Medicare in 2017: What’s New and Different

By: Jean Acevedo, LHRM, CHC, CPC, CENTC, President and Senior Consultant

The 2017 Medicare Physician Fee Schedule Rule (PFS) contains more payment changes than we have seen in quite some time. Although it’s a good idea for all Part B providers to attend webinar updates from your MAC (Medicare Administrative Contractor), specialty societies, or us here at Acevedo Consulting, we wanted to make you aware of some of the highlights found in the final rule. Space constraints won’t allow a full discussion on each area, nor for us to touch on everything, but this should at least peak your interest.

CMS finalized a number of new PFS policies that will improve Medicare payment for services provided by primary care physicians for patients with multiple chronic conditions, mental and behavioral health issues, and cognitive impairment conditions. The final rule addresses other topics related to the Medicare program, such as enrollment requirements for providers and suppliers in Medicare Advantage, and the Medicare Diabetes Prevention Program (MDPP) expanded model. There is much in this final rule that reflects a broader CMS strategy to create a health care system that results in better care, smarter spending, and healthier people. As I read the PFS rule, I could see how it ties in with MACRA and MIPS – or what CMS is now calling its Quality Payment Program (QPP).

CMS is continuing the Agency’s ongoing efforts to improve payment within traditional fee-for-service Medicare for primary care and patient centered care management. CMS is finalizing several revisions to the PFS billing code set to more accurately recognize the evolving work of primary care and other cognitive specialties to accommodate the changing needs of the Medicare patient population. Historically, care management and cognitive work has been “bundled” into the evaluation and management visit codes (E&M) used by all specialties. This has meant that payment for these services has been distributed equally among all specialties that report E&M visit codes, instead of being targeted toward practitioners who manage care and/or primarily provide cognitive services such as primary care or rheumatology physicians. Here are some examples: Continue Reading

These changes as well as others were addressed in our complimentary webinar "2017 Medicare Changes" on December 6th.  If you missed it or would like to listen again the recording can be viewed here.

It’s Important to Ensure Your Medicare Enrollment Information is Accurate!

Here are a few very important reasons why…

By: Rachael Lowe, CPC, CPMA, CEMC, Director of Client Services

Providers can have their Medicare privileges revoked.

The Federal Register indicates in 42 CFR 424.516(d) that physicians and other organizations who are enrolled in the Medicare program are responsible for notifying Medicare of what they refer to as “reportable events”.  We have had the opportunity to assist hundreds of physician practices and other organizations with their Medicare enrollment needs over the years and find that "reportable events" are often overlooked.   While some of what they consider a reportable event may seem like a minor administrative change, the recourse for not reporting the change to Medicare could be as tragic as having Medicare privileges revoked.

While we encourage all Medicare providers to review the complete listing of reportable events, the below are those that we see most commonly.

• Within 30 days a provider must report:
  • A change of ownership
  • An adverse legal action
  • A change in practice location (a move or location addition)
• Within 90 days a provider must report all other changes in enrollment. This includes those listed as an authorized official(s) or delegated official(s).

Similar to our observations, a recent report from the Office of the Inspector General (OIG) found that of over three-quarters of Medicare providers included in their sample had owner names on record with CMS that did not match those that were submitted to the OIG. Owners are individuals or corporations with a five percent (5%) percent of more ownership or controlling interest.  Other observations were noted, such as sanction checks not being performed properly, etc. The entire report can be viewed here. 

There are other ways in which not reporting enrollment changes could affect your bottom line.  Continue Reading

The Importance of Documenting the Medical Necessity of Services

by: Joanna Bennett, CHC, CPC, Associate Consultant

Over the last couple of years I have been in frequent contact with a Nurse Reviewer at First Coast Service Options (FCSO), Florida’s Medicare contractor, regarding denials of laboratory services. When FCSO denied a claim for a client of ours, I asked them for a reason and a specific example of a patient so I could go back and review the record. What I’ve frequently heard from them was that there was no sign or symptom to support the need for the test. This made me search for where this statement came from. And, it turned out it was listed in the CMS’ Evaluation and Management Service Guide. Per the E&M Guide, “for every service billed, you must indicate the specific sign, symptom, or patient complaint that makes the service reasonable and necessary.” As you see, FCSO was quoting the CMS’ Guide which is applicable everywhere, not just in Florida.

Additionally, I was told by FCSO, a diagnosis code on the order or in the clinician’s note is not enough to support the medical necessity of the test. Again I wondered, where are they quoting this statement from? Reading one of FCSO’s Local Coverage Determinations (LCDs) I found it. Continue Reading