Blog and Helpful Articles

Medicare Billing for Seasonal Flu Vaccines

As you know, Medicare began covering annual influenza immunizations in 1993 for all Medicare beneficiaries. Medicare covers both the costs of the vaccine and its administration by recognized providers. There is no coinsurance or co-payment applied to this benefit, and a beneficiary does not have to meet his or her deductible to receive this benefit.

As we head into winter and flu season, flu shots are on the rise; even drugstore chains are offering them on-site to Medicare beneficiaries. Providers need to make sure they are submitting proper claims, with correct CPT-4 codes, for any flu vaccines administered to Medicare patients. As of January 1, 2011, CPT code 90658 was discontinued for the seasonal influenza vaccine; the correct code(s) to use are: Q2035, Q2036, Q2037, Q2038, and Q2039. In addition to the influenza CPT code above, providers must also submit the administration code (G0008). Below are some useful links to a quick reference guide & payment allowances for the seasonal flu vaccine.

Payment allowances for 09/30/2011 through 08/31/2012
Quick Reference Information: Medicare Immunization Billing

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What We’re Reading – Medical identity theft is a growing problem

Nothing seems to be off limits these days. Not only are people stealing identities for financial gain, but also for medical purposes.  In this article, Jim Koenig, director & leader of PwC’s identity theft practice said, “Medical identity theft is still a small percentage of the total amount of identity theft that occurs, but it’s the fastest-growing segment.” 

The article explains that there are two types of victims:  the willing and the unwilling.  The willing are considered victims of “Robin Hood crimes”, meaning they lend their friends/families their identities.  The unwilling victims are found to be health care insiders: employees working for the health care providers.  Being the willing or unwilling victim of medical identity theft can be dangerous for the patient because incorrect information has been added to his/her medical records.  This type of fraud is also costly for the provider if the insurance company recoups reimbursement for a visit that resulted from identity theft.  A simple way to prevent medical identity theft is to request photo identification from the patient and keeping a copy in the record.  Another easy fix for medical identity theft involves asking the patient questions that only he or she would know.  Incorrect or unusually slow answers to simple questions could be a red flag for medical identity theft. Check out the rest of the article for more tips to stop this type of healthcare fraud.

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What We’re Reading – Five ways for physician to manage their online reputation

In the wave of social media, physicians have to focus more on just word of mouth for positive and/or negative comments these days.  Regardless of whether or not the physician has an online presence, everything about the practice – good or bad – is.  Physicians need to continuously manage and in some cases correct and/or defend negative information; this is referred to as ‘online reputation management.’  “As quickly as online content can spread, especially in the age of social media, experts say online reputation management should be a key component to any business plan.”  For most physicians, five simple strategies can result in proper management of the online reputation. Read the article for more detail.

1.   Google yourself
2.   Correct mistakes & false information
3.   Create your own content
4.   Embrace constructive criticism
5.   Address actionable items

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The Revalidation of Provider Enrollment Information

The revalidation process is a requirement of the Affordable Care Act for all Medicare providers and suppliers to revalidate their enrollment information in the Medicare program under new enrollment screening criteria.  The revalidation process affects only those Medicare providers who submitted their initial applications prior to March 25, 2011.  (Revalidation won’t affect providers who submitted their applications on or after March 25, 2011.)

CMS has extended the revalidation period for another two years which means the notices will be sent on a regular basis through March of 2015.  When you receive your revalidation notice, you must respond either through internet-based PECOS, which is the most efficient way, or by completing the appropriate CMS 855 application form.  The first set of revalidation letters were sent to Medicare providers who are actively billing and who were not listed in PECOS.  The letter is sent to the primary practice or special payment address if the provider is not listed in PECOS.  If the provider is found in PECOS, the letter is sent to the special payments and correspondence addresses simultaneously.  If those addresses are the same, CMS sends one to the primary practice address as well.

For those providers who are not listed in PECOS and have not received a revalidation letter, we suggest that you contact your Medicare contractor.  If you are an institutional provider and deemed by CMS to pay a fee for your revalidation, you can submit your fee by ACH debit or credit card.  The revalidation won’t be processed until payment has been made.  Don’t forget to submit the Certification Statement along with your receipt of payment.

The revalidation process does not change other aspects of the enrollment process; providers should continue to submit their routine changes (address updates, reassignments, additional practice locations, etc.) in the usual manner.  If you have a routine change and also have received a revalidation letter, transact them separately.

Providers and suppliers who fail to submit enrollment forms 60 days from the date of the revalidation letter may experience a deactivation of their Medicare billing privileges.

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What We’re Reading – Use of Technology Urged to Combat Racial, Ethnic Disparities in Health Care

The authors of the article, “Bridging the Digital Divide in Health Care: The Role of Health Information Technology in Addressing Racial and Ethnic Disparities,” contend that Health Information Technology (HIT) can be successful in eliminating health care disparities experienced by minority patients.  The authors suggest that health care organizations take the following steps:

  • Automate and standardize the collection of race/ethnicity and language data.
  • Prioritize use of the data for indentifying disparities and tailoring quality improvement efforts.
  • Focus HIT efforts to address fragmented care delivery for racial/ethnic minorities and limited-English-proficiency patients.
  • Develop focused computerized clinical decision support systems in clinical areas with significant health disparities.
  • Include input from racial/ethnic minorities and those with limited English proficiency in developing patient HIT tools.

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What We’re Reading – Docs need more EHR training, survey suggests

A recent study conducted by AmericanEHR Partners found that physicians need at least three to five days of training to feel comfortable using their electronic health-record system. With two weeks or more of training, the “ease of use” ratings increased. Interestingly, nearly 50% of the surveyed physicians reported receiving three days or less of training on their electronic health-record system. The study also found that physicians reported higher levels of satisfaction when they were involved in selecting the electronic health-record system being used.

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How should I prepare for ICD-10?

From time to time, we hear about consultants scaring the daylights out of providers with horror stories about the transition to ICD-10.  We disagree with that approach, although it’s important to have a healthy respect for any system that – from one day to the next – essentially quadruples the number of diagnosis codes and scrambles them into a completely different system of nomenclature.  The keys are understanding and preparation. 

Understanding

The transition from ICD-9-CM to ICD-10-CM requires an in-depth understanding of the new code set, how it’s designed and its specific nomenclature which departs significantly from the system in widespread use today.  We believe the important thing to do right now is to expose providers and staff to the new system so they begin to lose some of the fear.  There is a good bit of information online about ICD-10, and consultants abound to help you with the educational process.  [Shameless promotion: CCG can conduct a one-hour educational session in person, or via webinar, to take the mystery out of ICD-10]  It’s critical to begin the ICD-10 conversation early and plant the seeds for the provider habits that will facilitate a smooth transition.

Preparation

Because the change in code sets is essentially two years away, too much preparation can disrupt operational processes.  For paper-based providers, a good bit of education and coaching can be done early in the process because their coding will not be impacted by the additional documentation required by ICD-10.  In a nutshell, your clinicians can ‘practice’ honing certain documentation skills and habits long before they are a requirement.  How about that for an advantage to paper charts!

However, many providers are in various stages of transitioning to electronic medical records (EMRs) that, at this time, do not support the significant changes in documentation required for ICD-10.  Consequently, their preparation will occur on a different schedule with the goal of lessening the impact to office productivity predicted by industry experts. Keep in mind that productivity snags can affect patient care, patient throughput, and provider reimbursement and profitability.

For example, the American Academy of Professional Coders (AAPC) reports that it could take as long as a year for productivity to rebound following ICD-10 implementation.  Coders in Australia and Canada reported a six-month curve for their productivity to return to pre-implementation levels.

In January 2012, CCG will launch its ICD-10 training curriculum for providers and staff.  Click here to request additional information when it is available to the public.

For information on ICD-10, see our blog post “What exactly is ICD-10”.

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What We’re Reading – How to improve communication skills in the work place

Communication is a significant issue in any work environment. Whether one is shy or being verbally attacked on the job, this article explains how to address each situation and how to improve interpersonal communication.  This skill is especially crucial because we live in a world where email and texting have replaced telephonic conversation, and we sometimes don’t realize how rusty that skill can become.  It’s important to remember that self-expression is not just a 🙂 or 🙁 face at the end of an electronic message; it encompasses words as well as body language and facial expressions.

Whether in the workplace or in a family relationship, good communication is critical.  Enjoy this author’s great tips!

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What We’re Reading – Investigation Finds Drug Abusers Exploiting Medicare Benefit

An investigation in 2008, by the Government of Accountability Office, found approximately 170,000 Medicare recipients with suspicious prescription-use patterns.  The study identified 14 frequently abused medications and found that patients were “doctor shopping” in order to obtain multiple prescriptions for the powerful drugs.  For example, a Medicare recipient in Georgia was able to obtain a prescription for 3,655 oxycodone pills by visiting 58 different providers.

Taxpayers are responsible for three-fourths of the cost of the Medicare prescription drug program.  The cost of the program is nearly $55 billion a year.  In 2008, the cost of the suspicious prescriptions totaled $148 million.  Currently, federal law does not allow Medicare to limit the access of beneficiaries with suspicious prescription-use patterns.  However, Medicare acknowledges the abuse of the prescription drug program and is looking for ways to prevent the abuse.

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What exactly is ICD-10?

ICD-10-CM (based on the International Classification of Diseases, 10th edition, Clinical Modification) is a standard set of codes used for conveying a patient’s clinical profile, if you will.  Defined codes are used primarily to facilitate the gathering of data, its analysis, benchmarking and eventual use in health planning and policy.  To be honest, the purpose of ICD-9-CM was the same; the big difference is that the specificity of ICD-9-CM codes pales in comparison to ICD-10-CM.  (Imagine…. ICD-9-CM has approximately 14,000 diagnosis codes; ICD-10-CM has over 70,000!)

Many other countries have been using ICD-10 for some time, and the US is late to the game.  By adopting the use of this new code set, the US will be able to benchmark and compare its population’s morbidity and mortality to those in other countries.

The widespread use of ICD-9 (with the exception of workers’ compensation cases) will end on September 30, 2013.  ICD-10 kicks off on October 1, 2013 with no grace period.  Although the short-term changes affect software vendors and clearinghouses – who are busy upgrading systems – the long-term impact to providers will be significant.

The biggest challenge for clinicians will be in documentation.  (If you’ve been in this business long enough, you know this is always the issue!)  With such a huge increase in the number of diagnoses, it stands to reason that the amount of specificity required in the provider’s documentation will also be great.  For example, one change that accounts for 62% of the fracture codes, and 36% of all ICD-10 codes, is specifying ‘right’ and ‘left’.  This is a fairly simple change for a physician to make in his/her documentation, and one that can be started right now.

Other changes require time and education to coach new skills.  One area that is fraught with potential challenge is the creation of combination codes.  These require clinicians to link conditions that have associated symptoms or complications.  The positive aspect is the reduced number of diagnosis codes required to report the condition; the difficulty will be in the provider’s ability to successfully document in a manner that links conditions appropriately.  As a side-note, one small aspect to accurate risk adjusted reimbursement for capitated providers requires providers to correctly associate manifestations to diabetes as appropriate.  After almost nine years, some clinicians still struggle with this seemingly simple, and highly publicized and trained concept. 

For information on how to prepare for ICD-10, see our blog post.

Source:  American Academy of Professional Coders (AAPC)

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