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January 28, 2015

What’s New in 2015? Ask-the-Contractor Teleconference

Tuesday, January 13, 2015

What’s New in 2015?

Sustainable Growth Rate (SGR)
  • The Protecting Access to Medicare Act of 2014 provides for a 0% update to the physician fee schedule (PFS) for services furnished between January 1, 2015 and March 31, 2015
    • Conversion Factor for this period is $35.7547
  • Current law requires physician fee schedule rates to be reduced by an average of 21.2% from the CY 2014 rates effective April 1, 2015, unless Congress makes changes

Revisions to Geographic Practice Cost Indices (GPCIs)

  • CMS adjusts payments under the PFS to reflect local differences in the cost of operating a medical practice
  • The CY 2015 GPCIs also reflect the application of the statutorily mandated 1.0 work GPCI floor for physician fee schedule areas.
  • The statutory 1.0 work GPCI floor is scheduled to expire under current law on March 31, 2015
  • The GPCIs reflect the elimination of the 1.0 work GPCI floor from April 1, 2015 through December 31, 2015

Find Fee Schedules:

Digital Mammography
  • To ensure that the higher resources needed for 3D mammography are recognized, CMS is paying for 3D mammography using add-on codes that will be reported in addition to the 2D mammography codes.
    • CMS will revisit payment for 2D and 3D mammography for 2016

Anesthesia Related to Screening Colonoscopies

  • Medicare waives the Part B deductible and coinsurance applicable to screening colonoscopy to include separately provided anesthesia as part of the screening service so that the coinsurance and deductible do not apply to anesthesia for screening colonoscopy

Telehealth Services

  • The following services have been added to the list of services that can be furnished to Medicare beneficiaries under the telehealth benefit:
    • Annual Wellness visits
    • Psychoanalysis
    • Psychotherapy
    • Prolonged evaluation and management services

Incentive Programs:
Physician Quality Reporting System (PQRS):
  • 2015 Payment Adjustments: eligible professionals and group practices who did not report data on Physician Quality Reporting System (PQRS) quality measures for covered professional services during the 2013 program year will see a payment adjustment to the PFS for dates of service beginning in 2015.
  • The applicable percent for payment adjustments under PQRS are as follows:
    • -1.5% adjustment in 2015
    • -2.0% adjustment in 2016 and subsequent years

 

PQRS Help Desk
  • If you have questions or need assistance with PQRS reporting please contact the QualityNet Help Desk.  
  • Available Monday – Friday; 7:00 AM–7:00 PM CST
  • Phone: 1-866-288-8912
  • Email: Qnetsupport@hcqis.org

Electronic Health Record (EHR) Incentive Program

If a provider is eligible to participate in the Medicare EHR Incentive Program, they must demonstrate meaningful use in either the Medicare EHR Incentive ProgramExternal PDFor in the Medicaid EHR Incentive ProgramExternal PDF to avoid a payment adjustment.

  • Medicare eligible professionals who are not meaningful users will be subject to a payment adjustment beginning with dates of service in 2015.
  • Eligible professionals receive the payment adjustment amount that is tied to the year that they did not demonstrate meaningful use.

Information Center: CMS EHR Web PageExternal Website

  • Check Eligible Professional registration status and status on incentive payment in EHR program
  • Request duplicate remittance or 1099
  • Assist with registration, attestation inquiries, and password resets
    • Or call: 1.888.734.6433 (7:30 a.m. – 6:30 p.m. CT)

Dollars & Cents Updates

  • CY 2015 Part B Deductible: $147.00.  More info: CMS MLN Matters article MM8982External PDF.
  • For providers that are required to pay a fee to submit a CMS-855 application: the fee increased to $553 in CY 2015.
  • Therapy caps for 2015:
    • PT+ speech language pathology: $1,940
    • OT: $1,940
    • “Exceptions” process remains in place through 3/31/2015 (may be extended through subsequent legislation)

Accuracy: Comprehensive Error Rate Testing (CERT) Program

  • CMS calculates the Medicare Fee-for-Service (FFS) improper payment rate through the CERT program. Each year, CERT evaluates a statistically valid random sample of claims to determine if they were paid properly under Medicare coverage, coding, and billing rules.
  • The fiscal year (FY) 2014 Medicare FFS program improper payment rate is 12.7%, representing $45.8 billion in improper payments, compared to the FY 2013 improper payment rate of 10.1 percent or $36.0 billion in improper payments1.
  • The table outlines the improper payment rate and projected improper payment amount by claim type for FY 2014. The reporting period for this improper payment rate is July 1, 2012 -June 30, 2013.

Service Type

Improper Payment Rate

Improper Payment Amount

Inpatient Hospitals

9.2%

$10.4B

Durable Medical Equipment

53.1%

$5.1B

Physician/Lab/Ambulance

12.1%

$11.0B

Non-Inpatient Hospital Facilities

13.1%

$19.2B

Overall

12.7%

$45.8B

CERT

Documentation is the key to preventing most CERT errors.

  • Know the signature requirements for medical records and what to do if the requested records aren’t signed or the signature is not valid: CMS MLN Matters article MM6698External PDF is a good place to start.
  • Orders must demonstrate the medical necessity for the test/service and must also be signed.

CERT Resources 

Coding Changes
  • Access a list of added and deleted HCPCS and CPT codes and codes with changes in the narrative description for 2015 from the CGS website.
  • Remember: National Correct Coding Initiative (NCCI) edits and Medically Unlikely Edits (MUEs) may be updated as often as every quarter.  Updates are posted on the CMS NCCI web pageExternal Website.
  • New HCPCS modifiers for 2015 for “distinct procedural services”: XE, XP, XS, XU.  Read more in MLN Matters article MM8863External PDF.  Caution: supporting documentation required in records.
  • New code for chronic care management: CPT code 99490.  Further guidance may be forthcoming; meanwhile, adhere to the requirements in the CPT narrative and check with your specialty association for more information.
  • Reminder: the ICD-10 compliance date is 10/1/2015.

It’s Never Too Late “Get Back to Basics”

Being compliant with rules, regulations, guidelines, and changes means staying informed. 

  • Stay connected through professional organizations – examples include AAPC, AHIMA, HFMA, and state medical associations.
  • Sign up for the CGS Email Notification Alerts   
  • Know how to find your way around the CGS website
  • Bookmark the CMS website: www.cms.govExternal Website.
  • Save time: register to use the myCGS web portal (recent added functions: electronic claims filing, redeterminations, and reopenings).
  • Still need help?  Call our friendly Provider Contact Center representatives:
    • 866-276-9558
    • Select the best option for your type of question: General, EDI, Provider Enrollment, Reopenings, and Overpayments

Know when educational opportunities are offered in your area, over the phone lines, and through the internet.

Questions and Answers

Click on a question to expand or Show All / Close All

  1. Will there be any changes in 2015 to the G code reporting process? i.e. process on unexpected discharges for reporting or able to report more than one G code at a time?
  2. Whenever I submit a CPT with 2 units for the same date of service, both services are denied. Why are you denying both and not allowing one of the units.

    • Medically Unlikely Edits
      “Medically Unlikely Edits” (MUEs) are a separate set of NCCI edits designed to identify the maximum number of units that would normally be performed by a provider on a single date of service.  These are not “frequency parameters” – these edits are designed to prevent billing errors that result from entering an incorrect quantity for services.

      • Most MUEs are available on the CMS websiteExternal Website and may be updated as often as quarterly.   MUE changes are not retroactive unless the change is to update the file with a retroactive date.
      • MUE denials are coding denials, not medical necessity denials; therefore, it is not appropriate to issue an Advance Beneficiary Notice of Noncoverage (ABN) to shift liability to the beneficiary.
      • Before you submit claims pay special attention to the quantity; look at the specific CPT or HCPCS code and the number of units associated with that code from the MUE file. 
      • If the number of services you submitted is correct and reflects medically necessary care provided to the patient, and your claim is denied based on an MUE, you may appeal the denial.  Keep in mind that first-level appeals (Redeterminations) must be submitted within 120 days of the date of the initial determination (i.e., date on your Remittance Advice).  Include supporting documentation with your request.  Redeterminations may be submitted electronically through our secure web portal, myCGS, or on paperPDF (tip: complete the form electronically, then print, sign, attach supporting documentation, and mail). 
      • The MUE Adjustment Indicator (MAI) provides the rationale for the edit:

        MAI

        Explanation

        1

        Claim line edit

        2

        Absolute date of service edit; “per day edits based on policy”

        • CGS will not pay in excess of an MUE value with MAI indicator 2

        3

        Date of service edit: “per day based on clinical benchmarks”

      If You Disagree with an NCCI or MUE Edit:

      • To request a reconsideration of an NCCI edit, follow the instructions on the CMS NCCI web pageExternal Website.
      • To request a reconsideration of an MUE value, send your request, the rationale, and any supporting documentation, to:

        National Correct Coding Initiative
        Correct Coding Solutions, LLC
        PO Box 907
        Carmel, IN 46082-0907
        Fax: 317-571-1745

      Reference:

  3. When will the 2015 Physician Fee Schedule be loaded?
  4. We are curious if Chronic Care Management CCM can only be billed by family physician PCPs?

    • Chronic Care Management can be rendered by a physician or by other qualified health care professionals. Complex Chronic Care Management can be provided by a physician or under the direct the supervision of a physician.

  5. I am a provider with less than 20 FTE would I qualify to submit paper claims?

    • The Administrative Simplification Compliance Act (ASCA) prohibits payment of initial health care claims not sent electronically as of October 16, 2003, except in limited situations:

      • Small Provider Claims: The word “provider” is being used generically here to refer to physicians, suppliers, and other providers of health care services. Providers that have fewer than 25 full-time equivalent employees (FTEs) and that are required to bill a Medicare intermediary are considered to be small. Physicians and suppliers with fewer than 10 FTEs and that are required to bill a Medicare Administrative Contractor (MAC) or Durable Medical Equipment (DME) are classified as small. See section 90.1 of Chapter 24 of the Medicare Claims Processing Manual (Pub. 100-04) for more detailed information on calculation of FTE employees and this ASCA requirement in general.
      • Roster billing of inoculations covered by Medicare, except for those companies that agreed to submit these claims electronically as a condition for submission of flu shots administered in multiple states to a single MAC;
      • Claims for payment under a Medicare demonstration project that specifies claims be submitted on paper;
      • Medicare Secondary Payer Claims when there is more than one primary payer and one or more of those payers made an “Obligated to accept as payment in Full” (OTAF) adjustment;
      • Claims submitted by Medicare beneficiaries or Medicare Managed Care Plans;
      • Dental Claims;
      • Claims for services or supplies furnished outside of the U.S. by non-U.S. providers;
      • Disruption in electricity or communication connections outside of a provider's control expected to last more than two business days.
      • Claims from providers that submit fewer than 10 claims per month on average during a calendar year.

      Providers are to self-assess to determine if they meet one or more of these situations and should not submit a waiver request when they meet one or more of these situations. Please note that some of these situations are temporary or apply only to certain claims, when the temporary situation expires or when billing other types of claims, providers must submit their claims or those other types of claims electronically, and in the HIPAA standard.

  6. I filed an EHR hardship exception application prior to the deadline July 1, 2014. On December 30, 2014, we received a letter that informed us that the adjustment will be applicable to us. The letter does not indicate a date and it appears to have no information about our specific case. How do we find out or talk with someone about our case submitted back in July?
  7. Is there a place I can find how many units you can bill on CPT code?

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