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2010 MEDICARE UPDATE

Uncertainty with the 2010 physician fee schedule and the looming 21.2% fee cuts, consultations no longer being paid by Medicare, and new Ambulatory Surgery Center (ASC) Conditions for Coverage guidelines are a few of the issues facing ophthalmology in 2010.  Below is a recap of the Medicare changes for 2010.

Physician Fee Schedule
The 2010 final rule contained a 21.2% fee cut for physician fees.  Congress approved two extensions to the fee cuts freezing the rates at the modified 2009 physician fee schedule rates through March 31, 2010.  Congress failed to approve another extension before Spring recess and the Centers for Medicare and Medicaid Services (CMS) held claims through April 14, 2010, to give Congress additional time to act.

On April 15, 2010, President Obama signed into law the “Continuing Extension Act of 2010” which extends the zero percent update through May 31, 2010.   The law is retroactive to April 1, 2010.  The April 1 claims that were being held by CMS were released for payment on April 15, 2010.  Due to the new law, CMS will make retroactive adjustments to any claims that have been paid the 21.2% reduction.

The new Extension Action will, hopefully, give Congress, CMS and the medical societies time to work on a more permanent fix to the flawed Sustainable Growth Rate and the physician fee schedule payments.

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Consultations
Effective January 1, 2010, Medicare no longer pays for consultations.  This includes consultations performed in the office or outpatient department of the hospital, inpatient hospital consultations, and consultations performed in a nursing home. 

Consultations performed in the hospital or nursing facility should now be billed with the initial hospital care or initial nursing facility care codes.  Admitting physicians will need to append the AI modifier to let Medicare know they are the “principal physician of record” and responsible for the patient’s total care while in the hospital or nursing home.  Subsequent care visits will need to be reported as subsequent hospital care codes and subsequent nursing facility care codes.   While Medicare requirements have reserved the use of initial hospital or nursing home visits for the admitting physician in the past, CMS has made the above change effective January 1, 2010.

Consultations requested by a referring physician in the office or outpatient department of the hospital will need to be billed as new or established patient visits, either evaluation & management services or eye codes.    CMS redistributed the savings by increasing the work RVUs for new or established office visits and initial hospital and nursing home visits.  They also increased payment for the global surgery to reflect the higher value of office visits furnished during the global fee period.  The eye codes, 92002-92014, were not included in the RVU increase.

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Incentive Bonuses
CMS will continue its 2% incentive bonus payments for physicians who participate in the Physician Quality Reporting Initiative (PQRI) program using claims-based or registry-based reporting and the Electronic Prescribing (E-Prescribing) program. 

  • PQRI now has two reporting periods – January 1, 2010, through December 31, 2010, or July 1, 2010 through December 31, 2010.  If you have not yet begun to report PQRI for this year, you can still receive the 2% bonus on the 6 month reporting period.  PQRI can be reported via claims based reporting or a Registry.  Remember the 2% bonus is based on the total allowed covered services paid by Medicare during the reporting period.
  • E-Prescribing is much easier to report in 2010.  You only have to report on one measure indicating a patient visit results in an E-Rx being placed, and you only have to report 25 times during the reporting period of January 1, 2010 through December 31, 2010.  E-Prescribing can be reported through qualified registries or through qualified EHR products and is now permitted at the group level rather than at the individual eligible practice level.

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ASC Fee Schedule
ASCs received a 1.2% inflation increase in the conversion factor for 2010 as well as a 50-cent increase in the ASC conversion factor.  In addition, the Hospital Outpatient Department (HOPD) received a 2.1% increase which directly impacts the 2010 payments for ASCs.

ASCs are in their third year of a four-year payment transition which is a 75/25 blend of the 2007 ASC payment rates and the current HOPD rates.  The full 65% transition rate will be implemented in 2011.

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ASC Conditions for Coverage
In May, 2009, new ASC Conditions for Coverage (CfCs) were to be implemented by ambulatory surgery centers and outpatient department of the hospital to improve infection control and provide 24 hour advance notices to Medicare beneficiaries.

The state survey agencies have begun unannounced on-site inspections.  They come with 3-5 inspectors and they are there 3-5 days.  If you have not yet implemented these new guidelines, you should do so immediately.  Go to the CMS website at:  http://www.cms.gov/CFCsAndCoPs/16_ASC.asp.  Or contact Rose and Associates for additional information.

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Diagnosis Codes
There are a few new diagnosis codes for ophthalmology in 2010.

  • 209.31 – Merkel cell carcinoma of the face (eyelid, including canthus)
  • 209.31 – Merkel cell carcinoma of the face (eyelid, including canthus)
  • 239.8 – Neoplasms of other specified sites (Retina and choroid, dark area of retina, retinal freckle)
    1. 239.89 – Other specified sites
  • 372.06 – Acute chemical conjunctivitis (Acute toxic conjunctivitis). 
    1. Excludes burn of eye and adnexa (940.0-940.9), chemical corrosion injury of eye (940.2-940.3)
  • V10.90 – Personal history of unspecified malignant neoplasm
    1. Personal history of malignant neoplasm NOS
  • V87.44 – Personal history of inhaled steroid therapy
  • V87.45 – Personal history of systemic steroid therapy
    1. Personal history of steroid therapy NO

Practices are urged to purchase new ICD-9-CM diagnosis coding manuals annually to avoid possible payment delays or denials.  Don’t forget also, that ICD-10-CM is coming October 1, 2013.  It is not too soon to learn about this new coding system and start working with your vendors to make implementation easier.

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2010 OIG WORK PLAN

Each year, the Office of Inspector General (OIG) releases a Work Plan outlining areas of interest with regard to program enforcement for CMS.  There are four new areas of concern for 2010 and three repeat areas of concern.

  • E-Prescribing Incentive Payments.  The OIG will assess if, and if so, to what extent incentive payments for e-prescribing activities in 2009 were made in error. If erroneous payments were made, the OIG will assess CMS’s actions to remedy erroneous payments and its plans for overseeing payments made.  Ophthalmology is one of the top participating specialties of the e-prescribing program. 
  • Compliance with Assignment Rules.  Physicians participating in Medicare agree to accept the Medicare allowed amount by the carrier as the full charge for the items or services provided less any coinsurance and deductible amounts.  The OIG will mainly assess beneficiaries’ awareness of their rights and responsibilities regarding potential billing violations and Medicare coverage guidelines.  To avoid exposure in the future, make sure staff is aware of the basic billing rules for participating providers.  If an over-collection is made in error, refund the patient immediately rather than holding the overpayment towards a future visit.
  • Comprehensive Error Rate Testing (CERT) Program.  The OIG will review the CERT payment methodology for determining the 2009 error rates.  Historically, the primary focus has been on misuse of modifiers, high levels of exams (level 4 E&M and code 92004), and other outliers identified in their paid claims review.  CMS has contracted with a review organization to perform a random review of its CERT contractor’s payment determinations for 1,000 Part A and Part B claims.  They will determine whether the independent review organization met its contractual obligations to CMS and will provide an analysis of the organization’s review.  Based on the outcome of the review, we could see CERT audits increase in the future.
  • Services Billed with Dates of Service After Beneficiary’s Date of Death.The OIG will review claims with dates of service after beneficiaries’ dates of death to identify and recover improper payments.  This issue has been a work in progress and will most likely continue for a few more years.  This should not be an issue in ophthalmology, but the billing department needs to make sure any claims submitted to Medicare after a patient’s date of death is filed with the date the service was actually performed, not the posting date.
  • Place of Service Errors.The OIG will again review physician coding of place of service on Medicare Part B claims for services performed in ambulatory surgery centers and outpatient hospital departments.  Federal regulations provide for different levels of payments to physicians depending on where the services are performed.  Medicare pays a higher amount when a service is performed in a non-facility setting, such as a physician’s office, than it does in an ASC or hospital outpatient department.

Since this is an ongoing area of concern, you need to make sure all your services are billed with the correct place of service.  If a service, such as a laser, is performed on the ASC side of the firewall, you must indicate place of service as ASC on the claim form.  It does not matter that you consider the laser room an extension of the office.  If the service is performed behind the ASC firewall, it is considered place of service ASC.

  • E&M Services Provided During Global Fee Period.  The OIG is continuing to review industry practices related to the number of office visits provided by physicians and reimbursed as part of the global surgery fee.  This is an ongoing investigation with periodic recommendations made to CMS. 

While it was not specifically addressed in the 2010 OIG Work Plan this year, the use of modifier -24 during the global fee period is an ongoing issue.  Before appending the -24 modifier, ask yourself if the patient would have had the problem if surgery had not been performed.  If the answer is no, do not append modifier -24 to the office visit.  A different diagnosis does not automatically justify billing the office visit if the problem is directly related to the surgery.

  • Use of the –GY Modifier.  Modifier –GY is to be used for coding services that are statutorily excluded or do not meet the definition of a covered service.  Medicare patients are liable, either personally or through other insurance, for all charges associated with these services.  Providers are not required to provide patients with advance notice of charges for services that are excluded from Medicare by statute.  As a result, patients may unknowingly acquire large medical bills that they are responsible for paying.  The OIG plans to examine patterns and trends for physicians’ and suppliers’ use of modifier –GY.

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MANDATORY PECOS ENROLLMENT

In October of last year, CMS implemented the first phase of a new policy requiring physicians who order or refer services to be enrolled in the Provider Enrollment, Chain and Ownership System (PECOS) database.  Physicians were supposed to be enrolled in the database by January 4, 2010, or claims would be rejected.   

Currently billing physicians receive a warning edit that makes it appear a claim has been denied.  The billing physician, of course, has no control over whether the referring physician is enrolled in PECOS.  The second phase of the policy requires physicians who enrolled in Medicare prior to 2003 to re-enroll through PECOS.

CMS has delayed implementation of the second phase of modifications to PECOS regarding ordering/referring providers from April 5, 2010, until Jan. 3, 2011.

Prior to the Jan. 3, 2011, implementation date CMS will:

  • Continue to place warnings on claims in which the ordering/referring physician is not enrolled in PECOS;
  • Update the Medicare Ordering/Referring file;
  • Remind providers who enrolled in Medicare prior to 2003, but have not completed the revalidation process, to submit a new enrollment application either in the paper form or by using Internet-based PECOS.

You can go to the CMS website at www.cms.hhs.gov/MedicareProviderSupEnroll to see if you are currently enrolled in PECOS.  Just click on “Ordering/Referring Report” on the left-hand side and download the list.  If you are not on the list, you need to work towards re-enrolling via PECOS prior to January 3, 2011.

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PREMIUM IOLS

Physicians may bill the patient using code V2787 for the additional work involved in implanting astigmatism-correcting intraocular lenses (IOLs) performed in conjunction with conventional cataract surgery. When implanting presbyopia-correcting IOLs, use code V2788.  Bill Medicare for the conventional cataract surgery as usual, and bill the patient for the extra work and time involved in implanting the premium IOLs.

The ambulatory surgery center or hospital may bill the patient for the extra work involved and/or the cost differential in these premium lenses and the $150 already included in the facility fee for a conventional IOL. Medicare is billed for the conventional cataract surgery which includes payment for the conventional IOL. Bill the patient code V2787 or V2788 as above.

Remember, you are not required to bill Medicare for these excluded services unless the patient asks you to do so for a secondary payer denial.

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MEETINGS & LECTURES

  •  Coding & Reimbursement Seminar for Alcon Products.   Speaker:  E. Ann Rose.
    • Columbus, OH – April 29, 1010
    • Portland, OR – May 20, 2010
    • San Diego, CA – June 3, 2010
    • Chicago, IL – June 17, 2010
    • St. Louis, MO – July 22, 2010
    • Tampa, FL – August 5, 2010
    • Salt Lake City, UT – August 19, 2010
    • Dallas, TX – September 16, 2010
    • Philadelphia, PA – October 7, 2010
    • Phoenix, AS – October 28, 2010

    To register for Alcon seminars go to the ARS website at: http://www.alcon.com/en/professionals/reimbursement-services.asp

Please contact us or call (800) 720-9667 for additional information regarding the above lectures and meetings.

 

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