800-781-2362 with any questions regarding Form HP-1. Thank you for your cooperation.

Robert E. Beloten, Chair

 

Source

NYS WCB Proposes New Fee Schedule

 

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NYS WCB Chair Proposes Non-Acute Pain Medical Treatment Guidelines

 

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Important Deadlines Approaching for EHR Incentive Program

 

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New PQRS Frequently Asked Questions Now Available

 

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Learn More about the New Remittance Advice Codes for PQRS Claims-Based Reporting

 

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