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:
- Aetna issues physician terminations over frequency of E/M visits
- Physicians receiving notice from CHPI encouraged to verify data accuracy by July 31
- Anthem Blue Cross begins medical chart reviews in July
- Anthem Blue Cross announces further changes to reimbursement policies and claims software
- Three months until ICD-10 implementation: If you’re not preparing, you should be
- Slight increase to Medicare reimbursement rates effective as of July 1
- Anthem confirms error in policy change notice; new requirement will not affect physicians
- Share your experience with Noridian by taking a survey
- CMA works to address problems posed by CURES 2.0 launch on July 1
- Ensure your practice information is up-to-date with contracted payors
- Medi-Cal to delay payments for two weeks in June
- New Paid Family Leave Benefits Form required July 1
- Duals demonstration passive enrollment effective August 1 in Orange County
- The Coding Corner: ICD-10-CM: The well-documented patient history
The California Medical Association (CMA) has received several reports from physicians in the San Francisco Bay Area that they’ve received contract termination notices from Aetna due to their above-average use of high-level Evaluation and Management (E/M) codes. The termination letters, issued by Aetna in mid-January, advised physicians that upon review of claims for a one year period, their usage of high level E/M codes was “significantly outside the norm” of comparative physicians within their market.
CMA has learned that approximately 40 physicians within the Northern California Aetna PPO network were issued the notice of termination. Contrary to the one-year timeframe for review stipulated in the termination notice, Aetna has advised that the review actually included approximately 30 months of prior claims data. Physicians whose billing pattern of high-level E/M codes exceeded two standard deviations above the mean for their assigned marketplace were issued a notice of termination per Aetna.
As a result, CMA sent a letter to Aetna outlining a number of serious concerns regarding this initiative, including the following:
- Patients’ access to care may be unnecessarily jeopardized if physicians are not offered a meaningful opportunity to appeal or address the underlying issue prior to physician termination from the network.
- The inappropriateness of terminating physicians who billed outside the norm with respect to higher level E/M codes, without any prior-notice or opportunity to correct or explain the medical necessity of the care at issue, or to appeal the termination.
- The termination of physicians based solely on their billing levels without first engaging them to discuss factors that may have led to higher than average billing, such as physicians treating a sicker patient base (e.g., HIV patients or seniors with underlying conditions), thereby wrongly punishing providers who treat these most vulnerable patients.
While physicians have been advised by Aetna of the right to request both a reconsideration of the Aetna E/M findings as well the ability to submit a separate appeal of their termination from the Aetna network, both processes failed to advise physicians of what information Aetna would consider relevant for review of this issue. However, feedback to CMA from physicians who were successful in the appeal of their termination highlighted valid reasons why their billing patterns differed from the norm, including being an urgent care practice or serving a high-risk population.
This underscores the need for physicians and their staff to carefully read all payor correspondence; ensure contractual notices of any kind are immediately routed to the physician for review and response; and call CMA with any questions.
Physicians impacted by the Aetna termination are encouraged to contact CMA at (916) 551-2865 or firstname.lastname@example.org for additional assistance.
On May 29, 2015, approximately 18,000 physicians in California were notified of a new quality rating program through the California Healthcare Performance Initiative System (CHPI). CHPI is managed by staff from the Pacific Business Group on Health (PBGH), but has its own board of directors.
The letter states that 19 quality measures were constructed using claims data from Medicare fee-for-service, Anthem Blue Cross, Blue Shield of California and United Healthcare. This claims data includes both commercial and self-funded health plan data from HMO, PPO, POS and Medicare Advantage products.
Along with the letter, CHPI provided affected physicians with their individual quality measurement scores based on patient care provided January 1, 2010, through December 31, 2012. Physicians were assigned a star rating of one to four stars, based on where they fall as a percentile within a “peer group,” for each measure as well as a rate, which is the composite score. The peer groups utilized for comparison purposes were:
- Primary care physicians (PCP)
- Non-PCP and non-pediatricians, regardless of specialty
Physicians who wish to verify the accuracy of the data used to calculate their scores can do so through the CHPI online portal. In order to access the review and correction portal, physicians will need their medical license number and the physician identifier (Physician ID) from the upper left corner of their mailed report. According to the letter, CHPI will treat the data as complete and accurate even if the physician has not logged into the online portal during the review and correction period. In response to California Medical Association (CMA) requests, however, CHPI will no longer deem non-review during this period as a physician’s acknowledgement that the data is accurate and complete.
Physicians who review their data and identify errors have until July 31, 2015, to report any discrepancies via the CHPI online portal. At the close of the physician review and correction period, discrepancies will be evaluated and applied, with the results recalculated prior to the ratings being released to the public. After July 31, the review and correction period will close, and physicians will be unable to review or report discrepancies.
CHPI has advised CMA that in addition to publishing the ratings publicly, it will also release an aggregated data file to the aforementioned participating plans following the recalculation this fall. CMA inquired as to how the data would be utilized by the plans, but as of the time of publication, it was not known.
More information on the CHPI ratings methodology can be found on the CHPI website. Additionally, physicians who did not receive a letter but would like to confirm whether they are included in CHPI’s rating results can use the CHPI physician lookup at https://lookup.medinsight.milliman.com and enter their medical license number. A tutorial and FAQ on the review and corrections portal is also available.
If you have questions or concerns about the CHPI rating results, you may email the PBGH staff overseeing the program at email@example.com or leave a voicemail at (415) 615-6353 and they will respond within 48 hours. Physicians who do not hear back within 48 hours or who identify a high volume of discrepancies in the data used to calculate their scores are encouraged to contact CMA at (916) 551-2061 or firstname.lastname@example.org.
In July, Anthem Blue Cross will begin chart reviews on enrollees who purchased Affordable Care Act (ACA)-compliant plans in either the individual and small group insurance markets (both on and off the exchange, known as “Covered California”).
The records requests are a result of the commercial risk adjustment program created by ACA Section 1343. The primary goal of the risk adjustment program is to spread the financial risk borne by payors more evenly in order to stabilize premiums and provide issuers the ability to offer a variety of plans to meet the needs of a diverse population.
Because the information reported by physicians and other providers is at the heart of payment adjustments, health plans must engage providers by requesting copies of medical records that accurately reflect diagnoses and/or underlying health conditions to comply with risk adjustment program requirements [77 Fed. Reg. 17220, 17241 (March 23, 2012)].
During the risk adjustment audit, Anthem will review diagnosis code data obtained from the medical records of ACA-compliant individual and small group patients. This is not a typical audit on the physician practice; rather, Anthem is looking to identify conditions/illnesses that demonstrate patients who are at risk for being sicker or patients who are predicted to be healthier. This information will be utilized to determine a risk score, which is a measure of how costly an individual is anticipated to be, and will be reported to the Centers for Medicare and Medicaid Services. If at the end of the annual risk adjustment assessment, Plan A has a lower risk average score than Plan B, then Plan A has to issue a payment to Plan B. In a nutshell, the program is intended to prevent payors from cherry picking only healthy enrollees.
Anthem reports it will also utilize the data to better manage patient health conditions.
Anthem has contracted with Inovalon, Inc., a secure clinical documentation service, to conduct the medical chart reviews. Inovalon will utilize several methods of collecting medical record information from physician practices, including:
- Scanned or faxed medical records that providers’ offices send to Inovalon
- Onsite medical record reviews by clinical personnel
- Automated medical record retrieval from the provider’s electronic health record (EHR) system (only upon authorization from the practice)
In cases where fewer than six medical records are being requested for review, Inovalon will contact each provider’s office and request the information via fax or mailing of medical chart information.
In cases where Inovalon is requesting more than six medical records to review, the company will contact the provider’s office and arrange a time convenient to visit the office to collect the appropriate information or to discuss accessibility of the information from the provider’s EHR system.
Questions about the letter or the enclosures can be directed to Inovolan at (877) 448-8125. Anthem has also published an FAQ about the commercial risk adjustment records request. Questions about the initiative can be directed to Inovolan at (800) 390-3180 or CRA@anthem.com.
Anthem Blue Cross recently notified physicians of additional upcoming changes to its reimbursement policies and claims editing software, ClaimsXten. The additional changes, scheduled to go into effect on September 14, 2015, come less than 90 days after Anthem’s most recent set of changes were implemented in July, and less than a month prior to the implementation of ICD-10.
Anthem states that the additional changes are necessary to bring its claims editing system in line with correct coding guidelines.
Anthem did not provide a detailed listing of all the incorporated changes; rather, it provided a reference sheet showing examples of the types of edits that will be incorporated as part of its September update. Concerned that the lack of detail could lead to confusion for physician practices on one policy change, the California Medical Association (CMA) asked Anthem for clarity on the Inpatient Evaluation and Management (E/M) services example. Specifically, the first example states, “Inpatient Evaluation and Management services (i.e., inpatient admission, observation services, and consultation services) should be billed only once by the same provider during an inpatient stay.” CMA asked Anthem to clarify whether the scope of the change is limited to the three services listed or whether it includes other inpatient E/M services.
Anthem has advised CMA that the intent of the policy change is to prevent multiple physicians from billing for the same service on the same date. For example, only one physician should bill for an inpatient admission E/M service. The payor further clarified that the policy change applies to any inpatient E/M services which do not warrant multiple physician claims, such as the three listed, and also includes discharges.
Additionally, Anthem will implement edits to ensure appropriate usage of modifiers -54, 55, 56, 76, 77, 78 and 79, as well as modifiers -26 and TC.
Because of these changes, physicians may notice a difference in how certain codes and code pairs are adjudicated.
Along with the notice, Anthem enclosed copies of several reimbursement policies including its Bundled Services and Supplies policy (CA – 0008); Assistant Surgeon Services policy (CA-0009); and Modifiers 59 and XE, XP, XS & XU (Distinct Procedural/Separate/Unusual Service) policy (CA-0023) that were updated since the mailing in March.
Physicians are encouraged to review all of the claims editing changes as well as the corresponding detailed payment policies to understand how the changes will affect their individual practices.
Physicians can also access this information via the Blue Cross ProviderAccess website (log in, then select “Reimbursement Policies and McKesson ClaimsXten Rules” under the “What’s New” section).
Questions about any of the claims editing rules or payment policies can be directed to the Anthem Provider Care Department at (800) 677-6669.
Contact: CMA reimbursement helpline, (888) 401-5911 or email@example.com.
With the implementation of ICD-10 only 90 days away, the window for physician practices to prepare for the transition is rapidly closing. Physicians must be prepared. While the California Medical Association (CMA) has been pressing Congress to further delay the October 2015 ICD-10 implementation, three House and Senate Congressional Committee Chairmen with health care jurisdiction have announced they will not support any further delay of ICD-10. Therefore, CMA and all of organized medicine have turned their attention to the Centers for Medicare and Medicaid Services (CMS) to mitigate the problems associated with implementation.
CMA is urging CMS to establish a two-year transition period to avoid payment disruptions and claims processing errors. During this grace period, physicians would continue to code diagnoses using ICD-10, but it would allow physicians a learning period, whereby contractors could identify common errors, provide feedback and resolve problems without resorting to claim denials that could bankrupt physician practices and extend patient waiting times.
CMA is asking CMS to adopt the following protections:
- Conduct more comprehensive testing prior to implementation to identify issues that could reject valid claims.
- Establish a two-year grace period in which claims will not be denied for errors and physicians will not be penalized for mistakes or subject to recovery audit contractor audits.
- Extend hardship exemptions to those practices unable to make the transition.
- Provide advance payments in cases where a physician’s claims are denied and cash flow would be greatly reduced.
While CMA works with CMS to mitigate the disruptions associated with ICD-10 implementation, we urge physicians to prepare immediately.
If you haven’t begun preparing, CMS says there is still time; however, practices now need to move with a greater sense of urgency to ensure they will be ready for the transition on October 1, 2015.
To help physicians prepare for the transition, CMA has created an ICD-10 transition webpage, as well as an ICD-10 transition guide, which is available at www.cmanet.org/icd10.
Additionally, in partnership with your local county medical society and the California Medical Group Management Association (MGMA), CMA is offering statewide, two-day ICD-10 code set seminars this summer.
The two-day boot camps include 16 hours of intensive general ICD-10 code set training, along with hands-on coding exercises. Each attendee receives the ICD-10-CM Code Set Draft Book and the AAPC Code Set Course Manual. 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.
The AAPC ICD-10 course 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 $599. AAPC typically charges $799 for this course.
The remaining seminars are scheduled for the following dates in these counties.
- San Bernardino, July 7–8, 2015
- Los Angeles I, July 8–9, 2015
- Sonoma/Marin/Mendocino/Lake, July 13–14, 2015
- Los Angeles (Torrance), July 14–15, 2015
- Sierra Sacramento, July 15–16, 2015
- Yuba/Sutter/Colusa/Placer/Nevada, August 4–5, 2015
- San Joaquin, August 10–11, 2015
- Stanislaus/Merced, August 12–13, 2015
- Orange County, August 19–20, 2015
- North Valley, August 24–25, 2015
- Los Angeles II, August 24-25
- Humboldt/Del Norte, August 26–27, 2015
- San Diego II, August 27–28, 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.
For additional information, contact Juli Reavis at (916) 551-2046 or firstname.lastname@example.org.
A 0.5 percent physician payment increase will go into effect for dates of service from July 1 through December 31, 2015. This mid-year increase is a result of the Medicare Access and CHIP Reauthorization Act). The Centers for Medicare & Medicaid Services released the updated RVU files reflecting the payment increase and new conversion factor, $35.9335 (previously $35.7547).
Noridian, the Medicare Administrative Contractor for California, has posted the new fee schedule that will be in effect from July 1 through December 31, 2015. There will be an additional 0.5 percent increase on January 1, 2016.
In the June Network Update, Anthem Blue Cross published an article advising that, effective May 1, 2015, physicians and facilities would be required to obtain a pre-certification from the payor for Medicare Advantage patients with planned admissions, and to “notify” Anthem within one business day of unplanned inpatient admissions for Medicare Advantage enrollees. The article further stated that failure to do so would result in an administrative denial of the claim.
The California Medical Association (CMA) inquired about the policy with Anthem, expressing concern that the requirement would impose a costly administrative burden for emergency and on-call physicians, would detract from patient care, and would unfairly place physicians at risk for non-payment.
In response to CMA’s inquiry, Anthem clarified that the new requirement will only apply to facilities, and will not apply to physicians. The payor further advised that they regret the error and any confusion it caused and will publish an update correcting the error in the August Network Update.
The Centers for Medicare and Medicaid Services (CMS) announced last week that it is asking physicians to participate in a provider satisfaction survey about Noridian, California’s Medicare Administrative Contractor.
According to CMS, the survey shouldn’t take more than 10-15 minutes and is being administered by the CFI group. You can access it here. The California Medical Association (CMA) encourages practices to share their experience with Noridian by taking the survey.
If you experience technical difficulties accessing or submitting the survey, please contact CFI Support at email@example.com.
The Department of Justice (DOJ) announced last week that an update to the Controlled Substance Utilization Review and Evaluation System (CURES) database would go live July 1, but with browser requirements that could potentially cut off access for thousands of prescribers and dispensers.
According to the DOJ, CURES 2.0 would require users to have Internet Explorer version 11, Safari, Firefox or Chrome Internet browsers installed on their systems in order to access the database.
In response to member concerns, the California Medical Association (CMA) met with DOJ to discuss the browser incompatibility issue. DOJ has committed to a short-term solution by phasing in CURES 2.0 over the next few months and will maintaining CURES 1.0 until January 2016. There still remain unanswered questions, however, including how this impacts registration of new users, and CMA is still assessing if all users will be able to address the compatibility issues by January.
CMA and other stakeholders continued to express concerns to DOJ about the readiness of CURES 2.0 and the system’s capacity to run versions 1.0 and 2.0 concurrently. We are pleased that DOJ has now agreed to undergo real world testing of the system on a limited basis as the next step and will delay implementation of the new version statewide.
Based on communications with DOJ, CMA has produced a summary of what CURES users should know about the launch of the new system, including updates on access and registration changes. Click here to read the summary.
As both a long-term solution and the full scope of those impacted have yet to be determined, please contact CMA if the CURES 2.0 browser restrictions pose a problem for you.
Click here to read DOJ’s announcement of the CURES 2.0 software upgrade rollout.
Contact: CMA’s Legal Information Line at (800) 786-4262 or firstname.lastname@example.org.
Every practice understands the importance of collecting up-to-date demographic information from patients, including changes to a patient’s address, phone number, insurance, and eligibility and benefits. Ensuring these items are up-to-date guarantees that the practice can quickly communicate with patients about test results or other medical issues, as well as schedule and confirm appointments. Accurate patient insurance, eligibility and benefits information also helps to prevent unnecessary denials delays in payment, and goes a long way toward ultimately saving time and money for the practice.
It is equally important that physicians ensure their practice demographic information is up-to-date with any contracted payors.
Reason #1 – Up-to-date practice information such as specialty, address, tax identification number (TIN), practice name, and complete list of physicians in the practice, along with their national provider identification (NPI) numbers, ensures that payments and other vital contractual notices are received by the practice.
Reason #2 – Providing updated, accurate practice information to payors ensures that your information is displayed correctly to patients looking for a physician through payors’ provider directories and to referring physicians looking for an in-network specialist for their patient.
Reason #3 – It will likely keep your practice compliant with your contracts. Most payors have language in their contracts that requires physicians to notify the payor in writing of any changes in their practice.
To ensure that all of your information is accurate, practices are encouraged to review their information with each contracted payor on an annual basis, at minimum. However, if a practice is moving, adding or losing providers, changing the practice name and/or TIN, closing a practice or changing specialties, it’s important to inform the payor ahead of time. Information that should be reviewed includes, but is not limited to:
- Practice name
- Practice TIN
- Practice and physician NPIs
- Practice physical address
- Practice phone number
- Pay-to address
- Physician or lead administrator email address (if available)
- Practice fax number
- Whether the practice is open/closed to new patients
- Languages spoken (if published)
- Products with which the practice is contracted
- Providers included in the contract
- Providers leaving/joining practice
- Hospital privileges
The California Medical Association (CMA) has queried the major payors on their process for updating provider demographic information and compiled their responses into a new resource for physicians, “Updating Provider Demographic Information with Payors,” which is available free for CMA members at www.cmanet.org/ces.
Practices should be advised that updates to provider demographics may take up to 90 days to complete – so submitting an update to the payor as soon as information changes is extremely important.
The California Department of Health Care Services recently announced it would delay payments for two weeks in June so that those claims are paid out of the 2015-2016 fiscal year budget. This “checkwrite” delay will impact providers as outlined below.
Fee-for-service provider payments
Payments to providers who render services through Medi-Cal funded programs that were scheduled for the June 18, 2015, checkwrite will be deferred to July 2, 2015. Programs impacted include:
- Medi-Cal (including Family PACT)
- Child Health and Disability Prevention
Fee-for-service provider payments (including state-only programs)
Payments to providers who render services through Medi-Cal and state-funded programs that were scheduled for the June 25, 2015, checkwrite will be deferred to July 2, 2015. Programs impacted include:
- Medi-Cal (including Family PACT)
- Child Health and Disability Prevention
- Healthy Families
- California Children’s Services (CCS-state only, CCS-Healthy Families, CCS-Medi-Cal)
- Genetically Handicapped Persons Program (GHPP-state only, GHPP-Medi-Cal)
Payments to the Every Woman Counts program are excluded from all June checkwrite holds.
In fall 2014, the Employment Development Department revised the Claim for Paid Family Leave (PFL) Benefits form, DE 2501F. The initial deadline to discontinue use of the old form (12-03) was May 1, 2015, however, this date was extended to July 1, 2015. Effective July 1, 2015, only the new form, DE 2501F Rev. 1[7-14], will be accepted. To order new forms, practices can visit the EDD Forms and Publications page or call 1-877-238-4373.
Physicians are also reminded that they can certify claims for Disability Insurance and PFL online via the EDDs electronic claim filing system, SDI Online. The system allows physicians/practitioners, claimants, employers and voluntary plan administrators to submit claims and other supporting documents online. For more information about SDI Online or to establish a physician/practitioner account, visit www.edd.ca.gov/disability.
For California workers covered by State Disability Insurance (SDI), PFL provides up to six weeks of benefits for individuals who must take time off work to care for a seriously ill child, parent, parent-in-law, grandparent, grandchild, sibling, spouse, or registered domestic partner, or to bond with a new child.
For more information on the process of creating an SDI online account and completing the online doctor’s certificate, practices can listen to CMA’s On Demand webinar, “Utilizing the New State Disability Insurance (SDI) Online System."
Passive enrollment for the Medicare/Medi-Cal duals demonstration will begin on August 1, 2015, in Orange County. If patients do nothing, they will automatically be enrolled in CalOptima for their Medi-Cal and Medicare benefits. The California Department of Health Care Services (DHCS) reports most of these patients are already enrolled in Cal Optima for their Medi-Cal benefits. Affected patients will be notified by CalOptima 90, 60 and 30 days prior to their enrollment date, which means the first enrollee notices were mailed by the plan at the end of April. A brochure will be released in conjunction with the 60-day notice in June. Individuals will be automatically enrolled over a 12-month period based on birth month.
CalOptima reports that contract amendments to include the duals product were sent out to all of its currently contracted physicians in late March.
While the dual eligible patients in affected areas have the choice to opt out of the Medicare managed care plan and stay in fee-for-service Medicare, there is no ability to opt out of enrollment in CalOptima, Orange County’s only Medi-Cal managed care plan.
For more information on how patients can opt out, click here. Additional information on populations who are mandatorily enrolled and do not have the ability to opt out of a Medicare managed care plan can be found on the Cal Duals website (populations exempt indicate “exempt from passive enrollment”).
The demonstration—known as the Coordinated Care Initiative (CCI) or Cal MediConnect—was authorized by the state in July 2012 in an effort to save money and better coordinate care for the state’s low-income seniors and persons with disabilities. The program began with a three-year demonstration project that expected to see a large portion of the state's dual eligible beneficiaries transition to managed care plans. The project was expected to impact approximately 450,000 duals in eight counties – Alameda, Los Angeles, Orange, Riverside, San Diego, San Mateo, San Bernardino and Santa Clara. However, in November 2014, DHCS announced that CCI would not move forward in Alameda County, bringing the total possible enrollment into the program to approximately 430,000. The decision, made with input from local stakeholders, was based on concerns with the financial solvency of Alameda Alliance for Health, the CCI plan in Alameda County.
The California Medical Association has created a visual timeline of the implementation dates by county. Also available on our website are sample patient letters. Physicians may wish to proactively send these letters to their dual eligible patients so patients will know the plans and medical groups you contract with and can select appropriately at enrollment time.
DHCS has created a Physician Toolkit that includes answers to frequently asked questions about Cal MediConnect that is available on the Cal Duals website at www.calduals.org/physician-toolkit. For more details on Cal MediConnect, visit www.cmanet.org/duals.
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.
Accurate coding—and optimal reimbursement—rest on the strength of the provider’s documentation. One commonly under-documented element is the patient history, but this is a deficiency that’s easy to avoid, if you follow four steps.
1. Document the patient’s chief complaint. Every encounter must have a chief complaint, or a reason that the patient is seen. The provider must personally document the chief complaint, even if the patient or a staff member previously recorded the reason for the visit.
The chief complaint is always a problem. “Follow-up” is not a chief complaint. If the patient doesn’t have a problem (e.g., well patient check-up), the service is preventive.
2. Describe a history of the chief complaint. The history must be relevant to the presenting problem(s), and should seek to answer these questions:
- Location: Where is the problem?
- Quality: How would you characterize the problem?
- Severity: How bad is the problem?
- Duration: How long has the problem bothered you?
- Timing: How often does the problem bother you?
- Context: Is the problem associated with any particular event or action?
- Associated signs/symptoms: Have you noticed any other symptoms since this problem started to bother you?
- Modifying factors: Have you done anything to make the problem better/worse?
Just as the provider must document the chief complaint, he or she must personally document the history of current illness. Copying the nurse’s notes, for instance, is not appropriate.
3. Demonstrate a review of pertinent body systems. The “review of symptoms” (ROS) is the patient’s positive and negative responses about his or her experiences with symptoms. Providers should indicate as “positive” for symptoms any body system(s) that pertain to the chief complaint. All systems that are “positive” for symptoms, and those with “pertinent negatives” (negative responses where you would expect to see a “positive” response for symptoms) should include at least a brief explanation. Avoid blanket statements, such as “all systems unremarkable.”
The provider does not have to record the ROS. For example, ancillary staff may obtain the ROS, or you may ask the patient to complete a questionnaire or checklist. If the ROS is obtained on a separate form, the provider should sign and date the form to certify that he or she reviewed the information, and that the information is germane to the current visit.
4. Be brief, and be consistent. When relevant, you may document additional patient information supplied by a family member or caregiver. But in all cases, quality of documentation matters more than quantity. Many services (appropriately) will include a review of the patient’s past medical history, family medical history, and social history (e.g., is the patient married, employed, a smoker, etc.); however, details that do not pertain to the current visit or otherwise inform the provider’s medical decision-making for that visit detract from, rather than enhance, the record.
Finally, providers must ensure that documentation is internally consistent. Contradictory data is a common error. For example, the chief complaint may state one reason for the visit, but the history of present illness may detail a different problem.
Providers may not be able to meet all of the above requirements for all patients (e.g., there may be a language barrier, or the patient may be unconscious or otherwise uncommunicative). In such cases, the provider should document the circumstances, and explain that he or she was unable to obtain the information from the patient or other source.
AETNA: Providers wishing to update their office demographic information with Aetna are now being directed to NaviNet, Aetna’s secure provider website, to update their information electronically. Formerly, providers seeking to update their demographics (including email addresses, mailing address, phone or fax numbers) were limited to contacting the Aetna Provider Service Center to facilitate changes. Physicians may now access the “Update Provider Profiles” function through Navinet, where updated demographic information may be submitted and verified online.
ANTHEM BLUE CROSS: Anthem has advised that advanced lipoprotein testing is considered an investigational procedure and deemed not medically necessary for cardiovascular disease risk assessment and management. As such, effective for dates of service beginning October 9, 2015, the following codes will be denied.
|83698||Lipoprotein-associated phospholipase A2 (Lp-PLA2)|
|83700||Lipoprotein, blood; electrophoretic separation and quantitation|
|83701||Lipoprotein, blood; high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed (eg, electrophoresis, ultracentrifugation)|
|83704||Lipoprotein, blood; quantitation of lipoprotein particle numbers and lipoprotein particle subclasses (eg, by nuclear magnetic resonance spectroscopy)|
MEDI-CAL: On June 12, Medi-Cal announced that it would be adding Viekira Pak to the Contract Drugs List for the treatment of chronic hepatitis C, effective for dates of service on or after July 1, 2015. Usage of Viekira Pak will require a treatment authorization request and will be restricted to use in the treatment of chronic Hepatitis C Virus infection in adults 18 years of age or older, and to a maximum quantity of 112 tablets per dispensing with the duration of therapy lasting up to 12 or 24 weeks from the dispensing date of the first prescription.
TRICARE/UMVS: TRICARE has announced an update to its Breast Pump policy, allowing coverage of breast pumps and supplies and breastfeeding counseling effective July 1, 2015. Additionally, TRICARE will retroactively allow coverage beginning December 19, 2014, for these supplies and services. TRICARE’s breastfeeding support benefit is considered to be preventive care; therefore, the equipment, supplies and services covered under this benefit are exempt from cost-shares and copays. This coverage is for all pregnant TRICARE beneficiaries, as well as beneficiaries who legally adopt and intend to personally breastfeed. To be covered, the breast pump and supplies must be obtained from a TRICARE-authorized provider, supplier or vendor. For manual or standard electric breast pumps and associated supplies (including breast pump kits), this includes any civilian retail store or pharmacy. For patients who pay out of pocket or who have previous paid out of pocket for a covered breast pump, a completed claim form must be submitted with a copy of the prescription for the breast pump, along with your receipt for reimbursement.
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 email@example.com.
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 firstname.lastname@example.org. Questions about membership, including technical website issues, should be directed to CMA's member help center, (800) 786-4CMA or email@example.com.
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 firstname.lastname@example.org.