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 automatically opts physicians into Core narrow network product
- Senate delays vote on SGR until April, CMS to delay 21% cuts until mid-month
- CHDP group providers must re-attest by April 17 to receive ACA primary rate increase
- Physicians warned of identity theft tax scam
- ICD-10 training seminar dates and locations announced
- Practice check-up: How scheduling strategies can reduce disruptions and long patient wait times
- Reminder: July ICD-10 end-to-end testing forms due in April
- Share your feedback by taking this brief electronic payment survey
- Meet your CMA Affinity Partner: Union Bank
- The Coding Corner: Hypertension in ICD-10
United Healthcare (UHC) recently issued notifications to 19,000 practices included in its commercially contracted provider network, advising of their inclusion in the UHC Core product. The new UHC Core plan will access a significantly narrowed network and will be marketed to employer groups seeking lower premiums for their employees. Additionally, indications are that UHC will also utilize the narrowed Core network for its potential future exchange products in 2016.
UHC advised the California Medical Association (CMA) that reimbursement for the Core product line will be at the commercial fee schedule rates outlined in the UHC physician agreement. Those providers with multiple fee schedules in their contract will be paid at the fee schedule indicated for the United Healthcare Choice/Choice Plus benefit plans.
UHC also advised CMA that the only option for physicians who wish to opt out of the Core product network is to terminate the underlying UHC commercial agreement. There is no ability to opt out of just the Core network.
Physicians who are unsure about whether or not they are affected by this change, those who have general questions about the notice or those who wish to dispute their participation in the Core plan network can contact UHC Network Management at (866) 574-6088.
The U.S. Senate failed to take a vote to permanently fix the Medicare sustainable growth rate (SGR) formula and extend the Children’s Health Insurance Program (CHIP) in March, and will take the measure up when it returns from a break on April 13. Majority Leader Mitch McConnell (R-KY) said shortly after the budget debate at 3 a.m. on the Senate floor, “It’s encouraging this passed the House with such a large bipartisan majority, and I want to assure we’ll move to it very quickly when we get back…I think there is every reason to believe it’s going to pass the Senate by a very large majority.”
The measure, a rare bipartisan achievement in a deeply divided Congress, was overwhelmingly approved on Thursday by the U.S. House of Representatives. The bill would create a new payment formula focused on the quality of care. To help pay for these higher rates, the bill would also impose higher premiums on wealthier Medicare beneficiaries and impose cuts on hospitals for post-acute care.
The California Medical Association (CMA) is pleased that both Senators Barbara Boxer and Diane Feinstein were prepared to support the legislation and applauds the landslide vote of 392-37 in the House. This momentum should propel the Senate to act quickly when they return from recess. CMA will continue to stay in touch with our Senators over the recess and monitor the situation closely. We will keep fighting until we achieve passage, because we are too close now to let this opportunity slip away.
Thanks to every California physician who called, emailed and met with our Congressional Representatives to secure their votes. We had an overwhelming vote of support from the California Congressional delegation.
Regarding payment for services between April 1-14: Physician services provided on or after April 1 will be subject to a cut of 21 percent. However, the Centers for Medicare and Medicaid Services (CMS) is instructing its carriers to “hold” for 10 business days any claims for services provided on April 1 and beyond, until legislation can be passed and signed into law that reverses the 21 percent cut. The 10-day business hold means that April claims will be held through Tuesday, April 14. Since no claims by law can be paid sooner than 14 calendar days from their receipt, this hold should have little practical impact on Medicare remittance in the short-term, although billing for copayments and claims reconciliation will be more complicated.
CMA and American Medical Association are advising against submitting claims with reduced amounts reflecting the 21 percent cut. Physicians have the option of holding claims and submitting them after the new fee schedule is released. If you choose to submit claims in the interim, CMA suggests that both participating and non-participating physicians bill their usual and customary fees-for-services to Medicare. Billing at your customary fee ensures that Medicare pays the highest amount possible when the claim is processed.
In the unexpected event that Congress allows the 21 percent cut to take effect, Medicare would pay physicians at the reduced amount no matter what the physician billed and no further action would be necessary. However, non-participating physicians who have collected balance billing amounts for unassigned claims based on the currently-allowed amount could be required to make refunds to their patients based on new, lower balance billing amounts.
The California Department of Health Care Services (DHCS) has experienced various difficulties issuing the Affordable Care Act (ACA) primary care rate increase funds on Child Health and Disability Prevention (CHDP) Program claims.
Most recently, the California Medical Association (CMA) learned that CHDP providers practicing as part of a group would be required to re-attest as a group to get paid. Previously, physicians had been instructed to only attest as individuals.
DHCS issued an updated “NewsFlash” on March 30 to explain the additional steps that will be required. Groups and clinics that have not already attested and submitted usual, customary and reasonable (UCR) data must do so on behalf of eligible providers in order to receive the payment increase. If you have already received increased CHDP payments, you do not need to take any further action.
The attestation period and final day to add or update the UCR charges for the ACA rate increase is April 17, 2015.
The extension does not apply to individual CHDP providers and was granted solely to CHDP group providers who have not already successfully attested on behalf of their individual providers.
The California Medical Association (CMA) has recently become aware of a tax scam directed at physicians. CMA has received reports from physicians that fraudulent federal income tax returns have been filed using physician names, addresses and social security numbers. In many cases, the fraudulent tax return includes the name of an unknown person listed as the physician's spouse. Generally, this other name is a prior patient of the physician.
Affected physicians are likely to learn of the scam by receiving a 5071C letter from the IRS alerting them of possible fraud. Physicians may also have received a rejection notification when attempting to electronically file their taxes. This occurs because a return has already been filed using that social security number.
If you learn that your identity has been compromised in this way, act quickly and consider the following steps.
IRS – If you have become aware that you are a victim of this scam, the IRS 5071C letter provides instructions about contacting the IRS through its identity theft website, or by phone at (800) 830-5084, to let officials know you did not file the return referred to in their letter. If you are a victim, you may not be able to electronically file your return this year, in which case you should file a paper return and attach an IRS 14039 Identity Theft Affidavit to describe what happened.
Also attach copies of any notices related to this issue that you received from the IRS, like the 5071C letter. Be sure to notify your tax preparer if this happens to you. Verify with the IRS and your tax preparer where to mail your paper tax return, based on the type of return you are filing and your geographic area.
If you have not received a notification from the IRS but believe your personal information may have been used fraudulently or are concerned about whether you may have been victimized, call the IRS Identity Protection Specialized Unit at (800) 908-4490. Additional information is available on the IRS website.
Office of the California Attorney General – Physicians affected should register the identify theft with the California Attorney General. Not only is the Attorney General's website a great resource for identify theft victims, but more information about the victims of this tax scam makes it more likely that an investigation could determine the source of the scam.
FTC – File a complaint with the Federal Trade Commission (FTC). This not only helps the FTC identify patterns of abuse, but the printed version becomes your "Identity Theft Affidavit." That affidavit, along with a police report, constitutes your Identity theft report, which you will need for the IRS. The FTC also recommends several other immediate steps to take and provides relevant helpful information on its website.
Police Report – Consider filing a report with the local police in the jurisdiction where you reside. Bring with you all documentation available, including the state and federal complaints you filed. This will likely be necessary if there is financial account fraud as a result of the identity theft. However, if the only fraud is tax fraud, the police report is likely unnecessary unless specifically requested by the IRS.
Social Security Administration – Call the Social Security Administration's fraud hotline at (800) 269-0271 to report fraudulent use of your Social Security Number. In case your number is being used for fraudulent employment, you can also request your Personal Earning and Benefits Estimate Statement from the Social Security Administration website or call (800) 772-1213. Make sure to check the report for accuracy.
Additional Information – Consult the U.S. Department of Justice (DOJ) website for additional information, including checklists, about identity theft and fraud.
Financial Accounts – Physicians should also consider taking steps to protect their various financial accounts, such as running a credit report or placing a credit freeze on any existing credit cards. The FTC, Attorney General and DOJ websites referenced above provide several suggestions on how to protect your financial interests in the event of identity theft.
CMA will continue to monitor this fraudulent tax scheme and keep physicians up to date. If you have been a victim of this scheme, and may have information to help us determine the scope of the situation, please contact the CMA Center for Legal Affairs at (800) 786-4262.
The California Medical Association (CMA), in partnership with your local county medical society and the California Medical Group Management Association (MGMA), is now offering statewide, two-day ICD-10 code set seminars this summer. A full schedule of dates and locations is now available at www.cmanet.org/AAPC-ICD10.
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 will 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 Code Set Course Manual and ICD-10-CM Code Set Draft Book. 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 and will have access to AAPC’s online ICD-10-CM Assessment Training Course through December 31, 2015.
To register, please visit www.cmanet.org/AAPC-ICD10 and select the course nearest you or call (800) 786-4262. Space is limited and is on a first-come, first-served basis. Additional dates will soon be added in the areas of Santa Barbara/San Luis Obispo and Yuba/Sutter/Colusa counties.
Check the events page above for updates.
This is the second in a series of articles aimed at highlighting key areas practices should examine in an effort to improve practice performance. This month we focus on how effectively managing the appointment schedule can have a positive impact on both patient and practice satisfaction.
It’s rare that an appointment schedule in a medical office survives a day without any changes. No-shows, cancellations and last-minute emergencies will always crop up and cause shifts and changes. But these changes don’t have to disrupt the flow of the office. Here are a few things to consider:
To double book or not to double book
Many practices experience no-shows and/or a high demand for appointments when the schedule is full. To address these situations, many practices will book multiple patients into a single slot. However, double booking will likely guarantee some bad patient experiences. If you have a double booking system in place right now, the California Medical Association (CMA) recommends you review that process.
One thing to consider before double booking is the patient’s “show” record. Double booking two patients with perfect “show” records in the same slot is likely to guarantee a long wait for one of them. But, it may be a reasonable strategy to consider double booking if your scheduling system can provide information on the patient’s track record of showing up on time. If you have information on the probability of the patient keeping the appointment, consider double booking a patient with a perfect “show” record with another that has a poor “show” record. Double booking without this kind of information will almost certainly create a traffic jam at the practice and at least one unhappy patient.
Taking charge of your appointment schedule
Oftentimes, there is no rhyme or reason to how patient appointments are scheduled. In an effort to meet patient demand, sometimes patients are simply crammed into an already busy schedule without considering the appointment type and/or the amount of time needed for the appointment. For example, new patient visits generally require about twice as much time as an established patient visit, while follow-up appointments are typically the shortest.
If your practice doesn’t have a schedule template, create one by identifying the amount of time required for each different type of appointment. Working with the physician(s), determine the average amount of time the physician needs for new patient visits, established patient visits, follow-up visits, well care visits, etc. Build that information into your scheduling system so when you are creating an appointment, the amount of time is automatically calculated based on the type/need.
More in-depth triage
Beyond the schedule template, it can also be helpful for schedulers to do a more in-depth triage with patients to identify whether additional time will be needed. For example, an established patient visit to address multiple complaints will likely require more time than the average established patient visit. Training your office staff who are responsible for scheduling to ask specific questions such as, “Do you have any other issues to discuss with the doctor?” as well as encouraging patients to be on time (or even early) in order to prepare them to see the doctor will help to keep your practice running on schedule.
Pad the appointment time
Practices often make the mistake of advising patients to arrive at the time of their scheduled appointment. However, if the patient’s appointment is at 8 a.m. and he or she arrives at 8 a.m., after check-in at the front desk, completion of any necessary paperwork and rooming of the patient, it would be impossible for the physician to actually see the patient at 8 a.m. and therefore immediately puts the physician behind schedule. Imagine how far behind the physician will be if that patient is late to their 8 a.m. appointment!
While some practices report they advise patients to arrive 10-15 minutes early, let’s face it, most patients don’t comply. They remember their appointment time and rarely arrive any earlier.
One way to address this is to pad the appointment time by 10 minutes or so. For example, if the patient’s appointment is at 8 a.m., the practice may wish to advise the patient that the appointment is at 7:50 a.m. This allows time for check-in, paperwork and rooming so the patient is ready to see the physician at his or her scheduled appointment time of 8 a.m., which maximizes valuable physician time.
Following some simple, but well thought-out scheduling strategies can maximize the number of visits in a day, prevent a chaotic work environment and improve patient satisfaction.
The Centers for Medicare and Medicaid Services (CMS) announced that those providers who want to volunteer for the ICD-10 end-to-end testing taking place July 20-24 need to submit their information by April 17. The July testing will give a group of 850 volunteers the opportunity to find out if they are prepared to submit digital information to CMS for ICD-10.
CMS intends to select volunteers representing a broad cross-section of provider, claim and submitter types, including claims clearinghouses that submit claims for large numbers of providers. Testers who participated in the January and April end-to-end testing weeks are able to test again in July without re-applying.
Volunteers who participate in the testing must be able to submit claims with a future date and provide valid National Provider Identifiers, Provider Transaction Access Numbers and beneficiary Health Insurance Claim Numbers that will be used for test claims. To volunteer for the testing, register here.
Click here for more information on ICD-10 end-to-end testing.
Contact: Michele Kelly, (213) 226-0338 or email@example.com.
As many payors are shifting from traditional paper checks to alternative electronic methods of payment, provider organizations are growing increasingly concerned that some entities are charging excessive fees for these payments or are using “virtual” credit cards (VCCs), instead of Automated Clearing House Electronic Funds Transfer (ACH EFT). VCCs require the physician to pay a merchant fee ranging from 2-5 percent, typically, to access the funds. This payment methodology, which is often implemented without physician notification or choice, results in lost revenue and increased administrative burden for practices.
The American Medical Association, in conjunction with the American Dental Association and Medical Group Management Association, is conducting a brief survey regarding physician experiences with these new electronic methods of payment. If you have experience with virtual credit cards or EFT in your practice, please take this brief survey by May 8 to share your experiences and help bolster advocacy on health plan payment issues.
It will take fewer than 5 minutes to complete, and all responses will be kept strictly confidential.
Financial solutions for your practice
Union Bank® has developed a package of discounted banking services specifically for California Medical Association (CMA) members, including business credit and checking accounts, merchant services, payroll processing solutions and treasury management solutions.
For many physicians, the challenge of reduced reimbursements, escalating administrative costs, tightening regulations and rising insurance premiums add up to a critical need for practice efficiency. Understanding that physician practices require a banker to have specialized industry knowledge is the driving principle behind the Union Bank commitment to serving physicians' financial needs. Union Bank helps to ensure your practice is financially healthy. Acting as a single point of contact, your Union Bank representative leads a team of specialists who work together to identify key areas where Union Bank products and services can help increase the financial fitness of your practice. Below are just a few of those services.
- Save up to $250 in fees on a business loan or line of credit
- Save up to $1,000 in loan packaging fees on a Small Business Administration 7(a) business loan
- Equipment financing documentation fee waiver up to $250
- No annual fee business credit card
Business Checking Account
- $100 off first order of checks when you open a new Union Bank business checking account
- Earn $200 in reduced fees
Payroll Processing Solutions
- Get up to 15 percent in monthly payroll savings
Treasury Management Solutions
- Treasury management set-up fee waiver offers up to $590
For product details and important disclosure information, visit www.unionbank.com/cma.
©2014 MUFG Union Bank, N.A. All Rights Reserved. Member FDIC. Equal Housing Lender. Union Bank is a registered trademark and brand name of MUFG Union Bank, N.A.
CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from Peggy Stilley, the Director of ICD-10 Development and Training for AAPC, a training and credentialing association for the business side of health care.
Hypertension is a common condition treated in most practices. In ICD-9, diagnosis code selection in category 401 is based on the type of hypertension treated: benign, essential, primary, malignant or unspecified. In ICD-10, the diagnosis codes are simplified and the hypertension table is no longer necessary. The concept of controlled and uncontrolled are not a part of the coding choice, although good clinical documentation should include the status of the patient and the type of hypertension being treated.
Combination codes have been created to report hypertension with associated conditions.
Categories for hypertension include:
- I10 Hypertension (benign, essential, primary)
- I11 Hypertensive heart disease
- I12 Hypertension and chronic kidney disease
- I13 Hypertensive heart and chronic kidney disease
Category I11, hypertension with heart disease, is assigned when a causal relationship is stated or implied in documentation, such as hypertensive heart disease or heart disease due to hypertension. Use a second code to identify the type of heart failure, if present.
Example: A patient is seen for a three-month check-up for hypertensive heart disease. He has no chest pain, no complaints and blood pressure (BP) readings at home are normal. Labs will be drawn and he will follow-up in three months.
- I11.9 Hypertensive heart disease without heart failure
Category I12, hypertension and chronic kidney disease, is assigned for hypertensive chronic kidney disease. The coding guidelines state an assumed relationship when both hypertension and chronic kidney disease (CKD) are documented. A secondary code is needed to identify the stage of CKD.
Example: A patient with malignant hypertension and stage 5 CKD is admitted to the emergency room with elevated BP and edema.
- I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease
- N18.5 Chronic kidney disease, stage 5
Category I13, hypertensive heart and chronic kidney disease, is assigned when both hypertensive heart and hypertensive chronic kidney disease are documented in the medical record. The relationship is assumed between hypertension and CKD, but must be implied or stated for hypertension and heart disease. A second code is used to identify the stage of CKD. If heart failure is present, a third code is used to identify the type of heart failure (diastolic, systolic, left ventricular, combined diastolic or systolic).
Example: A patient is admitted with acute diastolic heart failure due to hypertension with end stage renal disease (ESRD).
- I13.2 Hypertensive heart and renal disease with heart failure due to hypertension with end stage renal disease
- I50.31 Acute diastolic (congestive) heart failure
- N18.6 ESRD
When both hypertension and heart disease are stated in documentation, but the causal relationship is not stated or implied, each code is reported separately and the combination code is not used.
Example: A 67-year-old patient is seen for benign hypertension. He continues to smoke two packs of cigarettes per day, and does not want to stop. BP is 165/110. Physician adjusts medications, counsels on smoking. Diagnosis is benign hypertension without good control, nicotine dependence.
- I10 Hypertension (essential, benign, primary)
- F17.210 Dependence, nicotine, cigarette, uncomplicated
Hypertension, whether uncontrolled, untreated or not responding to current medication, is assigned code I10. An instructional note provided for categories I10-I15 states to use an additional code to identify exposure to environmental tobacco smoke (Z77.22), history of tobacco use (Z87.891), occupational exposure to environmental tobacco smoke (Z57.31), tobacco dependence (F17-) or tobacco use (Z72.0).
Subjective: 75-year-old female is seen for follow up for chronic hypertensive heart disease. She has been having ongoing shortness of breath and orthopnea. Recent EKG demonstrates findings consistent with cardiomegaly, but no recent change since a prior EKG. Currently she is on Lasix, Lanoxin and Atenolol. Social history shows her to be a former smoker.
Objective: BP = 175/95. Heart rate=100. Chest X-ray shows mild pulmonary edema. There is 2+ pitting edema in both ankles.
Assessment: Hypertension – poorly controlled chronic diastolic congestive heart failure
- I11.0 Hypertensive heart disease with heart failure
- I50.32 Chronic diastolic (congestive) heart failure
- Z87.891 History of tobacco use
In this case, hypertensive heart disease is documented with the causal relationship, allowing for combination code I11 to be used. An instructional note at I11.0 states to use an additional code to identify the type of heart failure. In this example, it is chronic (congestive) heart failure. An instructional note provided for categories I10-I15 states to use Z87.891 for history of tobacco use.
"Thank you, CMA, for your help resolving our issues. We appreciate everything you do.”
Marvin H. Kamras, M.D.
Camellia Women's Health
Member since 1977
MEDI-CAL: Effective for dates of service on or after April 1, 2015, CPT codes 59050 and 59051 are reimbursable only when billed in conjunction with ICD-9 diagnosis codes 655.03 – 659.93, V23.0 – V23.89 and V89.01 – V89.09. CPT 59050 is limited to use during labor within 48 hours before delivery and may not be billed by the primary physician, attending physician, physician assistant, nurse practitioner or nurse midwife. For additional information, please see the Medi-Cal provider manual.
WORKERS’ COMPENSATION: The Division of Workers’ Compensation has advised that for independent medical review submissions that have not received a resolution within the required 45-day timeframe, the injured worker or his or her designee (physician) is urged to contact Maximus Federal Services to inquire on the status. Maximus Federal Services can be contacted by phone at (855) 865-8873, by fax at (916) 605-4270 or by email at IMRhelp@maximus.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.