This information was recently reported in Imaging Economics:

UnitedHealthcare Changes Radiology Accreditation and Pre-Authorization
Following CMS announcing new accreditation standards, insurance giant, UnitedHealthcare, Minneapolis, is considering revising its own advanced imaging provider accreditation standards. In addition, it is expanding its pre-authorization requirements for imaging. Advanced imaging services are defined by CMS and UnitedHealthcare as CT, MRI, PET, and nuclear medicine. Based on a review of CMS publication that will describe its own criteria, UnitedHealthcare reports that it will review its own accrediting standards and perhaps modify those standards to be aligned with the CMS accreditation requirements.

Should changes be made to its standards, UnitedHealthcare said it will inform providers of the effective date with a formal letter 90-days in advance of implementation.

In addition, effective February 15, 2010, UnitedHealthcare will now require all network physicians (including UnitedHealth Premium® Quality and Cost Efficiency designated physicians) to participate in its Radiology Notification & Authorization Program.

The program requires prior notification for the following outpatient imaging procedures: CT scans, MRIs, MRAs, PET scans, and nuclear medicine studies, including nuclear cardiology. Previously, UnitedHealthcare only required referring physicians who signed up for the pre-authorization program.

The Radiology Notification Program is currently not active in AK, CT, ID, MN, MT, ND, NE, NJ, NY, OR, RI, SD, WA & WY. Additional details about the Radiology Notification Program and its changes are available on this UnitedHealthcare website.

The below message from CMS is important information for physician practices.

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. As you are aware, the Department of Defense Appropriations Act of 2010 provided a zero percent (0%) update to the 2010 MPFS effective for dates of service January 1, 2010, through February 28, 2010. 

We believe Congress is working to avoid the negative update that will take effect March 1.  Consequently, CMS has instructed its contractors to hold claims containing services paid under the MPFS for the first 10 business days of March. The holding of MPFS claims will only affect claims with dates of service March 1, 2010, and forward.  This hold should have a minimum impact on provider cash flow because, under current law, clean electronic claims are not paid any sooner than 14 calendar days (29 for paper claims) after the date of receipt.  Be on the alert for more information about the 2010 Medicare Physician Fee Schedule Update.

Please post your comments or questions here or contact us.

CMS sent this important information out on Friday, March 19, 2010:

The Centers for Medicare & Medicaid Services (CMS) will delay until January 3, 2011, the implementation of Phase 2 of Change Request (CR) 6417 (Expansion of the Current Scope of Editing for Ordering/Referring Providers for Claims Processed by Medicare Carriers and Part B Medicare Administrative Contractors (MACs)) and CR 6421 (Expansion of the Current Scope of Editing for Ordering/Referring Providers for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Supplier Claims Processed by Durable Medical Equipment Medicare Administrative Contractors (DME MACs)). 

This delay will give physicians and non-physician practitioners who order items or services for Medicare beneficiaries or who refer Medicare beneficiaries to other Medicare providers or suppliers sufficient time to enroll in Medicare or take the action necessary to establish a current enrollment record in Medicare prior to Phase 2 implementation.

Although enrolled in Medicare, many physicians and non-physician practitioners who are eligible to order items or services or refer Medicare beneficiaries to other Medicare providers or suppliers for services do not have current enrollment records in Medicare.  A current enrollment record is one that is in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and contains the NPI.  Under Phase 2 of the above referenced CRs, a physician or non-physician practitioner who orders or refers and who does not have a current enrollment record that contains the NPI will cause the claim submitted by the Part B provider/supplier who furnished the ordered or referred item or service to be rejected. 

CMS continues to urge physicians and non-physician practitioners who are enrolled in Medicare but who have not updated their Medicare enrollment record since November 2003 to update their enrollment record now.  If these physicians and non-physician practitioners have no changes to their enrollment data, they need to submit an initial enrollment application which will establish a current enrollment record in PECOS.

In a message sent out by CMS yesterday, they announced that action is required by some health care providers to receive supplemental payment. Below is their statement:

The Centers for Medicare & Medicaid Services (CMS) has identified a problem where claims were not automatically crossing over to supplemental payers even though the provider remittance advice indicated otherwise.  This problem began January 5, 2010.  Part A institutional claims and Part B professional claims, with the exception of supplier claims processed by Durable Medical Equipment Medicare Administrative Contractors (DME MACs), were impacted by this problem.  Claims processed by DME MACs were not impacted.  

Part A Institutional Claims
No action is required by Part A institutional providers.  As of February 2, 2010, CMS successfully implemented a systems fix to ensure that  all Part A institutional claims are now crossing over to supplemental payers as indicated on the remittance advice received by providers.  As part of the fix, CMS’ Medicare contractors were able to identify claims processed between January 5 and February 1, 2010, where the provider remittance advice indicated that the affected claims were crossed over to various supplemental payers but were not.   On February 2, 2010, the affected Medicare contractors began to send the affected claims to the Coordination of Benefits Contractor (COBC) to be crossed over to supplemental payers.  This effort is now largely completed.  Please allow until March 1, 2010, for supplemental payers to receive and process these claims before attempting to balance bill them for any remaining balances after Medicare.

Part B Professional Claims
Action is required on behalf of Part B professional providers where a remittance advice with an issue date between January 5, 2010, and February 12, 2010, has two or more service lines for a beneficiary where both of the following apply:

• One service line is 100 percent reimbursable (i.e., the approved amount and amount to be paid are equal,) AND    
• One service line where part of or the entire Medicare approved amount is applied to the Part B deductible and/or carries co-insurance amounts. 

CMS is not able to forward these beneficiary claims to supplemental payers even though the remittance advice may indicate otherwise.  Providers will need to identify these claims by reviewing their remittance advice with an issue date between January 5, 2010, and February 12, 2010, that contain the criteria noted above.  Once identified, providers will need to take action to balance bill the beneficiary’s supplemental payer.  As of February 12, 2010, this system problem was fixed and all claims are crossing over to supplemental payers as indicated on the provider remittance advice.  

The CMS has already notified supplemental payers of these issues.  We regret any inconvenience you may experience related to this Medicare claim supplemental payer crossover problem.

If you have questions or concerns, please post them here or contact us.

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