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:
- United Healthcare introduces Group Medicare Advantage PPO product
- DHCS identifies another glitch in issuing primary care rate increase for CHDP claims
- DWC implements annual changes to workers' compensation physician fee schedule
- Is your Medicare practice information up-to date?
- Anthem system error results in missing remittances
- Medi-Cal deactivates some physicians in error
- New fee reduction for Workers’ Compensation Independent Medical Review and Independent Bill Review submissions
- CMS extends meaningful use EHR attestation deadline to March 20
- CMS to conduct ICD-10 claims testing for physicians in June
- ICD-10 training seminars coming this summer
- Meet your new CMA Affinity Partner: COLA
- The Coding Corner: Breast imaging coding changes in 2015
Effective June 1, 2015, United Healthcare (UHC) will be introducing its Group Medicare Advantage PPO product in several southern California counties. The California Medical Association (CMA) has learned that contract amendments were mailed on February 24 to over 10,000 currently contracted UHC physician practices in Imperial, Orange, Los Angeles, Riverside, San Bernardino and San Diego counties that the payor intends on including in its provider network for this new product.
The insurer states that the new product, offered exclusively to employer/union group retirees, will offer greater access to a national network of UHC contracted providers.
Physicians who received the amendment will have 30 days from the date of receipt to notify UHC if they wish to opt out of participation in the new product without affecting their underlying United Healthcare contract.
As always, physicians are encouraged to carefully review all proposed amendments to payor contracts. Remember, you do not have to accept substandard contracts that are not beneficial to your practice.
Physicians who are unsure whether or not they are affected by this change, or those who have general questions about the amendment, can contact United Healthcare Network Management at (866) 574-6088.
The California Department of Health Care Services (DHCS) has experienced various difficulties issuing the Affordable Care Act primary care rate increase funds on Child Health and Disability Prevention (CHDP) Program claims.
Before the rate increases were implemented, some practices had been instructed by DHCS to bill CHDP claims at their Medi-Cal rates. This caused concern – based on DHCS’s pricing logic of paying the lesser of Medicare’s rate or the billed charges – that some practices would not qualify for the retroactive increases once the systems were updated to process claims at the higher rates.
In response to concerns, DHCS developed a web portal to allow physicians to enter their usual and customary rates (UCR). However, DHCS then discovered an error in its web app that required physicians who entered their UCR data prior to November 26, 2014, to have to reenter their information.
Recently, the California Medical Association (CMA) has learned that CHDP providers practicing as part of a group will be required to re-attest as a group to get paid. Previously, physicians had been instructed to only attest as individuals.
An updated “NewsFlash” is in process to explain the additional steps that will be required for CHDP doctors who bill as part of a group or clinic in order to be paid. CMA will publish an update as soon as the DHCS NewsFlash is released.
The California Division of Workers’ Compensation (DWC) has implemented its annual adjustments to the California workers’ compensation resource-based relative value scale (RBRVS) fee schedule effective for dates of service on or after March 1, 2015.
Under the RBRVS Physician Fee Schedule regulations, located under “Physician services” on DWC’s Official Medical Fee Schedule (OMFS) webpage, the calculations to determine maximum allowable amounts for each code incorporate a number of factors, including the assigned relative value units for each code along with the yearly adjusted conversion factor determined by DWC. DWC updates these factors annually respective of changes in the Medicare payment system.
DWC has reiterated that will not be publishing a composite fee schedule for physicians to access. Physicians seeking a streamlined method of determining correct reimbursement amounts for workers’ compensation medical services can contact DaisyBill, which offers an easy-to-use OMFS Calculator.
The February issue of CMA Practice Resources (CPR) contained an article discussing the importance of maintaining up-to-date practice demographic information with contracted managed care payors (see “Ensure your practice information is up-to-date with contracted payors”). This advice applies equally to government payors, such as Medicare, that you are enrolled in.
Medicare administrative contractors (MAC), such as Noridian in California, obtain practice contact information from a practice’s Medicare enrollment application, from either the Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or through a paper application. The MAC may contact you by mail, telephone or email, when necessary.
Outdated information may cause delays in payment, and even deactivation of your enrollment status if required actions, such as revalidation, are not completed timely. For example, some physicians recently received notices from Noridian that their National Provider Identifier (NPI) was being deactivated due to lack of response to a revalidation request. While Medicare did send a paper notice to affected physicians, in many cases, the practice had not updated its contact information with Medicare, and the paper notice went to the wrong address.
Most government payors require completion of enrollment forms for updates and changes. To ensure your practice’s information is up-to-date with Medicare, practices are encouraged to do the following:
- Complete the appropriate enrollment forms through the Internet or on paper to report changes. Changes generally cannot be made by letter.
- Complete any necessary forms to notify the contractor of changes in your office’s primary point of contact. Many agencies will speak only to the person enrolled, or the primary point of contact on the enrollment form. If you are not the contact, they may not assist you when needed.
- Notify the MAC or other government contractor of changes in address through the enrollment update process, even if it is to a different suite in the same building.
- Complete an enrollment update if your correspondence address changes, even if your physical address remains the same.
- Update all email addresses if they change. Government payors are often using email to contact physicians for needed information. Don’t forget to check your spam or junk folders for any emails that may come from contractors you submit claims to.
- Update phone numbers and area codes if they change. Don’t expect contractors to search for changes.
The Medicare link to paper enrollment forms and the Internet-based PECOS can be found on the Centers for Medicare and Medicaid Services (CMS) Medicare Provider-Supplier Enrollment page on the CMS website (see left sidebar). Click here for additional information on using the Internet-based PECOS.
Updates may take as little as 30 days, or as long as 120 days. Once the change is completed in the system, the physician will receive written confirmation. Prompt notification to government payors of any change will help ensure there are no disruptions in enrollment or payment for your practice.
In early February, the California Medical Association (CMA) began receiving reports from practices of missing Anthem Blue Cross remittances. CMA escalated the issue to the payor and has since learned that a system issue is to blame for the missing electronic remittance advices (ERA).
Anthem reports that the problem began in mid-December and affected ERAs for exchange/mirror and Federal Employee Program (FEP) claims. Somehow, the ERA function was turned off in the Anthem system for these product types. So, while practices received the money for the affected claims through electronic funds transfer (EFT), they have not yet received the detailed claims information in order to post to individual accounts.
A system fix was put into place on February 16 to fix the issue going forward. Practices can obtain missing ERAs through the ProviderAccess portal on the Anthem website or can contact Anthem customer service:
- For missing FEP remittances: (800) 322-7319
- For missing Covered California remittances: (855) 854-1438
CMA had also received some reports of missing CalPERS ERAs; however, Anthem reports the CalPERS issue was unrelated to the issue affecting exchange/mirror and FEP ERAs. Rather, it was due to a recent change in CalPERS claims processing that resulted in a several week delay in processing of ERAs. Physicians who are still missing CalPERS remittances can call (800) 677-6699 to request them.
On February 7, the California Department of Health Care Services (DHCS) performed a periodic review of activity and deactivated all providers that had not billed Medi-Cal for 12 consecutive months. All deactivated providers were notified by letter of the deactivation of their record.
On February 17, however, DHCS found that a small subgroup of providers, those with multiple locations under the same National Provider Identifier (NPI), were incorrectly deactivated due to a system error.
Physicians who received a deactivation letter and believe they were deactivated in error should contact DHCS at DHCSMASSDEACT@dhcs.ca.gov. Physicians who were deactivated because they had not billed Medi-Cal in 12 months can re-apply through the Provider Enrollment Division.
DHCS has advised that providers who are only utilizing their NPIs for rendering, ordering, referring or prescribing purposes can continue to do so, even if their record was deactivated.
Additional questions about the deactivation can be directed to DHCS at DHCSMASSDEACT@dhcs.ca.gov.
New fee reduction for Workers’ Compensation Independent Medical Review and Independent Bill Review submissions
The California Department of Industrial Relations (DIR) announced that fees for submission of an Independent Medical Review (IMR) or Independent Bill Review (IBR) for workers’ compensation were reduced effective January 1, 2015.
The following table summarizes the reduction in fees.
|Fee prior to December 31, 2014||Fee effective January 1, 2015|
|Independent Medical Review|
|Standard IMRs involving non-pharmacy claims||$420||$390|
|Standard IMRs involving pharmacy-only claims||$390||$345|
|IMRs terminated or dismissed, not forwarded to a medical professional reviewer||$160||$123|
|IMRs terminated or dismissed after case forwarded to a medical professional reviewer||$420||$390|
|Expedited IMRs involving non-pharmacy claims (no change in fee) ||$515||$515|
|Independent Bill Review|
|Terminated IBR not sent to review||$50||$47.50|
Physicians who submitted an IMR or IBR on or after January 1, 2015, will receive a refund for any fees paid in excess of the new fee schedule.
The Centers for Medicare and Medicaid Services (CMS) has extended the deadline for physicians to attest to meaningful use for the Medicare Electronic Health Record (EHR) Incentive Program 2014 reporting year. While the original deadline was February 28, physicians now have until 11:59 p.m., ET, on March 20, 2015, to attest.
CMS extended the deadline to allow providers extra time to submit their meaningful use data, but urges providers to begin attesting for 2014 as soon as they can.
This extension also allows eligible professionals, who have not already used their one “switch,” to switch programs (from Medicare to Medicaid, or vice versa) for the 2014 payment year. After that time, eligible professionals will no longer be able to switch programs.
Medicare-eligible professionals must attest to meaningful use every year to receive an incentive and avoid a payment adjustment. Providers who successfully attest for the 2014 program year will:
- Receive an incentive payment; and
- Avoid the Medicare payment adjustment, which will be applied January 1, 2016.
Note: The Medicare extension does not affect deadlines for the Medicaid EHR Incentive Program. Additionally, the EHR reporting option for the Physician Quality Reporting System (PQRS) has been extended until March 20, 2015. The California Medical Association will publish more information on the PQRS program extension as it becomes available.
How to Attest
Submit your data to the Registration and Attestation System, which includes 2014 Certified EHR Technology (CEHRT) Flexibility Rule options. Tips for speed:
- Attest during non-peak hours, such as evenings and weekends
- Start now to:
- Check that your information is up-to-date
- Begin entering your 2014 data
On October 1, 2015, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. To help physicians prepare for this transition, the Centers for Medicare and Medicaid Services (CMS) will be conducting a national testing week, from June 1-5. 2015.
This testing week will give trading partners access to the Medicare Administrative Contractors (MAC) and Common Electronic Data Interchange (CEDI) for testing with real-time help desk support.
While participants will not be able to conduct true end-to-end testing at this time, they will be able to test whether the contractor received a claim and learn whether it was accepted or rejected. However, the testing will not allow participants to determine whether the claim will be paid or if payment will be reduced.
Although registration is not required to participate, physicians should contact their local MAC (Noridian in California) for more information about how to submit test claims. Physicians participating in the testing will be able to determine their practices' readiness for ICD-10 implementation and provide CMS with data to help the agency prepare for industry-wide use of the code set next fall.
ICD-10 (The International Classification of Disease tenth revision) is a system of coding created in 1992 as the successor to the previous ICD-9 code set. ICD-10 will include new procedures and diagnoses, which the U.S. Department of Health and Human Services hopes will improve the quality of information available for quality improvement and payment purposes.
The California Medical Association (CMA) has released an ICD-10 transition guide, as well as information on live trainings and webinars that will be available for CMA members. Physicians can also take advantage of the American Medical Association’s free ICD-10 resources, including tip sheets that offer guidance on completing an impact assessment, determining training needs, conducting testing and improving documentation.
The California Medical Association (CMA), in partnership with your local county medical society and the California Medical Group Management Association (MGMA) will offer statewide, two-day ICD-10 code set seminars this summer.
The training is designed specifically for coding staff and intended to give attendees a comprehensive understanding of guidelines and conventions of ICD-10, as well as fundamental knowledge of how to decipher, understand and accurately apply codes in ICD-10.
This American Academy of Professional Coders (AAPC) course is the gold standard of training for coders and is being offered at a tremendous savings. CMA has negotiated a reduced price of $399 for CMA members and $499 for California MGMA members. The program is also available to non-members for the reduced price of $599; $200 of that may be applied to a new CMA membership following the course. AAPC typically charges non-members $799 for this course.
Training is provided onsite in a classroom format and would be conducted over two days, including 16 hours of intensive general ICD-10 code set training along with hands-on coding exercises. Each attendee receives the AAPC ICD-10-CM Work Book and recently published 2015 ICD-10-CM codebook. The onsite training course is approved for 16 continuing education units (CEU) through AAPC. Following the onsite training, attendees will be given an ICD-10 proficiency assessment to ensure understanding of ICD-10 concepts and guidelines.
CMA will announce the dates and locations of these seminars soon.
Contact: Sadye Reish, (916) 551-2030 or email@example.com.
The California Medical Association (CMA) is pleased to partner with COLA – a physician-directed organization whose purpose is to promote excellence in laboratory medicine and patient care through a program of voluntary education, consultation and accreditation. This member benefit provides a 15 percent savings on COLA’s Laboratory Accreditation Program and its educational products and services.
COLA is one of the select accrediting organizations approved by the Centers for Medicare and Medicaid Services (CMS)* for the Clinical Laboratory Improvement Amendments (CLIA) of 1988. Additionally, COLA is the first private accreditor to be approved by Laboratory Field Services (LFS), which maintains state oversight for the licensure of laboratories and laboratory personnel in California. In short, this means that California physician-operated labs that receive accreditation through COLA need only undergo one routine biennial survey in order to be compliant at both the state and national level.
Streamlining the dual compliance responsibilities for clinical laboratory testing within California and educating physician members on California’s complex state regulatory environment are just two key benefits of working with COLA. It also offers a toll-free telephone service for physicians to receive real-time, prompt technical assistance.
*Special Note: The applications of other CMS-approved accrediting organizations are pending. COLA strongly supports private-public collaborations that benefit quality in laboratory medicine.
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.
The CPT® 2015 codebook deleted a familiar breast ultrasound code (76645), while adding two new, more precise codes to describe the same procedure.
- 76641 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete
- 76642 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited
Code 76641 describes a complete examination of all four quadrants of the breast and the retroareolar region; 76642 describes a limited breast ultrasound (e.g., a focused examination limited to one or more elements of 76641, but not all four). To support the service performed and billed, the provider should document a thorough exam of the anatomic area(s), and provide image documentation and a final, written report of results, impressions, etc.
You may report either 76641 or 76442 once, per breast, per session. Both codes are unilateral. If medical necessity requires bilateral imaging, you may append modifier 50 Bilateral procedure. The 2015 National Physician Fee Schedule Relative Value File (January release) assigns a “1” bilateral indicator to 76641 and 76442, meaning that Medicare will allow 150 percent of the standard reimbursement for properly billed bilateral procedures.
Both 76641 and 76442 include examination of the axilla, if performed. For ultrasound exam of the axilla, only, see 76882 Ultrasound, extremity, nonvascular, real-time with image documentation; limited, anatomic specific.
Example 1: Ultrasound exam of four quadrants of left breast and left axilla. Report 76641. Standard reimbursement applies.
Example 2: Complete ultrasound exam of left breast and right breasts (e.g., all four quadrants examined in both breasts). Report 76642-50. Code 76642 is reimbursed at 150 percent of fee schedule value for Medicare payers.
Example 3: Complete ultrasound exam of left breast, with ultrasound exam of two quadrants of the right breast. Report 76642-LT (complete exam of left breast) and 76641-RT (limited exam of right breast). Standard reimbursement applies.
Also new to CPT® 2015 are three codes to describe digital breast tomosynthesis (DBT).
- 77061 Digital breast tomosynthesis; unilateral
- 77062 Digital breast tomosynthesis; bilateral
- 77063 Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure)
Codes 77061 and 77062 define unilateral and bilateral diagnostic DBT, respectively. Do not report either code with 76376 or 76377 (3-D rendering), or 77057 (screening mammography).
Code 77063 is an add-on code, to be reported with 77057 Screening mammography, bilateral (2-view film study of each breast) (or G0202 Screening mammography, producing direct digital image, bilateral, all views, when billing Medicare) for (bilateral) screening DBT. Do not report 77063 with 76376 or 76377 (3-D rendering), or 77055 or 77056 (Mammography).
The Centers for Medicare and Medicaid Services (CMS) announced in its 2015 Medicare Physician Fee Schedule Final Rule that 77061 and 77062 (diagnostic DBT) are not valid for Medicare billing. Instead, providers should report diagnostic DBT to Medicare using HCPCS code G0279 Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to G0204 or G0206).
Note that G0279 is an add-on code, which you must report with either G0204 Diagnostic mammography, producing direct digital image, bilateral, all views or G0206 Diagnostic mammography, producing direct digital image, unilateral, all views, as appropriate, for tomosynthesis with diagnostic digital mammography. Because CMS will not accept the stand-alone diagnostic DBT codes (77061 and 77062), providers have no way to report diagnostic DBT to Medicare, separate from a full-field digital mammogram.
“The expertise that CMA provided to us was instrumental in helping us navigate a particularly difficult situation. We would never have been able to resolve our issue without your support. We are extremely grateful for all that you do on our behalf!”
Malcolm Medical Group/Jon Scott, D.O.
CMA member since 1992
MEDI-CAL: Effective for dates of service on or after January 1, 2015, Sovaldi® (sofosbuvir) and Harvoni® (ledipasvir/sofosbuvir) will now be on the Medi-Cal Contract Drugs List for the treatment of chronic hepatitis C. Additional information regarding treatment authorization and restrictions for the use of these two medications can be found at medi-cal.ca.gov.
UNITED HEALTHCARE: United Healthcare has announced updates to its medical policy, drug policy, coverage determination and utilization review guidelines effective April 1, 2015. Included in the medical policy updates will be a new Hysterectomy For Benign Conditions policy limiting the use of certain types of hysterectomy procedures. Physicians can view all United Healthcare medical policies in their entirety online by visiting the United Healthcare website www.UnitedHealthcareOnline.com > Tools & Resources > Policies & Protocols > Tools & Resources > Policies, Protocols and Guides > Medical & Drug Policies and Coverage Determination Guidelines >Medical Policy Update Bulletin.
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.