CMA Practice Resources (CPR) is a free monthly e-bulletin from the California Medical Association’s practice management experts that focuses on critical payor and health care industry changes and how they directly impact the business of a physician practice. Each issue includes tips on reimbursement and contracting related issues along with information on the latest practice management news.
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In this issue:
- Meaningful use reporting deadline pushed back two weeks to March 13
- Don’t forget: Physicians must still report data for 2016 PQRS
- What regulations limit your ability to serve your patients? Tell CMA now!
- U.S. District Court blocks Anthem-Cigna merger
- Registration now open for 2017 Western Health Care Leadership Academy
- The Coding Corner: CPT® 2017: Medicare coding and coverage updates
The Centers for Medicare & Medicaid Services (CMS) recently announced that physicians would have two additional weeks to register and attest to meaningful use for 2016 and avoid the 2018 penalty. Physicians now have until Monday, March 13, to attest for the 2016 reporting year.
Physicians should note that CMS is only extending the attestation period, not the reporting period, so physicians must have concluded their reporting by December 31, 2016.
Although the Medicare meaningful use program is being phased out this year, physicians are still required to report meaningful use measures for 2016 to avoid a 3 percent Medicare penalty in 2018. According to CMS, approximately 171,000 physicians are expected to be penalized this year because they didn't attest to meaningful use for 2015.
Medicare meaningful use reporting will end in 2017, with eligible clinicians who do not participate in the new advanced alternative payment models transitioning to Medicare's new Merit-Based Incentive Payment System (MIPS).
To attest, providers should submit their data through the CMS registration and attestation system. Physicians may select an EHR reporting period of any continuous 90 days from January 1, 2016, through December 31, 2016.
CMA recommends that physicians attest during off-peak hours, such as evenings and weekends, to speed up the attestation process. Physicians are also urged to take time now to ensure that their Medicare enrollment information is up-to-date before entering their 2016 attestation data. Review the CMS Registration and Attestation Resources Page for other tips to success.
Please note the deadline referenced above only applies to the Medicare EHR program, not the Medicaid (Medi-Cal in California) program. For more details on the Medi-Cal program and deadlines, see http://medi-cal.ehr.ca.gov.
While 2017 will mark the beginning of the Merit-Based Incentive Payment System (MIPS) under the Medicare Access and CHIP Reauthorization Act (MACRA), physicians are reminded that they still must report data for the 2016 Physician Quality Reporting System (PQRS) program. The Centers for Medicare and Medicaid Services (CMS) has extended the deadline to submit the 2016 data using the electronic health records (EHR) reporting mechanism. Providers have only until March 13, 2017, to submit 2016 PQRS EHR data. This extension applies only to the EHR reporting mechanism. For more details, see the CMS "PQRS Reporting Using EHR Made Simple" guide.
Eligible providers who do not report 2016 PQRS quality measure data will be subject to a negative payment adjustment on all Medicare Part B Physician Fee Schedule services rendered in 2018.
For questions, please contact the QualityNet Help Desk at (866) 288-8912 or email@example.com. For more information on PQRS, see the California Medical Association (CMA) guide, "Getting Started with the Medicare Physician Quality Reporting System," available free to members in the CMA resource library.
President Donald Trump has issued an Executive Order requiring agencies to eliminate two regulations for every one they issue. The Administration has also created task forces “charged with calling out those rules that eliminate jobs or inhibit job creation; that are outdated, unnecessary or ineffective; or that impose costs in excess of benefits.”
More from Bloomberg:
“Within 90 days, they must provide a report to agency heads, identifying specific regulations that are ripe for repeal, replacement or modification. They are charged with calling out those rules that eliminate jobs or inhibit job creation; that are outdated, unnecessary or ineffective; or that impose costs in excess of benefits. The task forces are specifically directed to seek input from those affected by regulations, including small businesses; consumers; nongovernmental organizations; trade associations; and state, local and tribal governments.”
Physicians are no strangers to burdensome regulations, and we know not all regulations are created equal. Some regulations protect public health, while others are outdated or hurt doctors’ ability to expand their medical practice to serve more patients, especially those from low-income and underserved communities.
Let’s focus on the latter – what regulations would you like to see eliminated because they limit your ability to serve your patients?
Send your thoughts to firstname.lastname@example.org – we’ll include the best comments in an updated article in the next CMA Newswire.
A federal judge has blocked the $48 billion mega-merger between Anthem and Cigna (U.S. v. Anthem Inc., 16-cv-1493). The ruling favored the U.S. Department of Justice (DOJ) and 11 states, including California, who argued that the Anthem-Cigna merger would limit price competition and lower the quality of care that Americans receive.
“The California Medical Association (CMA) has opposed the Anthem-Cigna mega-merger since day one because it would hurt patients and increase health care costs,” said CMA President Ruth E. Haskins, M.D. “Limiting market competition would compel insurers to contract with fewer physicians, resulting in patients facing higher premiums and longer wait times for referrals – not to mention forcing many patients to pay out-of-pocket to see out-of-network doctors.”
Seventy-one percent of the nation’s metropolitan areas already lack competitive commercial health insurance markets. A merger between Anthem and Cigna would have further diminished competition in 121 metro areas throughout the 14 states where Anthem is licensed to provide commercial coverage.
“We are pleased that Judge Berman Jackson ruled in favor of providing patients with the affordable, quality care they deserve,” said Dr. Haskins. “Maintaining competition in California’s health insurance markets is essential – it gives patients more choice in managing their health care while keeping costs low.”
In January, another federal court blocked Aetna Inc.’s proposed merger with Humana on the grounds that it violated anti-trust law. CMA, which represents 43,000 physicians across all modes of practice, also opposed this $34 billion mega-merger, which would have disproportionately affected the accessibility and affordability of health care for millions of vulnerable seniors.
In March 2016, a CMA-backed survey of California physicians revealed that an overwhelming 85 percent opposed the Anthem-Cigna merger and 83 percent opposed the Aetna-Humana merger. Out of the 989 physicians surveyed from practices across the state, the majority expressed worries that health insurer consolidations could narrow physician networks (82 percent), force physicians to provide fewer services (90 percent) and pressure physicians into refraining from aggressive patient advocacy (75 percent).
The California Medical Association, along with our national presenting sponsor, The Physicians Foundation, is pleased to announce that we are now accepting registrations for the 2017 Western Health Care Leadership Academy. This outstanding event—ideal for physicians, nurses, medical practice managers, hospital chiefs of staff, medical and specialty society officers and executives, and more—will take place May 5-7 at the Marriott Marquis San Diego Marina.
Register today with the VIP Upgrade and enjoy special benefits, including express conference check-in, preferred seating, and "up close and personal" experiences with select keynote speakers, where you will have the chance to ask questions face-to-face in an exclusive setting.
The 2017 Western Health Care Leadership Academy continues its mission of providing information and tools needed to succeed in today’s rapidly changing health care environment. Attendees will hear from the experts and leaders of change. The conference will examine the most significant challenges facing health care today and present proven models and innovative approaches to transform your organization’s care delivery and business practices.
For more information and to register, visit www.westernleadershipacademy.com.
CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.
Medicare payers often stipulate unique codes and coverage requirements not found within the CPT® codebook. For example, in 2017 the Centers for Medicare & Medicaid Services (CMS) continues to require the use of dedicated “G” codes (in place of CPT® codes) to describe mammography. But, in a reversal of previous policy, CMS now will allow separate reporting of certain prolonged services that do not include time spent face-to-face with the patient.
Stick with “G” codes for mammography
The 2017 CPT® codebook introduced three new codes to describe mammography services. Unlike the codes they replaced (77051, 77052, 77055, 77056 and 77057), the new codes specifically include computer-assisted detection (CAD), when performed:
- 77065 Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral
- 77066 Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral
- 77067 Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed
Additionally, the new code descriptors exactly match those of HCPCS codes G0206, G0204 and G0202, respectively, which were required when reporting mammography to Medicare payors. The expected result is that Medicare would adopt 77065-77067 in place of the “G” codes for 2017. But, due to technical issues, CMS was unable to ready its systems to process claims using CPT codes 77065, 77066 and 77067. Although CMS intends to recognize the CPT® codes in 2018, mammography claims to Medicare in 2017 must continue to use G0206, G0204 and G0202.
Specifically, CMS instructs:
Mammography is described using the following codes:
- G0202 Screening mammography, bilateral (2-view study of each breast), including computer- aided detection (CAD) when performed.
- G0204 Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral.
- G0206 Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral.
Breast tomosynthesis is described using the following add-on codes:
- 77063 Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure)
- G0279 Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to G0204 or G0206).
When breast tomosynthesis is furnished, practitioners should report one of G0202, G0204, or G0206 and one of G0279 or 77063. For purposes of billing digital breast tomosynthesis, the appropriate, accompanying 2D image(s) may either be acquired or synthesized.
CMS now covers 99358, +99359 prolonged services
CMS typically does not allow separate payment for physician services that do not require face-to-face time with a patient. As of January 1, 2017, however, CMS has made an exception and will now allow Medicare coverage for non face-to-face prolonged service codes 99358 Prolonged evaluation and management service before and/or after direct patient care; first hour and +99359 …each additional 30 minutes (List separately in addition to code for prolonged service), in compliance with CPT® guidelines.
Source: CMS Transmittal 3678, Change Request 9905 (Dec. 16, 2016)
CPT® Evaluation and Management/Prolonged Services instructions dictate:
Codes 99358 and 99359 are used when a prolonged service is provided that is neither face-to-face time in the office or outpatient setting, nor additional unit/floor time in the hospital or nursing facility setting during the same session of an evaluation and management service and is beyond the usual physician or other qualified health care professional service time.
Codes 99358 and 99359 are to be reported in addition to other evaluation and management service codes, to which they relate. “For example,” the CPT® codebook explains, “extensive record review may relate to a previous evaluation and management service performed earlier and commences upon receipt of past records.”
In keeping with CPT® requirements, CMS stresses that “codes 99358 and 99359 cannot be reported during the same service period as complex chronic care management (CCM) services or transitional care management services. They are not reported for time spent in non-face-to-face care described by more specific codes having no upper time limit in the CPT code set.” CMS further stipulates, “99358 and 99359 can only be used to report extended qualifying time of the billing physician or other practitioner (not clinical staff).”
Codes 99358 and 99359 are time-based and include “the total duration of non-face-to-face time spent by a physician or other qualified health care profession on a given date providing prolonged services, even if the time…is not continuous,” according to CPT®. The codes are applied as follows:
Total duration of services
|< 30 minutes||Not reported separately|
|75-104 minutes||99358, 99359|
|105-134 minutes||99358, 99359 x 2|
Documentation should summarize the necessity and specific content of the prolonged services. See the CPT® codebook for additional guidelines to report prolonged services.
AETNA: The pharmacy drug list for Aetna commercial members will be updated on July 1, 2017. Starting on April 1, 2017, the list of upcoming changes to precertification, quantity limits and step-therapy programs can be viewed on the Formularies & Pharmacy Clinical Policy Bulletins page on the Aetna.com website.
ANTHEM BLUE CROSS: Anthem Blue Cross has decided not to implement the change to Sleep Studies and Related Services & Supplies. The change placing a frequency limit of one attended sleep study (CPT codes 95807, 95808, 95810, 95811, 95782 and/or 95783) every 60 days, was slated to be effective with dates of service on or after October 1, 2016, but will no longer be in effect.
UNITED HEALTHCARE: In 2017, United Healthcare will be retiring the UHCWest.com website address. Users will be transitioned to UnitedHealthcareOnline.com and Link, the gateway to United Healthcare’s online tools. Users will continue to have access to the content and transaction tools they need and will be notified when these are moving. To help ensure a smooth transition, United is asking UHCWest.com users to prepare now by registering for an Optum ID and connecting it to their Tax Identification Number. For more information, stay tuned to the Network Bulletin or visit UnitedHealthcareOnline.com > Help > Link – Learn More > Information for UHCWest.com.
The California Medical Association offers our members free programs to educate physicians and staff on a range of practice management issues. Space is limited, so register soon.
Upcoming CMA webinar: March 2017
Most webinars are held over the lunch hour, from 12:15 to 1:15 p.m. and are free for CMA members and their staff. See the event calendar for additional details and to register.
3/15: Cannabis in Medicine: A Review of Policy and Scientific Evidence: This webinar will cover the new state requirements under Proposition 64, “The Control, Regulate and Tax Adult Use of Marijuana Act” and present the most current clinical information pertaining to the potential medical uses of cannabis as well as its medico-legal policy context. Data will mainly be pulled from recent meta-analyses and systematic reviews from the past two to five years. The webinar will explicitly focus on whether or not evidence exists, and how strong any evidence is, for the use of cannabis to treat symptoms from a handful of diseases with particular focus on chronic and neuropathic pain.
Contact: CMA’s member help center, (800) 786-4262 or email@example.com.
The California Medical Association’s Center for Economic Services provides direct reimbursement assistance to CMA physician members and their office staff.
Reimbursement Help Line (888/401-5911)
- One-on-one educational and reimbursement assistance to physician members and their staff
- Tools and resources to empower physician practices
- Seminars and toolkits for physicians and their staff
- Staffed by practice management experts with a combined experience of over 125 years in medical practice operations
Need help? Contact CMA’s reimbursement experts at (888) 401-5911 or firstname.lastname@example.org.
To make sure that you are aware of important news from your contracting health plans, we encourage you to regularly read plans' provider newsletters and bulletins. Follow the links below to access the current issues.
AETNA: www.aetna.com. Click on "Health Care Professionals" in the main menu, then on "News for Providers" in the left sidebar.
CIGNA: www.cigna.com. Click on "Health Professionals" under "Customer Care" in the main menu. Then, scroll down and click on "Newsletters."
ANTHEM BLUE CROSS: www.anthem.com/ca. Click on "Providers" in the main menu, then on "Professional Network Update" under "Spotlight."
BLUE SHIELD: www.blueshieldca.com. Click on "I'm a Provider," then on "Announcements" under "News and Features."
HEALTH NET: www.healthnet.com. Click on "I'm a Provider" and then "California." Enter username and password, and then click "Online News."
MEDI-CAL: www.medi-cal.ca.gov. Click on "Publications" in the main menu, then on "Provider Bulletins."
MEDICARE/NORIDIAN: https://med.noridianmedicare.com/web/jeb/fees-news. Noridian publishes individual articles through the Latest Updates section in the left sidebar. The articles are condensed approximately every six-to-eight weeks into a Bulletin.
UNITED HEALTHCARE: www.unitedhealthcareonline.com. Click on "Tools & Resources" in the main menu, then on "Network Bulletin."
CMA RESOURCE: Find up-to-date profiles on each of the major payors in California.
If you have questions related to any of the articles in this issue, please contact CMA's reimbursement help line, (888) 401-5911 or email@example.com. Questions about membership, including technical website issues, should be directed to CMA's member help center, (800) 786-4CMA or firstname.lastname@example.org.
Let us know which topics you would like to see addressed in future issues. Contact CMA's Center for Economic Services at (916) 551-2061 or email@example.com.