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:
- Covered California tax credit mix-ups cause headaches for consumers
- GAO upholds award of Tricare West contract to Health Net Federal Services
- Are you exempt from ICD-10 PQRS penalties in 2016?
- Prime HealthCare terminates Molina contract impacting SoCal physicians
- Medi-Cal’s fiscal intermediary to change name from Xerox
- Webinar: Learn how to manage your professional reputation online
- The Coding Corner: How and when to append modifier 25
Physicians should be aware that approximately 35,000 Californians insured through Covered California were in for a shock when they received their premium bills last month. The source of the problem is two-fold, both related to clerical errors by the state health exchange.
Roughly 9,600 beneficiaries have, at least temporarily, lost federal premium subsidies because Covered California was unable to verify their income. The premium subsidies that enrollees receive are determined based on income. In order to verify income against a federal database, Covered California needs consent from enrollees. In December, Covered California discovered some enrollees hadn’t provided the necessary consent and as a result have, at least temporarily, lost their subsidies as of January 1, 2017. Affected patients are now receiving bills from plans for the full, unsubsidized amounts of their premiums. Once an enrollee provides the needed consent, Covered California has pledged to recalculate the tax credits and apply them retroactively to the beginning of the year.
Affected patients will be given a special enrollment period, and can enroll or make changes to their plans until February 28, 2017. (The standard enrollment period closed for all other individuals on January 31.)
Another group of 25,000 Covered California policy holders are also facing higher-than-expected premium bills because the exchange initially sent incorrect tax credit information to their health plans. Covered California confirmed that it provided incorrect subsidy information for some policy holders, resulting in inaccurate premium bills. The information has been corrected, and insurers are now sending out new bills. In most cases that means higher premiums than consumers had initially been quoted, and health plans are entitled to bill them for the difference.
Physicians who receive questions from their patients about either of these issues should direct them to contact Covered California directly at (800) 300-1506.
For physician practices, these two issues could result in changes to patient eligibility. Physicians are urged to be diligent in verifying patients' eligibility and benefits each time they are seen to ensure they will be paid for services rendered.
The U.S. Government Accountability Office (GAO) has upheld the Department of Defense’s (DOD) decision to award Health Net Federal Services the contract to provide managed care services to Tricare beneficiaries in its Western Region, which includes California and 20 other states.
As the California Medical Association (CMA) previously reported, the DOD announced in July 2016 that it had awarded the contract to Health Net. The contract, worth up to $17.7 billion over nearly six years, had previously belonged to United Healthcare Military and Veterans Services since 2013.
United protested the decision, but the GAO announced in mid-November 2016 that it would uphold the decision to award the west region to Health Net.
A nine-month transition period is expected, with Health Net expected to start health care delivery for Tricare patients sometime in late 2017. CMA will publish updates on the transition as more details become available.
On October 1, 2016, new ICD-10 code sets went into effect that will impact the ability of the Centers for Medicare and Medicaid Services (CMS) to process data reported on certain quality measures for the fourth quarter of 2016. Because of this, CMS announced that it will waive 2017 or 2018 Physician Quality Reporting System (PQRS) payment adjustments, if applicable, for any physician or group practice that fails to satisfactorily report for 2016 solely as a result of the impact of ICD-10 code updates on quality data reported for the fourth quarter of 2016.
Physicians and group practices must still report on 2016 PQRS measures, regardless of whether they believe they will be unable to satisfactorily report due to the ICD-10 code updates. CMS will determine after the data is submitted whether the clinician or group practice was among those impacted. The affected practices will be removed from the PQRS penalty prior to the release of the 2016 feedback reports.
CMS is anticipating that the following measure groups may be affected by the ICD-10 code updates:
- Cardiovascular Prevention
- Diabetic Retinopathy
The 2016 reporting deadline is February 28, 2017.
Click here to read the CMS FAQ on the ICD-10 update and its impact on PQRS.
The California Medical Association (CMA) recently learned that Prime HealthCare (which operates hospitals in Los Angeles, San Bernardino and San Diego counties) terminated its contract with Molina Healthcare effective December 4, 2016. Because of the large number of enrollees that would be affected, the termination required approval from the Department of Managed Health Care (DMHC). DMHC approval was received on January 9, 2017.
Physicians should be aware that services provided to Molina enrollees in Prime HealthCare facilities affected by the termination (see list below) should be paid at in-network rates through January 9, 2017, when the termination was approved by DMHC. Molina will also be responsible for ensuring that all enrollees are held responsible for only the in-network patient cost share for services provided during that interim period between the termination date and approval date.
CMA first became aware of contracting issues between Prime Healthcare and Molina in November when referrals of Molina patients to San Diego Prime hospitals were turned away.
The Prime HealthCare hospitals no longer contracted with Molina are noted below:
- Centinela Hospital Medical Center
- Encino Hospital Medical Center
- San Dimas Community Hospital
- Sherman Oaks Hospital
Inland Empire (San Bernardino County)
- Chino Valley Medical Center
- Desert Valley Hospital
- Montclair Hospital Medical Center
- Alvarado Hospital Medical Center
- Paradise Valley
The Prime HealthCare termination may also affect physicians who have participation agreements with Molina that require them to maintain active privileges at a contracted Molina hospital.
Physicians with questions can call Molina at (888) 562-5442, and follow the prompts to the utilization management department. Physicians can also call their county's Provider Services Director for assistance:
- Los Angeles: Aaron Sanchez – (888) 562-5442 x121254
- San Diego: Kerrie Resendes – (888) 562-5442 x121146
- San Bernardino: Sharlene Landau – (888) 562-5442 x125022
Xerox State Healthcare, LLC, the current Medi-Cal fiscal intermediary for the California Department of Health Care Services’ (DHCS) fee-for-service system, has separated from the Xerox Corporation and has become a new independent, publicly-traded company called Conduent State Healthcare, LLC.
The shift to the new Conduent brand name began on January 3, 2017. The transition is not expected to impact business operations, including those involving providers and beneficiaries. Providers are encouraged to open and read all information sent from DHCS, Xerox or Conduent to stay informed about the transition.
For more information, providers can subscribe to the Medi-Cal Subscription Service (MCSS) to receive notifications related to Medi-Cal Update bulletins, NewsFlash articles and System Status Alerts. Providers may sign up for MCSS by visiting www.medi-cal.ca.gov and completing the MCSS Subscriber Form.
The California Medical Association (CMA) will host a webinar on “How to Manage Your Professional Reputation Online” on Wednesday, February 8, from 12:15 to 1:15 p.m.
Presenters include Lisa Matsubara, legal counsel for CMA’s Center for Legal Affairs, and Laura Braden Quigley, vice president for CMA’s Center for Strategic Communications. With their vast experience and expertise, Matsubara and Quigley will provide attendees an overview on how to monitor your digital presence, take control of information about you and your practice online, and develop and implement a social media policy. This webinar will also discuss patient confidentiality, HIPAA and other legal concerns.
This webinar is free for CMA members; nonmembers may attend for $99. For more information, or to register, click here.
Contact: Juli Reavis, (916) 551-2046 or firstname.lastname@example.org.
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, and Suzan Hauptman, senior principal for ACE Med group specializing in auditing, assessments, coding, compliance, expert opinion, writing, reporting and education.
To apply modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service correctly, you must know what distinguishes a “separate, significantly identifiable” evaluation and management (E/M) service.
Not all E/M services are billable
All billable medical procedures include an “inherent” E/M component, to gauge the patient’s overall health and the medical appropriateness of the service. For example, if a patient has a mole removed, the procedure includes general preparation such as measuring vitals, updating medications, confirming the mole location and its current state, etc.
To report a separate E/M service with modifier 25 appended, the visit must be more involved. The available documentation should describe an independent, standalone E/M service, in addition to the procedure. The encounter note could include the patient history, a listing of co-morbidities and their possible effects on the current condition, a medically-warranted examination, and documented medical decision-making (for instance, deciding that the best treatment is a procedure performed that day). If the note touches only briefly on the current issue and the need for the additional service or procedure, consider the E/M service to be part of the procedure, and not separately billable.
Typically, if the E/M service is unrelated to the minor procedure (i.e., the E/M takes place for a different concern or complaint), the E/M service may be reported separately. Additionally, if the E/M service occurs due to exacerbation of an existing condition, or another change in the patient’s status, that service may be reported separately if it is independently supported by documentation. The American Academy of Family Physicians recommends that physicians ask themselves the following questions to help determining if modifier 25 is appropriate:
- Did you perform and document the key components of a problem-oriented E/M service for the complaint or problem?
- Could the complaint or problem stand alone as a billable service?
- Is there a different diagnosis for this portion of the visit?
- If the diagnosis is the same, did you perform extra physician work that went above and beyond the typical pre- or postoperative work associated with the procedure code?
CPT Assistant (May 2011) gives an example:
A 4-year-old slips on the edge of a pool, strikes the mandible and experienced a 3.5-cm serrated and curvilinear, full-thickness laceration of the chin. The child’s pediatrician elects to widely excise the serrated skin margins and undermine the dermis from the subcutaneous tissue to reduce the tension on the suture line. The wound is then approximated in layers with absorbable interrupted sutures and a running subcuticular closure.
This procedure would be reported 13132 Repair complex, forehead, cheeks, chin, mouth neck, axillae, genitalia, hands and/or feet; 2.6 to 7.5 cm. Any significant, separately identifiable evaluation and management service performed in addition to the wound repair would be reported separately using modifier 25.
As long as both the E/M service and the procedure are clearly documented, you don’t need separate notes (although separate notes can help).
Every service or procedure needs a diagnosis
Both the procedure and the separate, same-day E/M service must be linked to a diagnosis substantiated in the medical record. The diagnoses supporting each service may be the same, or different. Per Transmittal R954CP, “The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date” [emphasis added]. The E/M visit may be prompted by a complaint unrelated to the same day procedure (different diagnoses), or the procedure could be for a condition that was evaluated during the visit, or for a chronic condition that would benefit from the additional service (same diagnoses).
Append modifier 25 only to minor procedures
A minor procedure is any procedure/CPT® code with a zero- or 10-day global period, as defined by Medicare’s Physician Fee Schedule Relative Value File. Examples include many injections, minor integumentary repairs and endoscopic procedures (e.g., diagnostic colonoscopy). You should turn to modifier 57 Decision for surgery (rather than modifier 25) to report a separately identifiable E/M service that occurs on the same day, or on the day before, a major surgical procedure (a procedure or service with a 90-day global period), and that results in the physician’s decision to perform the surgery, according to the Medicare Claims Processing Manual, section 40.2.
CPT Assistant (March 2015) provides a coding example:
A patient is seen in the emergency room with acute appendicitis. The surgeon sees the patient, makes a diagnosis, and reaches a decision to perform surgery. The patient then promptly undergoes a laparoscopic appendectomy.
How to code
Report CPT code 99222 (or similar initial emergency department code) with modifier 57, along with the appropriate appendectomy code: 99222-57 and 44970.
MEDI-CAL: Effective November 1, 2016, several audiology codes were terminated and are no longer reimbursable by Medi-Cal. This has specific impact on tympanometry, CPT code Z0316, which was crosswalked into code X4540. Tympanometry services billed with Code X4540 are only reimbursed when performed as part of a comprehensive audiological evaluation. At this time, there is no code to bill for tympanometry services not performed as part of an initial or follow-up visit for detecting conditions such as otitis media, other middle ear disorders and/or hearing loss. Tympanometry services provided under any other circumstances are not separately reimbursable. For more information on Medi-Cal coverage for audiological services, including tympanometry, click here. For physician billing questions, refer to Medi-Cal’s Medicine: Otorhinolaryngologic Services section in the appropriate Part 2 manual. Medi-Cal will update this section once the entire audiology services cross-walk is complete, which is expected to occur later this year.
UNITED HEALTHCARE: For dates of service on or after April 1, 2017, United Healthcare (UHC) commercial plans are implementing a prior notification/prior authorization requirement for the medication Xolair (omalizumab). Failure to complete the prior notification/prior authorization process before administering Xolair may result in the claim being denied. UHC will determine if the member’s benefit plan requires services to be medically necessary in order to be covered. If so, UHC will conduct a clinical coverage review requiring patient medical records as part of its prior authorization process. If coverage is approved, care providers may purchase and directly bill UHC for this medication. For more information about the notification/prior authorization requirements for specialty medications, please refer to the Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Administrative Guides.
The California Medical Association offers our members free programs to educate physicians and staff on a range of practice management issues. Space is limited, so register soon.
Upcoming CMA webinar: February 2017
Most webinars are held over the lunch hour, from 12:15 to 1:15 p.m. and are free for CMA members and their staff. See the event calendar for additional details and to register.
2/8: How to Manage Your Professional Reputation Online: In today’s digital world, monitoring and managing an online presence has become essential. This webinar will provide an overview on how to monitor your digital presence, take control of information about you and your practice online, and develop and implement a social media policy. This webinar will also discuss patient confidentiality, HIPAA and other legal concerns.
2/22: Paying Employees Correctly: Wage and Hour Laws for Health Care Employers: Federal and state laws exempt certain employees, including some physicians, from wage and hour requirements, including overtime pay. If you have a problem distinguishing between exempt and nonexempt employees, you are not alone. This webinar will cover the basic wage and hours laws for health care employers in California and help you ensure your practice is classifying and paying employees appropriately.
Contact: CMA’s member help center, (800) 786-4262 or email@example.com.
The California Medical Association’s Center for Economic Services provides direct reimbursement assistance to CMA physician members and their office staff.
Reimbursement Help Line (888/401-5911)
- One-on-one educational and reimbursement assistance to physician members and their staff
- Tools and resources to empower physician practices
- Seminars and toolkits for physicians and their staff
- Staffed by practice management experts with a combined experience of over 125 years in medical practice operations
Need help? Contact CMA’s reimbursement experts at (888) 401-5911 or firstname.lastname@example.org.
To make sure that you are aware of important news from your contracting health plans, we encourage you to regularly read plans' provider newsletters and bulletins. Follow the links below to access the current issues.
AETNA: www.aetna.com. Click on "Health Care Professionals" in the main menu, then on "News for Providers" in the left sidebar.
CIGNA: www.cigna.com. Click on "Health Professionals" under "Customer Care" in the main menu. Then, scroll down and click on "Newsletters."
ANTHEM BLUE CROSS: www.anthem.com/ca. Click on "Providers" in the main menu, then on "Professional Network Update" under "Spotlight."
BLUE SHIELD: www.blueshieldca.com. Click on "I'm a Provider," then on "Announcements" under "News and Features."
HEALTH NET: www.healthnet.com. Click on "I'm a Provider" and then "California." Enter username and password, and then click "Online News."
MEDI-CAL: www.medi-cal.ca.gov. Click on "Publications" in the main menu, then on "Provider Bulletins."
MEDICARE/NORIDIAN: https://med.noridianmedicare.com/web/jeb/fees-news. Noridian publishes individual articles through the Latest Updates section in the left sidebar. The articles are condensed approximately every six-to-eight weeks into a Bulletin.
UNITED HEALTHCARE: www.unitedhealthcareonline.com. Click on "Tools & Resources" in the main menu, then on "Network Bulletin."
CMA RESOURCE: Find up-to-date profiles on each of the major payors in California.
If you have questions related to any of the articles in this issue, please contact CMA's reimbursement help line, (888) 401-5911 or email@example.com. Questions about membership, including technical website issues, should be directed to CMA's member help center, (800) 786-4CMA or firstname.lastname@example.org.
Let us know which topics you would like to see addressed in future issues. Contact CMA's Center for Economic Services at (916) 551-2061 or email@example.com.