Good news for radiology groups struggling to comply with date overlap (date of test versus date of interpretation) and place of service (test in hospital, read somewhere else).

The Centers for Medicare & Medicaid Services (CMS) announced on Friday, February 5, 2010, that it has rescinded Change Request (CR) 6375, Transmittal 1873 sent via RO-6657, dated December 11, 2009, and will replace it with another CR in the future, pending further policy clarification on date of service and place of service reporting for the interpretation of diagnostic tests. According to CMS, the revised CR will address the full spectrum of clinical scenarios. The agency also rescinded the accompanying MLN Matters article, MM6375. Another MLN Matters article will be issued when the new CR is released.

A new requirement is in place as of the first of this year requiring office-based accreditation for procedures requiring certain levels of sedation/anesthesia. This mostly impacts pain procedures, GI and cosmetic done in the office. Anything involving a major nerve block up to full anesthesia is included. There has been confusion with some thinking this was delayed; however, we want to be sure the word is out there that this is a requirement. Rule is 844 IAC 5-5: this is a rule from the Medical Licensing Board of Indiana….not a department of Health Facility rule. For details, go to http://www.in.gov/pla/2878.htm.

The RACs are actively running automated reviews on the CMS approved issues, and demand letters are being sent to providers. We want to take this time to encourage you to visit your Regional RAC website and update your contact information with them so that demand letters and other correspondence are directed to the correct person within your organization. Updating contact information can be done on-line.

As well, it is advised to keep an eye on the approved issues in all of the Regions. Each RAC has to seek approval on any issue they wish to pursue (even if approval is already granted to another region, they have to prove a reason to pursue the issue in their Region). So reviewing all of the approved issues keeps you abreast of the issues that could be coming to your Region. As well, any CERT or OIG or other agency or program issues that come out, could very likely be followed by a RAC requesting the issue approval for review. So keep your eyes on these programs as well so that you are aware.

Finally, if you have not already addressed how you will react to a request for medical records, you should address this now. Timeliness, accuracy and control over what is sent to the RAC is essential. In addition, if a medical record is requested that has previously undergone review by another audit program (like CERT), you need to advise the RAC on this issue and they will remove the record from the request. They are not to review a record if the issue being investigated has already undergone review. This leads me to my next question….do you have a system of tracking medical records that have been reviewed/audited, and the reason for the review?

For more information please go to http://www.cms.hhs.gov/RAC/

Link to Region A issues http://www.dcsrac.com/issues.html
Link to Region B issues http://racb.cgi.com/Issues.aspx
Link to Region C issues http://www.connollyhealthcare.com/RAC/pages/approved_issues.aspx
Link to Region D issues https://racinfo.healthdatainsights.com/Public1/NewIssues.aspx

CMS sent out the following information in a news release yesterday. The requirements for qualifying as a ’supervising physician’ remain open to debate lacking specific guidance from CMS. Should CMS require the ’supervising physician’ to be a ‘board-certified Diagnostic Radiologist,’ this will affect many in-office imaging services, such as MRI.

MRI, CT and PET Scans Among Services to be Affected - The Centers for Medicare & Medicaid Services (CMS) is designating three national accreditation organizations – the American College of Radiology (ACR), the Intersocietal Accreditation Commission (IAC), and The Joint Commission (TJC) - to accredit suppliers furnishing the technical component (TC) of advanced diagnostic imaging procedures.  The accreditation requirement will apply only to the suppliers furnishing the imaging services, and not to the physician’s interpretation of the images.

As required by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), all suppliers of the TC of advanced imaging will have to become accredited by an accreditation organization designated by the Secretary of Health and Human Services by Jan. 1, 2012.  The accreditation requirement applies to physicians, non-physician practitioners, and physician and non-physician organizations that are paid for providing the technical component of advanced imaging services under the Medicare Physician Fee Schedule.

MIPPA specifically defines advanced diagnostic imaging procedures as including diagnostic magnetic resonance imaging (MRI), computed tomography (CT), and nuclear medicine imaging such as positron emission tomography (PET).  The details of the accreditation organization selection process went through notice and comment rulemaking in the calendar year 2010 Physician Fee Schedule rule.

“While advanced diagnostic imaging procedures can be useful in identifying health problems that might otherwise require surgery, the rapid growth in their use raises important questions of quality and safety,” said Barry Straube, M.D., CMS chief medical officer and director of the CMS Office of Standards and Quality.  “The three organizations that will be accrediting suppliers have the expertise and authority to set a standard of excellence industry-wide.”

To be designated, the accrediting organizations had to demonstrate that they were experienced in the advanced diagnostic imaging area, and that their accreditation requirements met or exceeded the standards set out in MIPPA, including requirements for:

• Qualifications of non-physician personnel performing the imaging;
• Qualifications and responsibilities or medical directors and supervising physicians;
• Procedures to ensure the safety of the individuals furnishing the imaging procedure and of the persons to whom the services are furnished;
• Procedures to ensure the reliability, clarity, and accuracy of the technical quality of the diagnostic images produced by the supplier;
• Procedures to assist the beneficiary in obtaining his/her imaging records on request; and
• Procedures to notify CMS of any changes to the imaging modalities subsequent to the accrediting organization’s decision.

In addition, the accrediting organizations were required to develop a plan for reducing the burden and cost of accreditation to small and rural suppliers.  The accrediting organizations are also required to provide CMS with detailed information about their survey processes.

MIPPA specifically excluded from the accreditation requirement certain imaging services such as x-rays, ultrasound, and fluoroscopy procedures.  The law also excludes from the CMS accreditation requirement diagnostic and screening mammography, which are subject to quality oversight by the Food and Drug Administration under the Mammography Quality Standards Act.

CMS will issue further guidance to suppliers about meeting the accreditation requirements.  CMS plans to undertake a provider education outreach program to ensure that all affected suppliers understand the requirements and are able to comply with them prior to the Jan. 1, 2012, accreditation deadline. For more information, please see the CMS Web site at: www.cms.hhs.gov/medicareprovidersupenroll.

We asked Aetna Commercial if they were going to reimburse consult codes after CMS removed them from the Medicare Physician Fee Schedule and received this response:

Since the AMA still lists “consult” codes as active, Aetna will continue to accept and price these codes as valid after January 1, 2010, except as set forth below. We will continue to pay for these codes, according to your Aetna agreement, for members who are covered under our commercial benefits plans and our Medicare Advantage plans.

However, we will no longer recognize or pay for consult codes for members covered under our Medicare Open^SM Plan, a Private Fee-for-Service plan, or for claims from nonparticipating providers filing Medicare Advantage claims. Note that the PFFS plan is a non-contracted plan.

We hope you find this information helpful. What questions do you have about consult codes? Post a comment and ask us.

As you may have read in our post in December, we consulted with most of the major commercial payers, and consult codes are still being accepted by them in 2010. However, there is much confusion over secondary claim coding related to consult visits when Medicare no longer accepts consult codes but commercial payers do. We, along with Joy Newby of Newby Consulting, Inc., want to add some clarification to this issue.

When commercial is the secondary, either bill the secondary using the visit code (not a consult code) or contact the secondary to ask if you can revise to a consult–assuming the visit was a consult by
definition.

When Medicare is the secondary, the claim will be denied if billed as a consult, even though the primary commercial accepted the consult code.

We recommend that prior to passing through to Medicare as a secondary, you assign the proper visit level code to the secondary claim.

The reference for this statement is in a MedLearn article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6740.pdf

To the extent possible and in consideration of possible legislative changes, the Centers for Medicare & Medicaid Services (CMS) is working with Congress, health care providers, and the beneficiary community to avoid disruption in the delivery of health care services and payment of claims for physicians, non-physician practitioners, and other providers of services paid under the Medicare physician fee schedule, beginning January 1, 2010.  In this regard, CMS has instructed its contractors to hold claims containing services paid under the Medicare Physician Fee Schedule (MPFS) for the first 10 business days of January (January 1 through January 15) for 2010 dates of service. This should have minimum impact on provider cash flow because, under current law, clean electronic claims are not paid any sooner than 14 calendar days (29 days for paper claims) after the date of receipt.  Meanwhile, all claims for services delivered on or before December 31, 2009, will be processed and paid under normal procedures.

After 10 business days, contractors will begin releasing held claims into processing under the fee schedule which implements current law.  This, of course, could result in claims being processed with the negative 21.2 percent update.  If a new law is enacted which changes the negative update effective January 1, CMS will correctly process claims under the new law and, if necessary, CMS is prepared to automatically reprocess most of those claims which have already been processed at the lower rate. 

Under the Medicare statute, Medicare payments to physicians and other affected providers are based upon the lesser of the actual charge or the MPFS amount.   Providers who submit charges that are greater than the negative 2010 MPFS will automatically have their claims reprocessed.  Physicians who submit charges that are equal to or less than the 2010 MPFS amount will need to request an adjustment.  Submitted charges on claims cannot be altered without a request from the physician/provider.

To the extent possible, providers may hold claims in-house until it becomes clearer as to whether new legislation will be enacted or until cash flow becomes problematic.  This will reduce the need for providers to reconcile two payments (i.e., the initial claim and the reprocessed claim), and it will simplify provider billings of beneficiary coinsurance and payment calculations for payers which are secondary to Medicare.

CMS has extended the 2010 Annual Participation Enrollment Program end date from January 31, 2010, to March 17, 2010– therefore, the enrollment period now runs from November 13, 2009, through March 17, 2010.

The effective date for any Participation status change during the extension, however, remains January 1, 2010, and will be in force for the entire year.

Contractors will accept and process any Participation elections or withdrawals, made during the extended enrollment period that are received or post-marked on or before March 17, 2010.

In addition, be on the alert for more information about other legislative provisions which may affect you.

In an effort to clarify how commercial payers will address the use of consult codes starting in January 2010, I inquired with the following payers: Cigna, Sagamore, Aetna, Aetna Work Comp, Anthem (Indiana), United (Midwest) and Medical Mutual of Ohio. All noted that they will continue to accept and reimburse for Consult Codes with their covered lives. The only exceptions are the Medicare plans provided by these payers. All Medicare plans offered through commercial payers will abide by Medicare billing rules. This presents some challenges for your practice in assuring the appropriate codes are billed for your Medicare patients. As well use of Consult Codes where Medicare may be a secondary crossover claim will certainly be an area for you to monitor and to determine the best process for your practice. As we receive updated information from commercial payers, we will pass it along. (For details on the CMS final rule, see linked article by Joy Newby, LPN, CPC, PCS of Newby Consulting, Inc.)

The Somerset Health Care Team invites you to our next Executive Roundtable session on Thursday, December 3, 2009. We hope you can join us–in person or via webinar. Presentations will include “Electronic Health Records Today: How to Cost Justify, Implement and Earn ARRA Dollars” by Allen Murphy of NextGen Healthcare and “2009 Health Care Review” by Cathy Weaver of Somerset.

The conference is being held at Somerset’s office in Indianapolis and can be accessed via webinar as well. The time will be from 11:30 a.m. to 1:00 p.m. (Eastern). Details and Registration.

The Federal Trade Commission just released news of another extension of the enforcement of the ‘Red Flags’ Rule, this one until June 1, 2010. Read the full news release on their site: http://www.ftc.gov/opa/2009/10/redflags.shtm