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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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Medicare to Remove 2% Reduction

Some good news on the Medicare front:

We have been informed that effective July 1, 2014 the 2% reduction for codes 98940, 98941 and 98942 will be eliminated. As you will recall, this 2% reduction was put in place as a result of the demonstration project that was determined not to be cost neutral. This will be removed effective July 1.

Respectfully submitted,
Mariangela Penna DC
NY CAC Representative


Urgent Medicare Bulletin: Service-Specific Prepayment Reviews of Chiropractic Services


Attention Services for Jurisdiction K Part B Chiropractic Providers in Connecticut and New York

National Government Services will be conducting service-specific prepayment reviews on CPT code 98940 in the Queens, NY area and CPT Code 98941 in CT and the upstate and downstate NY areas.

A prepayment review consists of a medical review of claims prior to payment. Request for records are most frequently electronically generated and referred as ADS letters. Please note that when medical records are requested for chiropractic services, it is necessary to submit all the specific documentation as notated in the ADS, which would include but is not limited to:
  • Services up to three (3) months prior to and including the date(s) of service in question
  • Advance Beneficiary Notice of Noncoverage
The primary focus of the audits will be to better identify common billing errors, develop educational efforts, and prevent improper payments. Providers will be receiving ADSs asking for documentation to support the service billed. Medical Review encourages providers to respond with the requested documentation in a timely manner to expedite adjudication of these claims.

Providers can assist in this process by:
  • Reviewing all contractor publications and LCDs
  • Understanding Medicare coverage requirements
  • Ensuring office staff and billing vendors are familiar with claim filing requirements
  • Performing self-audits of medical records against billed claims using coverage criteria, LCD, and coding guidelines
  • Responding to request(s) for records in a timely manner (CMS requires that providers respond to an ADS within 30 days of the request)
  • Ensuring documentation is legible and demonstrates that the patient’s condition warrants the services being reported and billed
Reports show that from June 2013 through March 2014, the average error rate for CPT code 98941 was:
Connecticut - 81.0
Downstate, NY area - 81.1
Queens, NY area - 91.2
Upstate, NY area - 76.6


EHR Incentive Program Eligible Professionals: Hardship Exception Applications due July 1

Are you a Medicare provider who was unable to successfully demonstrate meaningful use for 2013 due to circumstances beyond your control? CMS is accepting applications for hardship exceptions to avoid the upcoming Medicare payment adjustment for the 2013 reporting year. Payment adjustments for the Medicare EHR Incentive Program will begin on January 1, 2015 for eligible professionals. However, you can avoid the adjustment by completing a hardship exception application and providing supporting documentation that proves demonstrating meaningful use would be a significant hardship for you. CMS will review applications to determine whether or not you are granted a hardship exception. CMS has posted hardship exception applications on the EHR website for: Applications for the 2015 payment adjustments are due July 1, 2014 for eligible professionals. If approved, the exception is valid for one year.

New Hardship Exception Tipsheets
You can also avoid payment adjustments by successfully demonstrating meaningful use prior to the payment adjustment. Tipsheets are available on the CMS website that outline when eligible professionals must demonstrate meaningful use in order to avoid the payment adjustments.

Want more information about the EHR Incentive Programs?
Make sure to visit the Medicare and Medicaid EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.


Stage 2 Meaningful Use Requirements, Reporting Options, and Data Submission Processes for Eligible Professionals — Registration Now Open


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New Fact Sheet Available on How to Avoid the 2016 PQRS Payment Adjustment

Are you an eligible professional or part of a group practice participating in PQRS this year? If so, you must satisfactorily report data on quality measures during 2014 to avoid the 2016 payment adjustment.

Review the new fact sheet for guidance on how to avoid the 2016 PQRS Payment Adjustment.

Avoid the 2016 Payment Adjustment
You can avoid the 2016 payment adjustment by meeting one of the following criteria during the one-year 2014 reporting period (January 1–December 31):

If Participating as an Individual Eligible Professional
  • Meet the criteria for satisfactory reporting adopted for the 2014 PQRS incentive.
OR If Participating as a Group Practice
  • Meet the Group Practice Reporting Option (GPRO) requirements for satisfactory reporting.
  • Participate in PQRS via qualified registry reporting and report at least three measures covering one NQS domain for at least 50 percent of your group practice’s Medicare Part B FFS patients.
Want more information about PQRS?
Please visit the CMS PQRS website:


Reminder on the Appeals Process and Ways to Avoid Appeals

If an initial claim determination results in a denial, providers, participating physicians, and other suppliers have the right to appeal the decision. National Government Services has seen an increase in the number of claims submitted to Medicare Part B Appeals for review and may cause a delay in receiving your decision. We are processing appeal and reopening requests in an efficient manner and working diligently to resolve these issues expeditiously. Our goal is to minimize disruption to the provider/supplier and beneficiary community. You will receive a decision as soon as possible; we appreciate your patience during this period.

Important Information
  • Do not submit a duplicate appeal.
  • If you are a current NGSConnex user, you can check the status of your appeal at Please note: do not resubmit the appeal when using NGSConnex.
  • The appeals process, levels of appeal, documentation, and recommended forms can be found on our Web site under Review Process > Appeals.
  • A local coverage determination (LCD) is a decision a Medicare contractor will make to cover a particular item or service. A majority of appeal requests are the result of the initial claim not following the LCD. It is important to become familiar with LCDs and national coverage determinations (NCDs).
  • LCDs contain information to indicate medically reasonable and necessary documentation and should be used as an administrative and educational tool to assist with submitting correct claims for payment. LCDs are located on our Web site in the Medical Policy Center.
  • The Centers for Medicare & Medicaid Services Internet-Only Manual Publication 100-03, Medicare National Coverage Determinations (NCD) Manual describes whether specific medical items, services, treatment procedures, or technologies can be paid for under Medicare. All decisions that items, services, etc. are not covered are based on Section 1862(a)(1) of the Act unless otherwise specifically noted. More information on NCDs can be found on the Medicare Coverage Determination Process page on the CMS Web site.
  • Not all covered Medicare services are subject to either an LCD or NCD.
Below is a list of LCDs causing the increased number of appeals to National Government Services. Please use the links to become familiar with the policy and avoid future appeals.


New EHR Incentive Programs Tipsheet for Eligible Professionals Practicing in Multiple Locations

Are you an eligible professional practicing in multiple locations? Review the new Multiple Locations Tipsheet for information on how to successfully demonstrate meaningful use in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. The tipsheet includes guidance on determining if a location is equipped with certified EHR technology, calculating patient encounters, and what to do when different menu objectives and clinical quality measures (CQMs) are chosen across locations.

Guidance for Multiple Locations
Here are some key points to keep in mind if you are practicing in multiple locations:
  • To demonstrate meaningful use, 50 percent of patient encounters must take place at locations with certified EHR technology during the reporting period. 
  • A location is equipped with certified EHR technology if you have access to the certified EHR at the beginning of the EHR reporting period. 
  • You can add numerators and denominators from each certified EHR system for an accurate total. 
  • You should report on menu objectives and CQMs from the location with the most patient encounters if different locations chose different measures.
For More Information
Visit the CMS EHR Incentive Programs website for more resources to help you successfully participate.


EHR Incentive Programs: Learn More about the Batch Reporting Option for 2014

Are you part of a group practice with multiple eligible professionals or part of a system of eligible hospitals participating in the Medicare Electronic Health Record (EHR) Incentive Program? If so, you now have the option to submit your attestations through the batch reporting method. The batch reporting method – or attestation batch upload – is a new reporting method for 2014 that allows you to upload and submit attestations for multiple eligible professionals or eligible hospitals. You can submit your attestation with other members of your medical group or hospital system in a single file through the CMS Registration and Attestation System, while still tracking each eligible professional’s and eligible hospital’s individual meaningful use data. Providers in Stage 1 or Stage 2 of meaningful use can submit their attestation through batch reporting with 2014 certified EHR technology.

Please note: While batch reporting provides groups with the ability to submit attestations together, incentive payments are distributed to each eligible professional or eligible hospital. Providers participating in the Medicaid EHR Incentive Program should check with their state to determine if batch reporting is available.

What measures can you submit with batch reporting?
You can submit the following measure combinations through batch reporting:
  • Core measures and menu measures 
  • Core measures, menu measures, and clinical quality measures 
  • Clinical quality measures only
Helpful resources
For more information on submitting your groups’ attestations using the batch reporting method, review the new Batch Reporting User Guide. You may also visit the Attestation Batch Upload Page to view the batch templates and sample batch attestations.

Want more information about the EHR Incentive Programs?
Make sure to visit the Medicare and Medicaid EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.


Eligible Professionals Must Start Medicare EHR Participation in 2014 to Earn Incentives

Important Medicare Deadline Approaching for Eligible Professionals

If you are an eligible professional for the Medicare Electronic Health Record (EHR) Incentive Program, 2014 is the last year you can start participation in the Medicare EHR Incentive Program in order to receive incentive payments. Eligible professionals who begin participation in the Medicare EHR Incentive Program after 2014 will not be able to earn an incentive payment for that year or any subsequent year of participation. If you choose to participate in the Medicare EHR Incentive Program for the first time in 2014, you should begin your 90-day reporting period no later than July 1, 2014 and submit attestation by October 1, 2014 in order to avoid the payment adjustment in 2015.

Note: October 1 is the attestation deadline for eligible professionals in their first year of participation to avoid the payment adjustment. However, eligible professionals who miss this deadline can still demonstrate meaningful use during the last 90-day reporting period of the year (October through December 2014) and earn an incentive payment for 2014.

Providers Who First Begin Participation in 2014 must: To Earn Your Maximum Medicare Incentive
  • Demonstrate 90 days of Stage 1 of meaningful use in 2014 to earn up to $11,760. 
  • Demonstrate a full year of Stage 1 of meaningful use in 2015 to earn up to $7,840. 
  • Demonstrate a full year of Stage 2 of meaningful use in 2016 to earn up to $3,920.
If you successfully demonstrate meaningful use each year beginning in 2014, your total payment amount could be as much as $23,520.

Additional Resources
The EHR Incentive Program website offers several helpful tools and resources so you can successfully begin participation:


Review Your 2013 PQRS Interim Claims Feedback Data

Do you want to check your progress towards meeting the 2013 PQRS reporting requirements? Now you can.

If you are an individual eligible professional who reported at least one PQRS quality measure in 2013 via claims-based reporting, you can now view the entire calendar year (first through fourth quarter) of data using the 2013 PQRS Interim Feedback Dashboard.

If you reported individual measures or measures group(s), the dashboard will display your summary data by Taxpayer Identification Number (TIN) or individual detail by your National Provider Identifier (NPI).

The Dashboard data allows you to monitor the status of your claims-based measures and measures group reporting to see where you are in meeting the PQRS reporting requirements.

The Dashboard is available through the Physician and Other Health Care Professionals Quality Reporting Portal, with Individual Authorized Access to the CMS Computer System (IACS) sign-in.

Dashboard Resources

The following CMS resources are available to help you access and interpret your 2013 PQRS interim feedback data: Note: The Dashboard does not provide the final data analysis for full-year reporting, or indicate 2013 PQRS incentive eligibility or subjectivity to the 2015 PQRS payment adjustment or the Value-based Payment Modifier to be implemented in 2015. The Dashboard will only provide claims-based data for 2013 interim feedback. Data from other CMS programs will not be included for purposes of the 2013 Dashboard data feedback. Data submitted for 2013 PQRS reporting via methods other than claims will be available for review in the fall of 2014 through the final PQRS feedback report or the QRUR for 2013 PQRS GPROs.

For More Information about PQRS

For more information about participating in PQRS, visit the PQRS website. For additional support or questions, contact the QualityNet Help Desk.

Centers for Medicare & Medicaid Services (CMS) has sent this update. To contact Centers for Medicare & Medicaid Services (CMS) go to our contact us page.


Review New and Updated FAQs for the EHR Incentive Programs

To keep you updated with information on the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs, CMS has recently added three new FAQs and five updated FAQs to the CMS FAQ system. We encourage you to stay informed by taking a few minutes to review the new information below.

New FAQs:
  • For Eligible Professionals (EP) in the Medicaid EHR Incentive Program using the group proxy method of calculating patient volume, how should the EPs calculate patient volume using the “12 months preceding the EP’s attestation” approach, as not all of the EPs in the group practice may use the same 90-day period. Read the answer.
  • Can a hospital count a patient toward the measures of the “Patient Electronic Access” objective in the Medicare and Medicaid EHR Incentive Programs if the patient accessed his/her information before they were discharged? Read the answer.
  • When demonstrating Stage 2 meaningful use in the EHR Incentive programs, would an EP be required to report on the “Electronic Notes” objective even if he or she did not see patients during their reporting period? Read the answer.
Updated FAQs:
  • Do States need to verify the "installation" or "a signed contract" for adopt, implement, or upgrade (AIU) in the Medicaid EHR Incentive Program? Read the answer.
  • For Stage 1 and 2 meaningful use objectives of the Medicare and Medicaid EHR Incentive Programs that require submission of data to public health agencies, if multiple EPs are using the same certified EHR technology across several physical locations, can a single test or onboarding effort serve to meet the measures of these objectives? Read the answer.
  • For the Stage 2 meaningful use objective of the Medicare and Medicaid EHR Incentive Programs that requires the successful electronic exchange of a summary of care document with either a different EHR technology or the CMS designated test EHR, if multiple EPs are using the same certified EHR technology across several physical locations, can a single test meet the measure? Read the answer.
  • In calculating the meaningful use objectives requiring patient action, if a patient sends a message or accesses his/her health information made available by their EP, can the other EPs in the practice get credit for the patient’s action in meeting the objectives? Read the answer.
  • When reporting on the Summary of Care objective in the EHR Incentive Program, which transitions would count toward the numerator of the measures? Read the answer.
Want more information about the EHR Incentive Programs? Make sure to visit the Medicare and Medicaid EHR Incentive Programs website for the latest news and updates.


EHR Incentive Programs: New Meaningful Use Calculator Helps Providers Attest to Stage 2

Are you a provider participating in Stage 2 of meaningful use for the Electronic Health Record (EHR) Incentive Programs? If so, use the new CMS Stage 2 Meaningful Use Attestation Calculator to determine if you will successfully meet Stage 2 requirements. Like the Stage 1 calculator, eligible professionals, eligible hospitals, and critical access hospitals (CAHs) can enter and review their data for each measure. The tool then calculates whether or not you will successfully demonstrate Stage 2 of meaningful use. A results page explains why you may or may not receive an incentive payment by displaying a pass/fail summary for each measure.

Get Started
Take four easy steps to get started:
   • Select your provider type: eligible professional or eligible hospital/CAH
   • Answer questions on your meaningful use core objectives
   • Answer questions on your meaningful use menu objectives
   • Receive your results

Be sure to answer each measure you intend to meet by either filling in the numerator and denominator values or marking down an exclusion (for those that apply).

Please note: The attestation calculator is not actual attestation and does not guarantee that you will meet the program’s qualifications. It is only a guide of whether or not you would meet the program’s Stage 2 meaningful use requirements.

Resources Providers who have completed at least two years of Stage 1 of meaningful use will demonstrate Stage 2 in 2014. Additional Stage 2 resources:
   • Stage 2 Guide
   • Stage 2 Meaningful Use Specification Sheet Table of Contents for Eligible Professionals
   • Stage 2 Meaningful Use Specification Sheet Table of Contents for Eligible Hospitals and CAHs
   • Stage 2 Data Sharing Tipsheet for Eligible Professionals

Want more information? Visit the Registration and Attestation and Stage 2 pages for useful resources to help you successfully demonstrate meaningful use.


Historic Release of Data Gives Consumers Unprecedented Transparency on the Medical Services Physicians Provide and How Much They are Paid

On April 9, as part of the Obama administration’s work to make our health care system more transparent, affordable, and accountable, HHS Secretary Kathleen Sebelius announced the release of new, privacy-protected data on services and procedures provided to Medicare beneficiaries by physicians and other health care professionals. The new data also show payment and submitted charges, or bills, for those services and procedures by provider.

The new data set has information for over 880,000 distinct health care providers who collectively received $77 billion in Medicare payments in 2012, under the Medicare Part B Fee-For-Service program. With this data, it will be possible to conduct a wide range of analyses that compare 6,000 different types of services and procedures provided, as well as payments received by individual health care providers.

The information also allows comparisons by physician, specialty, location, the types of medical service and procedures delivered, Medicare payment, and submitted charges. Physicians and other health care professionals determine what they will charge for services and procedures provided to patients and these “charges” are the amount the physician or health care professional generally bills for the service or procedure.

Last May, CMS released hospital charge data allowing consumers to compare what hospitals charge for common inpatient and outpatient services across the country.

Full text of this excerpted CMS press release (issued April 9).


ACA to Appeal Following Setback in Class Action Lawsuit Against ASHN, CIGNA

Arlington, Va.—The American Chiropractic Association (ACA) today announced its intention to appeal the recent dismissal of its claims against American Specialty Health Inc. and American Specialty Health Networks Inc. (collectively, "ASHN"), and CIGNA Corporation and Connecticut General Life Insurance Company (collectively, "CIGNA"). Significantly, the dismissal was based upon a variety of procedural considerations--not the substance of ACA’s claims.

ACA’s legal counsel is optimistic about the chances of a successful appeal, noting that this area of the law is the subject of increasing judicial focus.

“Recently, there have been several significant rulings recognizing that providers are entitled to assert claims under ERISA to challenge benefit determinations by insurers, including with regard to recoupments of previously issued payments”,” said Brian Hufford, Esq., of Zuckerman Spaeder LLP, who represents ACA in the class action suit. "We believe that federal courts are increasingly recognizing that individual providers and associations such as the ACA have standing to assert the claims brought in this action.”

ACA's litigation against ASHN and CIGNA alleges, among other things, that CIGNA--in violation of ERISA--failed to comply with terms and conditions of its plan to afford subscribers or their health care providers an opportunity to obtain a "full and fair review" of denied or reduced reimbursement, and failed to make appropriate and non-misleading disclosures to subscribers or their health care providers.

"ACA took this action against ASHN and CIGNA because it is patients who suffer most when doctors must choose between providing necessary care and adhering to requirements imposed by payers," said ACA President Anthony Hamm, DC. "We will not rest until patients receive the care they need and have paid for through their insurance premiums."

Providers who believe they and/or their patients have been affected by ASHN and/or CIGNA's improper practices can visit the Chiropractic Networks Action Center to submit a complaint to 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 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


BREAKING NEWS: Senate Approves "Doc Fix" Bill, Delay of ICD-10


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Reminder: CMS-1500 Form (Version 08/05) Expires March 31

The timeline that CMS provided to allow providers to transition from the old version of the CMS-1500 claim form (08/05) is coming to an end. Effective April 1, claims will only be accepted if submitted on the new version of the claim form identified by the date 02/12 in the lower right hand corner. The CMS-1500 Form has been revised to give providers the ability to indicate whether they are using the International Classification of Diseases, ninth edition, Clinical Modification (ICD-9-CM) codes or its successor, the ICD-10-CM and allows for additional diagnostic codes to be reported. Additional changes were made to item numbers 14, 15 and 17, which now have qualifiers to identify provider roles such as ordering, referring or supervising. ACA has prepared a 1500 Claim Form Fact Sheet, which is free to members, to assist your clinic in making the needed changes. Further information from CMS on this topic can be found here.

Additionally, the National Uniform Claim Committee (NUCC) has developed a 1500 Reference Instruction Manual detailing how to complete the claim form. The purpose of this manual is to help standardize nationally the manner in which the form is being completed. The current version of the instructions (v 9.0) was released in July 2013: Version 9.0 7/13


Top 10 Appeals Questions and Answers From NGS Medicare

  1. How long do I have to submit my appeal request?

    Answer: You have 120 days from the date of the original Medicare remittance advice to submit an appeal. Multiple resubmissions of a claim will not extend the 120-day time limit. The time limit begins with the original denied/processed claim. 
  2. Can an appeal be filed past the 120-day limit?

    Answer: The time limit may be extended if good cause for late filing is shown. If good cause is not found, the request for appeal will be dismissed. The issue of good cause for the provider and beneficiary is addressed in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 29, Section 240. (982 KB) 
  3. Must a redetermination request have a signature, and what type of signature is needed?

    Answer: Yes, it must be a full signature (first and last name) on the redetermination request form in order for it to be a valid request. 
  4. How can I follow up on claims that are already in the appeal process?

    Answer: Please visit or call our IVR system at 877-908-9499. Both of these self-service tools allow providers/suppliers to obtain the status of all redetermination/reopening requests. Remember, the contractor has 60 days from the date the appeal was received to make a determination. 
  5. I have made corrections to my denied claim. Should I rebill?

    Answer: A claim should only be rebilled if the claim was rejected with message MA130. If the claim denies for any other reason, do not rebill as it could result in a duplicate claim or cause delay of payment. 
  6. What is a reopening?

    Answer: A reopening is an alternative to the appeals process where minor errors or omissions in filing claims have occurred. For more information regarding the appeals process, visit the Review Process > Appeals section on our Web site. 
  7. How do you determine whether you need to submit a first level appeal request (the redetermination) or a second level appeal request (the reconsideration)?

    Answer: An initial claim submission will show the MA01 remark code, which states you have 120 days to appeal and request a redetermination. If you see this remark code on your claim, you need to request a redetermination from us.

    Adjustments resulting from a redetermination decision can be identified by the remark code of MA02, “If you do not agree with this determination, you have the right to appeal. You must file a written request for appeal within 180 days of the date you receive this notice.

    Please note the difference in the amount of time to request a second level appeal, also known as the reconsideration. The MA02 message gives you appeal rights for the second level appeal or the reconsideration. If you wish to appeal claim adjustments with the MA02 remark code, you must file a reconsideration request to the Qualified Independent Contractor. 
  8. Do redetermination requests have to be made in writing?

    Answer: Yes, they have to be made in writing or sent electronically through the portal. 
  9. Where can I find the redetermination form?

    Answer: The National Government Services Medicare Redetermination Request form, along with additional information, is located under Quick Links > Forms.

    Related Content: Medicare Redetermination Request Form - First Level of Appeal (CMS-20027) 
  10. Can I request a redetermination for all services in question on a specific claim at one time, or must I submit a separate redetermination form for each service in question?

    Answer: No, you do not have to submit a separate form for each service on the claim. In fact, we encourage you to request a redetermination for all services in question on the claim at one time. This ensures a faster response since any adjustments that need to be performed on your claim can be done at one time. This will also cut down on the number of letters and remittances you receive from us.

These questions and answers come from the NGS Medicare frequently asked question (FAQ) database. FAQs cover a variety of topics and are a great resource for answering your questions, please visit our Web site at, choose your Jurisdiction and Business and click on the FAQ tab.