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:
- It’s the final countdown to ICD-10 implementation
- Blue Shield announces fee schedule changes effective November 1
- CMS clarifies ICD-10 grace period guidance
- United Healthcare to implement several new multiple procedure payment reductions
effective November 15
- United Healthcare identifies physician chemotherapy claims processing error
- Anthem Blue Cross offering incentive for completion of health assessments
- DHCS implements period of “deemed eligibility” for Cal MediConnect plans
- CMA continues to monitor health plan network directory accuracy
- Medi-Cal providers: Are you ready for ICD-10?
- The Coding Corner: ICD-10 coding for sinusitus
With less than one month until the implementation of ICD-10, practices should be in the final steps of preparation and training for conversion to the new code set on October 1, 2015. Within the next few days, practices should be verifying that their staff has received adequate ICD-10 training and are comfortable with the transition.
For physicians who may need documentation training prior to the implementation, the California Medical Association (CMA) has partnered with AAPC to offer discounted online training for physicians. The three-hour courses are offered by specialty and teach documentation requirements at the physician level. CMA members pay $249, 42 percent off of the standard price of $395. For more information on the 21 different specialty-specific documentation courses offered, visit www.cmanet.org/aapc (be sure to login to the CMA website to access member pricing).
Although practices should have already addressed the ICD-10 impact on their clearinghouses, billing companies and practice management software, practices should be conducting a final verification that all impacted entities and systems have been upgraded and are now ICD-10 ready.
If you aren’t yet prepared, there is still time. CMS’ ICD-10 Quick Start Guide outlines five steps to prepare for ICD-10 by the October 1 compliance date.
To help physicians prepare for the transition, CMA has updated its ICD-10 Transition Guide, which includes an ICD-10 transition preparation checklist. New information includes: new table indicating code categories that are expanded as well as those that are reduced under ICD-10; information on how payors will handle prior authorizations around the transition date; listing and links to CMA’s live ICD-10 training courses; information on the Centers for Medicare and Medicaid Services’ plans for flexibility during the first 12 months of the transition; and a visual of the anatomy of ICD-10 code structure, among other things.
For the latest news and information on the ICD-10 transition, see www.cmanet.org/icd10.
Blue Shield has announced changes to its physician fee schedule that will take effect November 1, 2015. In an August 24 notice to physicians, the insurer said that it would be increasing payment for the more commonly billed office visit codes.
The new rates will be available on the Blue Shield website beginning September 1 (go to www.blueshieldca.com/provider and log in, then select the “Professional Fee Schedule” link located under the "Claims" section menu). Physicians can also request a copy of the new fees by completing the allowance review form enclosed with the notice, or by calling the Blue Shield Provider Services Department at (800) 258-3091.
Physicians are encouraged to carefully review all proposed amendments to health plan or medical group/IPA contracts. The California Medical Association (CMA) reminds physicians that they do not have to accept substandard contracts that are not beneficial to their practices.
To help physicians understand their rights when a health plan has sent notice of a material change to a contract, CMA has published Contract Amendments: an Action Guide for Physicians, available in CMA's online resource library. The guide includes a discussion of options available to physicians when presented with a material change to a contract. Additionally, the guide includes a financial impact worksheet that will help physicians calculate the net impact of the fee schedule changes on their practices.
Click here to view a copy of the notice that was recently sent to physicians.
In early July, the Centers for Medicare & Medicaid Services (CMS) announced that for a period of one year, it will allow for flexibility in the claims payment, auditing and quality reporting processes as the medical community gains experience using the new ICD-10 code set.
CMS specifically clarified its statement that during the 12 months after ICD-10 implementation, contractors would not deny claims based solely on the specificity of the ICD-10 diagnosis code. However, according to the latest FAQ, claims will be rejected if they do not contain a valid ICD-10 code. CMS further defined a “valid code” as one that is coded to the maximum level of specificity. Claims will not, however, be rejected or audited simply because they contain the wrong code—as long as it is a valid code from the right family.
ICD-10 codes contain at least three characters, but sometimes as many as seven characters. The three-character "coding family" may then be further subdivided with more characters to provide additional specificity. If, for example, you submit a valid five-character code, you wouldn't be audited simply because you selected the wrong fifth character.
So, what does the CMS flexibility really mean? While coding to the correct level of specificity is the goal for all claims, claims will be processed and will not be audited as long as the first three characters are from the correct "coding family." This does not mean that you can submit claims that do not at least attempt to provide additional specificity, when required. If a submitted code is not recognized by the system as a valid ICD-10 code, it will be rejected. The physician can, in such an instance, resubmit the claims with a valid code.
To clarify, the ICD-10 implementation date of October 1, 2015, has not changed.
To help physicians prepare for the transition, the California Medical Association (CMA) has updated its ICD-10 Transition Guide, which includes an ICD-10 transition preparation checklist. The guide also includes, among other things, information on how payors will handle prior authorizations around the transition date; listing and links to CMA’s live ICD-10 training courses; more information on CMS' “grace period”; and a visual of the anatomy of ICD-10 code structure.
For the latest news and information on the ICD-10 transition, including the ICD-10 Transition Guide, see www.cmanet.org/icd10.
United Healthcare to implement several new multiple procedure payment reductions effective November 15
In its August 2015 Network Bulletin, United Healthcare (UHC) announced that, beginning with November 15, 2015, dates of service, multiple procedure payment reductions (MPPR) will be applied to several types of services, including:
- Technical component of diagnostic cardiovascular and ophthalmology procedures
- Professional component of diagnostic imaging services
- Some endoscopy procedures
UHC reports that it is implementing the reductions to better align with the Centers for Medicare & Medicaid Services (CMS). The new claim edits will apply for UHC commercial claims. Policy changes include:
Diagnostic cardiovascular – MPPR will apply to the technical component of cardiovascular services with a multiple procedure indicator (MPI) of 6, as indicated by CMS, when multiple services are provided to a patient on the same day by the same physician or multiple physicians in the same group practice reporting under the same federal tax identification number (TIN). Services will be ranked by the CMS Total Non-Facility Relative Value Unit (RVU). The services with the highest RVU will be considered primary service and will be processed at 100 percent of the allowable amount. Second and subsequent services will be reduced by 25 percent of the allowable amount. Procedure codes subject to this policy can be viewed by going to the CMS 2015 Physician Fee Schedule. Once there, click on the “2015 RVU15A” file, then download the “RVU15A (Updated 1/8/15)” file, then open the file titled “PPRRVU15_V1223c.csv.” The codes with a MPI of 6 (as indicated in column S “MULT PROC”) are subject to this new policy.
Diagnostic ophthalmology services – MPPR will apply to the technical component of ophthalmology services with MPI of 7, as indicated by CMS, when multiple services are provided to a patient on the same day by the same physician or multiple physicians in the same group practice reporting under the same federal TIN. Services will be ranked by the CMS Total Non-Facility RVU. The services with the highest RVU will be considered primary service and will be processed at 100 percent of the allowable amount. Second and subsequent services will be reduced by 20 percent of the allowable amount. Procedure codes subject to this policy can be viewed by going to the CMS 2015 Physician Fee Schedule. Once there, click on the “2015 RVU15A” file, then download the “RVU15A (Updated 1/8/15)” file, then open the file titled “PPRRVU15_V1223c.csv.” The codes with a MPI of 7 (as indicated in column S “MULT PROC”) are subject to this new policy.
Diagnostic imaging services – MPPR will apply to the professional component when multiple diagnostic imaging services assigned a MPI of 4 are furnished to the same patient in the same session by the same physician or multiple physicians in the same group practice reporting under the same federal TIN. Services will be ranked by the CMS Total Transitional Non-Facility RVU. The services with the highest RVU will be considered primary and processed at 100 percent of the allowable amount. Services with the lower RVU will be considered secondary and subsequent and reduced by 25 percent of the allowable amount. Procedure codes subject to this policy can be viewed by going to the CMS 2015 Physician Fee Schedule. Once there, click on the “2015 RVU15A” file, then download the “RVU15A (Updated 1/8/15)” file, then open the file titled “PPRRVU15_V1223c.csv.” The codes with a MPI of 4 (as indicated in column S “MULT PROC”) are subject to this new policy.
UHC reports that it will not apply professional component reductions when services are reported with modifier 59 or XE to identify different sessions.
Additionally, UHC announced it will also begin applying a multiple endoscopic reduction, in line with CMS, when multiple procedures are performed on the same day, by the same physician or multiple physicians in the same group practice reporting under the same federal TIN for commercial claims with a date of service on or after November 15, 2015. For more information on the details of the policy, see the UHC August Network Bulletin 2015 (page 25) on the UHC website.
Physicians are encouraged to review all of the multiple procedure reduction changes to understand how the changes will affect their individual practices.
Questions about any of the claims editing rules or payment policies can be directed to UHC at (877) 842-3210.
UnitedHealthcare (UHC) has identified an error in the processing of physician claims related to its Injectable Outpatient Chemotherapy Prior Authorization program requirement, which became effective June 1, 2015. Between June 1 and July 18, 2015, incorrect denials of “lack of prior authorization” may have been generated for injectable chemotherapy claims submitted with valid authorizations on file or submitted for patients with self-insured employer policies where preauthorization of injectable chemotherapy is not required. UHC has advised that a system fix was implemented on July 18, 2015, and all claims after this date should process correctly.
Claims that were denied incorrectly were automatically reprocessed for payment by UHC; all affected claims should have been reprocessed by the end of August 2015. If you have any questions, please contact UHC via email at firstname.lastname@example.org.
In Anthem Blue Cross' August Professional Network Update, the insurer announced it was offering financial incentives to physicians for completing member health assessments for patients with certain exchange/mirror products.
Anthem will be working with Inovalon throughout the year to contact physicians to request completion of the health assessments. The assessments will be completed using Inovalon’s secure, electronic tool (ePASS) or using the Encounter Subjective, Objective, Assessment and Plan (SOAP) Note provided with by Inovalon for each identified patient.
Beginning with patient assessments completed for dates of service on or after June 1, 2015, physicians will now be eligible to receive $100 for each properly submitted electronic SOAP note submitted through ePASS in addition to their normal office visit fee. Physicians electing to submit their patient assessment data to Inovolan via secured fax, instead of electronically, are eligible to receive $50 in addition to the office visit fee.
The information is being requested as part of a Covered California requirement that participating health plans collect and maintain information about the health status of their plan enrollees to better manage their health conditions.
According to Anthem, there are no penalties for non-compliance at this time.
Physicians who have questions regarding the program can contact Anthem Provider Services at (855) 854-1438. For specific health assessment questions, contact Inovalon at (877) 448-8125.
Effective September 1, 2015, Cal MediConnect will have the option to offer a one- or two-month period of “deemed eligibility,” defined as a grace period, to beneficiaries that lose Medi-Cal eligibility due to a change in circumstance. Cal MediConnect plans have the option to, but are not required to, offer this “grace period."
According to the 2013 Medicare-Medicaid Plan Enrollment and Disenrollment Guidance, a Cal MediConnect plan may choose to provide a one- or two-month period of deemed continued eligibility for individuals who lose Medicaid eligibility, if the individual is reasonably expected to regain Medicaid eligibility within one or two months. Plans that choose to offer this grace period must continue to offer the full continuum of benefits.
Effective with September enrollment, if the plan is offering this grace period and the beneficiary is deemed eligible, the eligibility verification through Medi-Cal’s automated eligibility verification system (AEVS) will reflect a new status under the “Eligibility Message” at the very end:
SUBSCRIBER LIMITED TO SERVICES COVERED BY HEALTH PLAN: (HCP Name) (HCP Telephone): (HCP) XXX, (HCP phone number) 1-800-XXX-XXXX.
If the beneficiary does not re-qualify within the plan’s period of deemed eligibility, their enrollment will be terminated.
To better understand which Cal MediConnect plans are offering the grace period, the California Medical Association asked the plans about their timeframe for potential deeming of Cal MediConnect beneficiaries:
|Plan Name||Offering Deemed Eligibility (Yes/No)||Number of Months|
|Anthem Blue Cross||Yes||1|
|Community Health Group||Yes||1|
|Health Plan of San Mateo||Yes||2|
|Inland Empire Health Plan||Yes||1|
|Santa Clara Family Health Plan||Yes||2, beginning Oct. 1, 2015|
If a plan opts to offer the grace period and the patient does not regain eligibility, the plan is responsible for payment for services incurred during the grace period. However, best practice is to always verify eligibility as close to, if not on, the date of service as possible and keep the AEVS confirmation in the patient’s medical record.
Last November, the California Department of Managed Health Care (DMHC) released the results of an audit of the Anthem Blue Cross and Blue Shield Covered California networks. Among other things, the audit found that 12.8 percent of the physicians listed on Anthem’s network were not accepting Covered California patients, while 12.5 percent were not in practice at the location listed in Anthem’s directory.
In the case of Blue Shield, only 56.7 percent of the physicians listed in Blue Shield's Covered California directory could be verified as accepting Covered California patients. These inaccuracy rates were consistent with the California Medical Association's (CMA) and some county medical societies' own verification efforts and analyses.
DMHC will be conducting a follow-up of its audit this fall to determine whether the health plans have resolved their inaccurate network directories. Physicians who are misidentified as participating in a network by Anthem or Blue Shield when in fact they are not, or whose information in a network directory is inaccurate, are urged to contact CMA’s Center for Economic Services at (888) 401-5911 or email@example.com.
The California Department of Health Care Services (DHCS) is asking Medi-Cal providers to take a brief survey about their readiness for the October 1, 2015, transition to ICD-10. The purpose of the survey is to determine provider and submitter health care transaction preparedness.
DHCS is encouraging Medi-Cal providers and submitters, including Family Planning, Access, Care and Treatment (Family PACT) providers, to take the survey. While participation is not required, provider responses to the survey will help Medi-Cal assess any issues or concerns that may hinder ICD-10 compliance. All answered surveys will be kept confidential and anonymous.
Click here to take the survey.
To help physicians prepare for the ICD-10 transition, the California Medical Association (CMA) has published an ICD-10 Transition Guide, which includes an ICD-10 transition preparation checklist.
CMA has also created an ICD-10 transition webpage, www.cmanet.org/icd10, that includes important news articles, ICD-10 training opportunities and other ICD-10 transition information.
CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from Peggy Silley, the Director of ICD-10 Development and Training for AAPC, a training and credentialing association for the business side of health care.
Codes for sinusitis are located in ICD-10-CM Chapter 10, Diseases of the Respiratory System (category J00-J99). There are important concepts to consider when documenting sinusitis; the selected codes will identify the affected sinus and time parameter (acute, chronic or recurrent).
When more than one sinus, but not all sinuses, are affected (pansinusitis), the codes for “other sinusitis” are to be assigned according to whether it is acute, recurrent or chronic. When the term Sinusitis with the subterms acute or chronic, affecting more than one sinus other than pansinusitis, is referenced in the Alphabetic Index, it sends the user to the other sinusitis codes J01, Acute; other sinusitis and J32 Chronic; other sinusitis.
- Acute sinusitis, recurrent sinusitis (includes abscess, empyema, infection, suppuration)
- Sinus affected
- Infectious organism
- Chronic sinusitis (includes abscess, empyema, infection, suppuration)
- Sinus affected
- Current use, history of, exposure to tobacco smoke
There are several instructional notes you must consider when applying the sinusitis codes. A note under category J01 Acute sinusitis states that an additional code (B95-B97) is used to identify the infectious agent, if known. Codes B95-B97 are secondary codes to identify Staphylococcus, Streptococcus or Enterococcus.
Example: Steven presents for a visit with facial pain. He said he had a cold last week with some nasal congestion and facial pain. His pain is primarily below the eyebrows. Upon examination, his frontal sinuses are tender to percussion and there is injection and erythema in the turbinates. He is diagnosed with acute frontal sinusitis:
J01.10 Acute frontal sinusitis, unspecified
Rationale: In this example, Steven presents with facial pain in the frontal sinuses. Based on the time parameter, this is considered acute.
An instructional note for category J32 Chronic sinusitis directs you to use an additional code to identify current, history of or exposure to tobacco/tobacco smoke.
- Exposure to environmental tobacco smoke (Z77.22)
- History of tobacco use (Z87.891)
- Occupational exposure to environmental tobacco smoke (Z57.31)
- Tobacco dependence (F17.-)
- Tobacco use (Z72.0)
Category J01 contains an Excludes2 that allows for reporting chronic sinusitis (J32.0-J32.8) in addition to acute sinusitis. Excludes II notes allow you to report both conditions where documentation supports both conditions as present, and where the category does not include a code for acute on chronic.
Case 1: Patient presents for consultation on his recurrent frontal and maxillary sinusitis. He was referred to the ear, nose and throat physician’s office after presenting to his pediatrician’s office for the fifth time in a year with this problem:
J01.81 Other acute recurrent sinusitis
Rationale: This example shows that the sinusitis has had five episodes in the past year, which is considered to be recurrent. Also, based on the lookup of sinusitis in more than one location, J01.81 other sinusitis is used.
Case 2: Subjective: Janice is seen in the office for discomfort in the maxillary region. For the previous four to five years, the patient had suffered from chronic sinus problems of a similar type. Symptoms include constant nasal congestion, coughing and snoring. The patient is exposed to secondhand smoke from family members.
Objective: An initial exam showed edematous red nasal mucosa and colored nasal discharge. Allergy testing results were negative. A CT scan confirmed bilateral maxillary blockage and bilateral thickening of the mucus membrane.
Assessment: Chronic maxillary sinusitis, Secondary tobacco smoke exposure:
J32.0 Chronic maxillary sinusitis
Z77.22 Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)
Rationale: Because the patient is experiencing discomfort in the maxillary region, and chronic sinusitis for four to five years, this is considered to be chronic maxillary sinusitis. She is also exposed to secondhand smoke.
UNITED HEALTHCARE: United Healthcare has announced updates to its medical policy, drug policy, coverage determination and utilization review guidelines effective September 1, 2015. Physicians can view all United Healthcare medical policies in their entirety online by visiting the United Healthcare website at www.UnitedHealthcareOnline.com> 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.