Fingerprint-based Background Check for CMS Enrollment

Posted on August 20, 2014August 20, 2014 by kellyausiello

Fingerprint-based Background Check for CMS Enrollment Effective August 6, 2014.

The implementation of fingerprint-based background checks as part of enhanced enrollment screening provisions contained in Section 640 of the Affordable Care Act has begun.

Fingerprint-based background checks will now be required for all individuals with a 5 percent or greater ownership interest in a provider or supplier that falls into the high risk category and is currently enrolled in Medicare or has submitted an initial enrollment application. The fingerprint-based background check requirement will be conducted in phases. In the first phase, providers or suppliers will receive notification of the fingerprint requirements from their MAC and will have 30 days from the date of the letter to be fingerprinted.

If an initial enrollment application is received by the MAC and the provider or supplier is required to obtain a fingerprint-based background check, the MAC will not begin processing the application until the fingerprint-based background check has been completed and the results are received. The effective date of enrollment will be determined by the date the fingerprint results are received.

Chapter 15, Section 19.2.1 of the “Program Integrity Manual” (PIM) provides the list of the three screening categories, the provider types assigned to each category, a description of the applicable screening processes and the procedures to be used for each category.

CMS awarded the Fingerprint-based Background Check contract to Accurate Biometrics located in Chicago, Illinois on July 8, 2014. Individuals with questions should contact Accurate Biometrics prior to being fingerprinted to ensure the fingerprint results are accurately submitted to the Federal Bureau of Investigation (FBI) and properly returned to CMS.

Accurate Biometrics may be contacted by phone (866-361-9944) or by accessing their website

at www.cmsfingerprinting.com.

Potential High Risk Applicants(DMEPOS, HHA and those with adjusted assignment by CMS to High Risk due to previous problems) can now expect the following agency screening actions;

(1) Verifies that a provider or supplier meets all applicable Federal regulations and State requirements for the provider or supplier type prior to making an enrollment determination.

(2) Conducts license verifications, including licensure verifications across State lines for physicians or nonphysician practitioners and providers and suppliers that obtain or maintain Medicare billing privileges as a result of State licensure, including State licensure in States other than where the provider or supplier is enrolling.

(3) Conducts database checks on a pre- and post-enrollment basis to ensure that providers and suppliers continue to meet the enrollment criteria for their provider/supplier type.

(4) Conducts an on-site visit.

(5) Conducts a fingerprint-based criminal history record check of the Federal Bureau of Investigation’s Integrated Automated Fingerprint Identification System on all individuals who maintain a 5 percent or greater direct or indirect ownership interest in the provider or supplier.

Application Fees = Don’t forget to submit your “fees”.

All providers and suppliers must submit the current application fees when they are;

initially enrolling in Medicare,
adding a practice location, or
revalidating their enrollment information,

Physicians, non-physician practitioners, physician group practices and non-physician group practices are exempt from the application fees UNLESS they are enrolling as a DMEPOS supplier via the CMS-855S.

The fee for January 1, 2014, through December 31, 2014 is $542.00.

42CFR424.518 As of 8/20/2014

Title 42: Public Health
PART 424—CONDITIONS FOR MEDICARE PAYMENT
Subpart P—Requirements for Establishing and Maintaining Medicare Billing Privileges

§424.518 Screening levels for Medicare providers and suppliers.

A Medicare contractor is required to screen all initial applications, including applications for a new practice location, and any applications received in response to a revalidation request based on a CMS assessment of risk and assignment to a level of “limited,” “moderate,” or “high.”

(a) Limited categorical risk—

(1) Limited categorical risk: Provider and supplier categories. CMS has designated the following providers and suppliers as “limited” categorical risk:

(i) Physician or nonphysician practitioners (including nurse practitioners, CRNAs, occupational therapists, speech/language pathologists, and audiologists) and medical groups or clinics.

(ii) Ambulatory surgical centers.

(iii) Competitive Acquisition Program/Part B Vendors.

(iv) End-stage renal disease facilities.

(v) Federally qualified health centers.

(vi) Histocompatibility laboratories.

(vii) Hospitals, including critical access hospitals, Department of Veterans Affairs hospitals, and other federally owned hospital facilities.

(viii) Health programs operated by an Indian Health Program (as defined in section 4(12) of the Indian Health Care Improvement Act) or an urban Indian organization (as defined in section 4(29) of the Indian Health Care Improvement Act) that receives funding from the Indian Health Service pursuant to Title V of the Indian Health Care Improvement Act.

(ix) Mammography screening centers.

(x) Mass immunization roster billers

(xi) Organ procurement organizations.

(xii) Pharmacies newly enrolling or revalidating via the CMS-855B application.

(xiii) Radiation therapy centers.

(xiv) Religious non-medical health care institutions.

(xv) Rural health clinics.

(xvi) Skilled nursing facilities.

(2) Limited screening level: Screening requirements. When CMS designates a provider or supplier as a “limited” categorical level of risk, the Medicare contractor does all of the following:

(i) Verifies that a provider or supplier meets all applicable Federal regulations and State requirements for the provider or supplier type prior to making an enrollment determination.

(ii) Conducts license verifications, including licensure verifications across State lines for physicians or nonphysician practitioners and providers and suppliers that obtain or maintain Medicare billing privileges as a result of State licensure, including State licensure in States other than where the provider or supplier is enrolling.

(iii) Conducts database checks on a pre- and post-enrollment basis to ensure that providers and suppliers continue to meet the enrollment criteria for their provider/supplier type.

(b) Moderate categorical risk—

(1) Moderate categorical risk: Provider and supplier categories. CMS has designated the following providers and suppliers as “moderate” categorical risk:

(i) Ambulance service suppliers.

(ii) Community mental health centers.

(iii) Comprehensive outpatient rehabilitation facilities.

(iv) Hospice organizations.

(v) Independent clinical laboratories.

(vi) Independent diagnostic testing facilities.

(vii) Physical therapists enrolling as individuals or as group practices.

(viii) Portable x-ray suppliers.

(ix) Revalidating home health agencies.

(x) Revalidating DMEPOS suppliers.

(2) Moderate screening level: Screening requirements. When CMS designates a provider or supplier as a “moderate” categorical level of risk, the Medicare contractor does all of the following:

(i) Performs the “limited” screening requirements described in paragraph (a)(2) of this section.

(ii) Conducts an on-site visit.

(c) High categorical risk—

(1) High categorical risk: Provider and supplier categories. CMS has designated the following home health agencies and suppliers of DMEPOS as “high” categorical risk:

(i) Prospective (newly enrolling) home health agencies.

(ii) Prospective (newly enrolling) DMEPOS suppliers.

(2) High screening level: Screening requirements. When CMS designates a provider or supplier as a “high” categorical level of risk, the Medicare contractor does all of the following:

(i) Performs the “limited” and “moderate” screening requirements described in paragraphs (a)(2) and (b)(2) of this section.

(ii)(A) Requires the submission of a set of fingerprints for a national background check from all individuals who maintain a 5 percent or greater direct or indirect ownership interest in the provider or supplier; and

(B) Conducts a fingerprint-based criminal history record check of the Federal Bureau of Investigation’s Integrated Automated Fingerprint Identification System on all individuals who maintain a 5 percent or greater direct or indirect ownership interest in the provider or supplier.

(3) Adjustment in the categorical risk. CMS adjusts the screening level from “limited” or “moderate” to “high” if any of the following occur:

(i) CMS imposes a payment suspension on a provider or supplier at any time in the last 10 years.

(ii) The provider or supplier—

(A) Has been excluded from Medicare by the OIG; or

(B) Had billing privileges revoked by a Medicare contractor within the previous 10 years and is attempting to establish additional Medicare billing privileges by—

(1) Enrolling as a new provider or supplier; or

(2) Billing privileges for a new practice location;

(D) Has been excluded from any Federal health care program; or

(E) Has been subject to any final adverse action, as defined at §424.502, within the previous 10 years.

(iii) CMS lifts a temporary moratorium for a particular provider or supplier type and a provider or supplier that was prevented from enrolling based on the moratorium, applies for enrollment as a Medicare provider or supplier at any time within 6 months from the date the moratorium was lifted.

(d) Fingerprinting requirements.

An individual subject to the fingerprint-based criminal history record check requirement specified in paragraph (c)(2)(ii)(B) of this section—

(1) Must submit a set of fingerprints for a national background check.

(i) Upon submission of a Medicare enrollment application; or

(ii) Within 30 days of a Medicare contractor request.

(2) In the event the individual(s) required to submit fingerprints under paragraph (c)(2) of this section fail to submit such fingerprints in accordance with paragraph (d)(1) of this section, the provider or supplier will have its billing privileges—

(i) Denied under §424.530(a)(1); or

(ii) Revoked under §424.535(a)(1).

MEDICAID PCP PAY IN 2015?

Posted on August 1, 2014 by kellyausiello

One of the more positive sections in the Affordable Care Act gave a temporary pay hike to the paltry amount primary care physicians were paid by Medicaid for evaluations and vaccine administration. Under the law, Medicaid fees for primary care increased in 2013 and 2014 to the same amount paid under Medicare. The raise was in hope that higher rates might entice more physicians to accept Medicaid as millions of more people were added to the coverage roles under the law.

Only twenty-seven states and Washington, DC, are actually participating in Medicaid expansion. The rest have opted out under the 2012 Supreme Court on the ACA. The Medicaid raise however still applies in all states regardless of their status and has helped physicians expand their capabilities.

Medicaid is jointly funded by federal and state governments, with Federal dollars providing the lion’s share. The federal money that makes the higher rates possible however is set to run out at the end of this year and according to an article in Kaiser Health News, only 6 states — Alabama, Colorado, Iowa, Maryland, Mississippi, and New Mexico intend to spend their own money to maintain the PCP rate increases. With the exception of Alaska and North Dakota who supported the raise on their own even before 2013, the physician in the remaining 42 states will see payments revert to the pre-2013 levels.

A bill, called the Ensuring Access to Primary Care for Women & Children Act, has be introduced in the Senate that is similar to what the Obama administration proposed in the budget but that one carried a $5.4 billion dollar price tag without a “pay for” provision.

Both Kaiser Health and Medscape are covering the issue in pretty good detail but it looks unlikely that any action will get through Congress any time soon.

How do you think this will affect Primary Care in the US?

Chiropractic Maximum Visits under NOVITAS Part B MAC Mandate.

Posted on July 26, 2014 by kellyausiello

CMS MAC NOVITAS Published LCD L34816 for Arkansas, Louisiana, Mississippi, Colorado, Texas, Oklahoma, New Mexico and revised for the states of Pennsylvania, New Jersey, Maryland, Delaware and District of Columbia to update the reference to L27480 to L34816 to reflect a maximum of twelve (12) chiropractic manipulation treatments per calendar month and thirty (30) chiropractic manipulation treatments per calendar year.

This LCD imposes both diagnostic limitations and total service limitations to chiropractic care. This is the “first” such restrictions placed on Chiropractic care and to our knowledge, J10 MAC B (Alabama, Georgia, Tennessee) is the only other policy with annual service restriction

L32342 limits utilization to 25 visits per year without assignment to the groups. (This policy, as are many other carrier policies on Chiropractic are will be reviewed in 2014

LCD TitleChiropractic Services

Original Effective DateFor services performed on or after 07/24/2014

Utilization Guidelines

The following number of chiropractic manipulation services per beneficiary is considered reasonable and necessary if the medical record supports the service regardless of the nature of the visit (i.e., acute injury, acute exacerbation).

Twelve (12) chiropractic manipulation treatments per calendar month. And, Thirty (30) chiropractic manipulation treatments per calendar year.

This LCD imposes diagnosis limitations that support diagnosis to procedure code automatic denials. Coverage diagnoses are displayed in four groups in this policy as described in the indications and limitations section of this policy. If 30 visits are performed for group D, then this will also serve as the maximum number of visits for the year.

Local Coverage Article: Chiropractic Services (A47798)

Chiropractic services are subject to national regulation, which provides definitions, indications and limitations for Medicare payment of chiropractic service. Please see Medicare Benefit Manual sections referenced above for national definitions, indications and limitations.

Medicare expects that acute symptoms/signs due to subluxation or acute exacerbation/recurrence of symptoms/signs due to subluxation might be treated vigorously. Improvement in the patient’s symptoms is expected and in order for payment for chiropractic services to continue, should be demonstrated within a time frame consistent with the patient’s clinical presentation. Failure of the patient’s symptoms to improve accordingly or sustained worsening of symptoms should prompt referral of the patient for evaluation and/or treatment by an appropriate practitioner.

This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. Medicare will allow up to 12 chiropractic manipulations per calendar month and 30 chiropractic manipulation services per beneficiary per calendar year. Despite allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment, and Medicare does not expect that patients will routinely require the maximum allowable number of services. Additionally, Medicare requires the medical necessity for each service to be clearly demonstrated in the patient’s medical record.

Covered diagnoses are displayed in four groups in this policy, with the groups being displayed in ascending specificity. Medicare does not expect that substantially more than the following numbers of treatments will usually be required:

Twelve (12) chiropractic manipulation treatments for Group A diagnoses.
Eighteen (18) chiropractic manipulation treatments for Group B diagnoses.
Twenty-four (24) chiropractic manipulation treatments for Group C diagnoses.
Thirty (30) chiropractic manipulation treatments for Group D diagnoses.

As per the definitions supplied in LCD L34816, all treatments must be categorized as either acute subluxation, chronic subluxation or maintenance therapy. An exacerbation of a previous injury should be categorized into either “acute” or “chronic” (e.g., an identifiable re-injury would fall under acute).

Group 1 Codes

98940 Chiropract manj 1-2 regions
98941 Chiropract manj 3-4 regions
98942 Chiropractic manj 5 regions

Group 1 : The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 98940, 98941 and 98942:

Primary Diagnosis Codes (DrR=These are always your primary diagnoses)

Covered for: Group 1 Codes

739.0 NONALLOPATHIC LESIONS OF HEAD REGION NOT ELSEWHERE CLASSIFIED
739.1 NONALLOPATHIC LESIONS OF CERVICAL REGION NOT ELSEWHERE CLASSIFIED
739.2 NONALLOPATHIC LESIONS OF THORACIC REGION NOT ELSEWHERE CLASSIFIED
739.3 NONALLOPATHIC LESIONS OF LUMBAR REGION NOT ELSEWHERE CLASSIFIED
739.4 NONALLOPATHIC LESIONS OF SACRAL REGION NOT ELSEWHERE CLASSIFIED
739.5 NONALLOPATHIC LESIONS OF PELVIC REGION NOT ELSEWHERE CLASSIFIED

Group 2 Secondary Diagnosis Codes

Group A Diagnoses Covered for: (Twelve (12) chiropractic manipulation treatments)

Group 2 Codes

307.81 TENSION HEADACHE
719.48*PAIN IN JOINT INVOLVING OTHER SPECIFIED SITES
723.1 CERVICALGIA
724.1 PAIN IN THORACIC SPINE
724.2 LUMBAGO
724.5 BACKACHE UNSPECIFIED
724.8 OTHER SYMPTOMS REFERABLE TO BACK
728.85 SPASM OF MUSCLE
784.0 HEADACHE
When using 719.48, you must specify spine as the site.

Group 3 : Group B Diagnoses Covered for: Eighteen (18) chiropractic manipulation treatments
Group 3 Codes

720.1 SPINAL ENTHESOPATHY
721.0 CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY
721.1 CERVICAL SPONDYLOSIS WITH MYELOPATHY
721.2 THORACIC SPONDYLOSIS WITHOUT MYELOPATHY
721.6 ANKYLOSING VERTEBRAL HYPEROSTOSIS
721.90 SPONDYLOSIS OF UNSPECIFIED SITE WITHOUT MYELOPATHY
721.91 SPONDYLOSIS OF UNSPECIFIED SITE WITH MYELOPATHY
724.79 OTHER DISORDERS OF COCCYX
729.1 MYALGIA AND MYOSITIS UNSPECIFIED
729.4 FASCIITIS UNSPECIFIED
846.0 LUMBOSACRAL (JOINT) (LIGAMENT) SPRAIN
846.1 SACROILIAC (LIGAMENT) SPRAIN
846.2 SACROSPINATUS (LIGAMENT) SPRAIN
846.3 SACROTUBEROUS (LIGAMENT) SPRAIN
846.8 OTHER SPECIFIED SITES OF SACROILIAC REGION SPRAIN
847.0 NECK SPRAIN
847.1 THORACIC SPRAIN
847.2 LUMBAR SPRAIN
847.3 SPRAIN OF SACRUM
847.4 SPRAIN OF COCCYX

Group 4: Group C Diagnoses Covered for: Twenty-four (24) chiropractic manipulation treatments
Group 4 Codes

353.0 BRACHIAL PLEXUS LESIONS
353.1 LUMBOSACRAL PLEXUS LESIONS
353.2 CERVICAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED
353.3 THORACIC ROOT LESIONS NOT ELSEWHERE CLASSIFIED
353.4 LUMBOSACRAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED
353.8 OTHER NERVE ROOT AND PLEXUS DISORDERS
722.91 OTHER AND UNSPECIFIED DISC DISORDER OF CERVICAL REGION
722.92 OTHER AND UNSPECIFIED DISC DISORDER OF THORACIC REGION
722.93 OTHER AND UNSPECIFIED DISC DISORDER OF LUMBAR REGION
723.0 SPINAL STENOSIS IN CERVICAL REGION
723.2 CERVICOCRANIAL SYNDROME
723.3 CERVICOBRACHIAL SYNDROME (DIFFUSE)
723.4 BRACHIAL NEURITIS OR RADICULITIS NOS
723.5 TORTICOLLIS UNSPECIFIED

Group 5 : Group D Diagnoses Covered for: Thirty (30) chiropractic manipulation treatments

Group 5 Codes

721.3 LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY
721.41 SPONDYLOSIS WITH MYELOPATHY THORACIC REGION
721.42 SPONDYLOSIS WITH MYELOPATHY LUMBAR REGION
721.7 TRAUMATIC SPONDYLOPATHY
722.0 DISPLACEMENT OF CERVICAL INTERVERTEBRAL DISC WITHOUT MYELOPATHY
722.10 DISPLACEMENT OF LUMBAR INTERVERTEBRAL DISC WITHOUT MYELOPATHY
722.11 DISPLACEMENT OF THORACIC INTERVERTEBRAL DISC WITHOUT MYELOPATHY
722.4 DEGENERATION OF CERVICAL INTERVERTEBRAL DISC
722.51 DEGENERATION OF THORACIC OR THORACOLUMBAR INTERVERTEBRAL DISC
722.52 DEGENERATION OF LUMBAR OR LUMBOSACRAL INTERVERTEBRAL DISC
722.6 DEGENERATION OF INTERVERTEBRAL DISC SITE UNSPECIFIED
722.81 POSTLAMINECTOMY SYNDROME OF CERVICAL REGION
722.82 POSTLAMINECTOMY SYNDROME OF THORACIC REGION
722.83 POSTLAMINECTOMY SYNDROME OF LUMBAR REGION
724.01 SPINAL STENOSIS OF THORACIC REGION
724.02 SPINAL STENOSIS, LUMBAR REGION, WITHOUT NEUROGENIC CLAUDICATION
724.03 SPINAL STENOSIS, LUMBAR REGION, WITH NEUROGENIC CLAUDICATION
724.3 SCIATICA
724.4 THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS UNSPECIFIED
724.6 DISORDERS OF SACRUM
738.4 ACQUIRED SPONDYLOLISTHESIS
756.11 CONGENITAL SPONDYLOLYSIS LUMBOSACRAL REGION
756.12 SPONDYLOLISTHESIS CONGENITAL
839.01 CLOSED DISLOCATION FIRST CERVICAL VERTEBRA
839.02 CLOSED DISLOCATION SECOND CERVICAL VERTEBRA
839.03 CLOSED DISLOCATION THIRD CERVICAL VERTEBRA
839.04 CLOSED DISLOCATION FOURTH CERVICAL VERTEBRA
839.05 CLOSED DISLOCATION FIFTH CERVICAL VERTEBRA
839.06 CLOSED DISLOCATION SIXTH CERVICAL VERTEBRA
839.07 CLOSED DISLOCATION SEVENTH CERVICAL VERTEBRA
839.08 CLOSED DISLOCATION MULTIPLE CERVICAL VERTEBRAE
839.20 CLOSED DISLOCATION LUMBAR VERTEBRA
839.21 CLOSED DISLOCATION THORACIC VERTEBRA
839.41 CLOSED DISLOCATION COCCYX
839.42 CLOSED DISLOCATION SACRUM
953.0 INJURY TO CERVICAL NERVE ROOT
953.1 INJURY TO DORSAL NERVE ROOT
953.2 INJURY TO LUMBAR NERVE ROOT
953.3 INJURY TO SACRAL NERVE ROOT
953.4 INJURY TO BRACHIAL PLEXUS
953.5 INJURY TO LUMBOSACRAL PLEXUS
953.8 INJURY TO MULTIPLE SITES OF NERVE ROOTS AND SPINAL PLEXUS

Notify your billing people and managers that they will see the following denials on your RA/EOBs.

These are the Edits and suggested MSN and RA messages.

Do not pay for manual manipulation of the spine in treating conditions other than those indicated in Pub. 100-02, Benefits Policy Manual, Chapter 15, Section 240.1.3 and deny claims for treatment of any condition not reasonably related to a subluxation involving vertebrae at the spinal level specified. Use the MSN 15.4, “The information provided does not support the need for this service or item.” For the RA, use the Claim Adjustment Reason Code 50, “These are non-covered services because this is not deemed a ‘medical necessity’ by the payer.”

Edit to verify that the claim has the primary diagnosis of subluxation. Use the MSN 15.4, “The information provided does not support the need for this service or item.” For the RA, use the Claims Adjustment Reason Code B22, “This payment is adjusted based on the diagnosis.”

One other little thing ….. Initial Treatment Date on Chiropractic Claims

Novitas also reminds providers that according to the Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 220 all chiropractic claims must contain the date of initial treatment or date of exacerbation of the existing condition so consistent with Medicare guidelines, Novitas will require that all chiropractic claims contain the initial treatment date or the date of exacerbation of the existing condition effective for dates of service July 24, 2014 and after.

They will edit to verify that the date of the initial visit or the date of exacerbation of the existing condition is entered in Item 14 of Form CMS-1500. Use the MSN 9.2, “This item or service was denied because information required to make payment was missing.” For the RA, use the Claims Adjustment Reason Code 16, “Claim/service lacks information which is needed for adjudication.

Assistant Physicians? Pseudo-Docs for Rural Missouri.

Posted on July 18, 2014July 19, 2014 by kellyausiello

A turf war is likely as Missouri plans to allow medical school graduates who did not match into residency programs to practice as “assistant physicians” in rural, under-served areas. The law was signed by Governor Jay Nixon, and officially creates the new position of “assistant physician.” An assistant physician is defined as any medical school graduate who has passed the prescribed medical examinations and who has not entered into postgraduate residency training prescribed by rule of the State Board of Registration for the Healing Arts.

The new Missouri program, as I understand it, permits medical school graduates who have not completed “any” internship or residency training to practice in a rather loose association with a fully-licensed physician within a 50 mile radius of the assistant’s location after only 30 days of close supervision. After that, they could treat patients without direct supervision in settings 50 miles away and will be able to prescribe Schedule III, IV, and V drugs and restricts their practice to providing only primary care services and only in medically under-served rural or urban areas of the state or in any pilot project areas.

The Missouri State Medical Association reportedly is in favor of the proposal while the Missouri Academy of Family Physicians and the American Academy of Physician’s Assistants are opposed.

Missouri has roughly some 900 PAs in their State who provide health services under some of the most restrictive supervision rules in the nation and consistently are awarded an “F” by the “Pearson Report” (www.webnp.net) for its policies on NPPs.

Like this plan for “assistant physicians”, the NPP must practice on site with the supervising physician for a minimum of 30 days before being permitted to practice more independently within a 50 mile radius of the collaborating physician in a HPSA designated area with the requirement that the collaborating physician work on site with the NPP at least once every two weeks and review at least ten percent of the nurse practitioner’s charts overall, including at least twenty percent of charts in which the patient was prescribed controlled substances.

We are curious as to how “prescriptive authority” will be handled for the assistant physicians and if the State law that requires any patient evaluated and treated by an NP that does not have a “self-limited or well-defined condition” be reevaluated by a physician within two weeks will be observed.

Our Advisory Board has mixed feelings on the concept but as head of the compliance division, I can already see an avalanche of issues with Medicare, Medicaid and virtually all the major meds since, to my knowledge, NO State permits medical school graduates to practice or be licensed without a least one year of internship.

I am also a little concerned as to why these graduates would not have been accepted for a first year’s program. According to available statistics, there are more than enough first year openings for every U.S graduate and every year, we see residency openings for primary care specialties (family medicine, general internal medicine, and general pediatrics) go unfilled by our U.S. medical school graduates.

While I recognize the real shortage in rural and inner-city locations, I am not convinced this is a “practical” solution that would be embraced by the healthcare community especially with the resistance we have seen on direct contract privileges for experienced PAs and NPs.

I am inclined to recommend a more reasonable approach for NPP regulations where they can be used more effectively and perhaps get some State funded incentives for physicians to enter primary care and also some funding for wider availability of telemedicine with specialist.

What say You?

Injections under Guidance ?

Posted on June 7, 2014July 12, 2014 by kellyausiello

What’s Up With Guidance?

We have been monitoring carrier changes with respect to the use of “guidance” with various injection procedures. As we look at the 2014 PFS look-up tools we see that code 76942 (ultrasound guidance for needle placement) has taken a dramatic cut in reimbursement with the Medicare reimbursement for 2014 set around $70.00, down from around $200.00 in 2013.

This code has been a target of Medicare for quite a while having been deemed both over valued and over used by practitioners. The first step against the code was to assign it to those codes subject to the multiple procedure payment reduction list. This reduced the payment to practitioners to 100% of the first procedure and only 50% on subsequent procedures.

Next, Medicare and others declared “injection guidance” procedures were limited to one (1) per day regardless of the number of injection type procedures performed. Now, they have retained that position for now but reduced the value of the code.

There is no AMA CPT coding restriction to reporting CPT code 76942 (Ultrasonic guidance for needle placement [eg, biopsy, aspiration, injection, localization device], imaging supervision and interpretation) when ultrasound guidance is medically necessary to accurately place the needle for the injection. Carriers however, feel in most cases, imaging guidance to penetrate an easily palpable joint seems neither reasonable nor necessary.

CPT code 76942 has both professional and technical components, meaning that a separate radiology report (not part of the procedure note) is required to meet the code’s radiology requirements. The specific documentation requirements for ultrasound guidance include the following:

A final, written report should be issued for inclusion in the patient’s medical record.
Ultrasound guidance procedures also require permanently recorded images of the site to be localized, as well as a documented description of the localization process, either separately or within the report of the procedure for which the guidance is utilized.
Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final, written report, is not separately reportable.

Other carriers are mounting challenges based on the “performing provider” charging that “interpretation” of the imaging is outside the scope of NPPs.

Although reporting code 76942 with the joint injection code 20610 is permissible, many payers are denying this service as not medically necessary. For example, under the Florida First Coast Medicare local coverage determination (LCD) 29307, “Imaging procedures performed routinely for the purpose of visualization of the knee to provide guidance for needle placement will not be covered. Fluoroscopy may be medically necessary and allowed if documentation supports that the presentation of the patient’s affected knee on the day of the procedure makes needle insertion problematic. No other imaging modality for the purpose of needle guidance and placement will be covered.”

Other Medicare carriers, such as National Government Services, have initiated payment recovery for CPT code 76942 on the basis of lack of medical necessity as well as recouping amounts paid for multiple procedures when only one unit was payable. We have seen similar actions by other carriers.

On the flip side, code 77002 for fluoroscopic guidance has been increased from around $74 to $96 for this fee schedule BUT we now seeing various restricting tactics on these procedures by NPP’s as well.

Carriers such as NGS also challenged fluoroscopic guidance when performed by nonphysician practitioners. In specific NGS invoked “in compliance with State laws” as part of their recovery tactics. We joined others in challenging this since it is NOT true in all States within their jurisdiction.

When questioned they did post the “specifics” for J6 Part B for the States of Illinois, Minnesota and Wisconsin…….and we published their answers in our MedCorp Alert.

“We have finally received specific answers from NGS on covered nonphysician practitioner radiology services within the J6 Part B for the states of Illinois, Minnesota, and Wisconsin.

Which nonphysician practitioners may use fluoroscopy or ionizing radiation?

Certified Registered Nurse Anesthetist (Specialty 43) – NO in all three states.
Certified Nurse Midwife (Specialty 42 NO in all three states
Clinical Nurse Specialist (Specialty 89)- NO in all three states.
Nurse Practitioner (Specialty 50)- Illinois and Minnesota: NO
- Wisconsin: YES, according to Wisconsin Administrative Code § DHS 157.03 and 157.76
Physician Assistant (Specialty 97)- Illinois: NO
- Minnesota: YES, according to Minnesota Rules 2007, Chapter 4732
- Wisconsin: YES, according to Wisconsin Administrative Code § DHS 157.03 and 157.76

Which nonphysician practitioners may provide supervision of radiology procedures?

Supervision of others by NPPs is NOT permitted in Illinois, Minnesota, or Wisconsin or under Medicare.

Which nonphysician practitioners may bill for the technical component?

Certified Registered Nurse Anesthetist (Specialty 43) NO in all three states.
Certified Nurse Midwife (Specialty 42) NO in all three states.
Clinical Nurse Specialist (Specialty 89) NO in all three states.
Nurse Practitioner (Specialty 50)NO in Illinois and Minnesota.
o Wisconsin: YES, only if personally performed
Physician Assistant (Specialty 97) NO in Illinois
o Minnesota and Wisconsin: YES, only if personally performed.

Which nonphysician practitioners may bill for the professional component?

All three States permit the professional component by Certified Registered Nurse Anesthetist (Specialty 43); Certified Nurse Midwife (Specialty 42);Clinical Nurse Specialist (Specialty 89); Nurse Practitioner (Specialty 50) and PA (Specialty 97)

Which NPPs may bill for global if the technical component is personally performed?

Certified Registered Nurse Anesthetist (CRNA) (Specialty 43) NO in all three states.
Certified Nurse Midwife (Specialty 42) NO in all three states
Clinical Nurse Specialist (Specialty 89) NO in Illinois and Minnesota.
- Wisconsin: YES
Nurse Practitioner (Specialty 50); NO in Illinois and Minnesota:
- Wisconsin: YES
Physician Assistant (Specialty 97) NO in Illinois
- Minnesota and Wisconsin: YES

While we have some “permissions” in some instances, CMS still essentially prohibits NPP performance under their required physician supervision level for the technical component of Fluoroscopic guidance codes as being level “03” which requires procedure must be performed under the personal supervision of a physician.” This applies to

77001-TC Fluoroguide for vein device;
77002-TC Needle localization by xray –
77003-TC Fluoroguide for spine inject

and would naturally extend to the procedures such as the 6449x facet joint injections that “require” either Fluroscopic or CT guidance.

To “double check” the “actual enforcement” of these levels, I contacted the specific contacts in CMS for these issues. Our exchange is below….

Dear Mr. Chan:

I am writing in regards to the reclassification of CPT codes 77001-77003 technical component of fluoroscopic guidance to “3” requiring personal supervision of the physician. This would appear to again preclude the use of NP/PA “personal performance” and/or the use of certified radiology technicians who have previously been permitted to operate the C-Arms under the general supervision of the physician.

Can you please provide us with the “specifics” on the fluoroscopic guidance procedures (who can and who can’t perform) so we can provide the proper guidance to our members as they call us with these questions. We are already getting quite a few calls based on the various June 2014 Medicare Advisory publication which is considerably lacking in details on this matter.

Dear Dr. Ramsdell,

Thank you for your email and your voice message concerning the technical component for CPT codes 77001 – 77003. In our April 2014 update to the Physician Fee Schedule, we corrected an inadvertent technical error to the files as displayed for January 1, 2014. In the January files, a “09” code (“Concept does not apply”) was inadvertently entered into the Physician Supervision of Diagnostic Procedures indicator for CPT codes 77001 – 77003. Previously the indicator for these codes was “03” (“Procedure must be performed under the personal supervision of a Physician”). The April update corrected the data file to reflect the established policies. Please see section 100.1.5, from Chapter 12 of the internet only claims manual (available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/internet_only_manuals.pdf), and 42 CFR 410.32(b)(1) for specific guidance regarding physician supervision.

I hope this clarifies any confusion.

Larry Chan

[RLR]Thank you for your reply. So if I am interpreting this correctly, the “physician” must be in the room when either a mid-level or a rad-tech operates the fluoroscope for guidance of the injection? This is the question we keep getting hit with and keep trying to get the specific yes or no on. We understand that the mid-level can not supervise the rad-tech.

{LC} You are correct. The supervision for the TC of these CPT code is “03” (“Procedure must be performed under the personal supervision of a Physician”). The Physician is to be present in the room with the tech.

These positions make it virtually impossible for a mid-level to perform injections that require guidance including those procedures where “fluoroscopic / CT guidance” is required and if the physician is required to be in the room, the economics would appear to be logically for him/her to perform the injection procedure in its entirety.

We would like your comments on this AND your assistance by writing or contacting HHS/CMS and your local Medical Association.

Electo-acupuncture to break up trigger points

Posted on June 5, 2014July 12, 2014 by kellyausiello

Our doctor uses electo-acupuncture to break up trigger points. Can I bill this under the TPI code 20552-20553 to Medicare or others.

NO. Acupuncture is not a covered service for Medicare, even if provided for the treatment of an established trigger point. Use of acupuncture needles and/or the passage of electrical current through these needles is not covered regardless of who is doing it. For your major medical carriers, acupuncture with electrical stimulation is a stand-alone service billed under 97813-97814 based on the “time component” of 15 minute increments. The actual “focus” of the procedure does NOT affect the billing code.

P-Stim Coding Discussion

Posted on June 5, 2014July 12, 2014 by kellyausiello

Coding Alert for P-Stim™ AGAIN!

Writing for the Academy: R.L. Ramsdell PhD, FACFEI, CFC, DABFE, LFMAAMA. Executive Director.

March 21, 2014

We are once again receiving coding questions and issues regarding the P-Stim™.

We originally published a special alert for this product on September 15, 2013 when members reported the sales representatives were recommending CPT 64553 “implant” code for the procedure and a billing of L8680 for the electrodes.

In our original alert to our members, we stated;

The Academy has received many recent inquires on the proper coding for electrical stimulation of auricular acupuncture points using the P-Stim™ device. Various coding scenarios were submitted from concerned members, including “stealth” coding using implant codes, as offered by some sales representatives as well as their claims of “coverage” by “Medicare and Most Major Medical Plans”.

Our investigations have shown these claims for the most part, are false and may be designed to create an unrealistic anticipation of payment and/or offer various “stealth coding” scenarios that could qualify the procedure for payment based solely on submission of inaccurate codes BUT would put the practitioner “at significant risk” for allegations of fraud or abuse on audit.

According to recent member reports, the sales people have now “altered” their coding suggestion to use CPT implant code 64555 for the procedure and E1399 for the electrodes.

First, let’s look at the FDA approval for the unit. You can view it for yourself at: http://www.accessdata.fda.gov/cdrh_docs/pdf5/K050123.pdf

Trade or Proprietary Name: P-Stim
Common Name: Electro-acupuncture device
Classification Name: Electro-acupuncture stimulator
Classification: Unclassified

Predicate Device: The legally marketed predicate device to which the P-Stim is substantially equivalent is the Acu-Stim (KO14273).

Intended Use:The P-Stim is intended for use as an electro-acupuncture device to stimulate appropriate auricular acupuncture points.

Device Description: The P-Stim is a miniaturized, battery-powered, transcutaneous electrical nerve stimulator that has a pre-programmed frequency, pulse, and duration for the stimulation of auricular acupuncture points.

The device connectsvia three stainless steel wires to acupuncture needles that have been applied to the appropriate auricular acupuncture points. The device is powered by three zinc air batteries, each with a voltage of 1.4 V. The device is on for 180 minutes, then off for 180 minutes, for a maximum period of up to 96 hours.

Based on the unit’s approval and accepted indications, we must again stress the most “basic instructions” on code selection contained in the CPT manual that prohibits misrepresentation through “stealth” coding.

Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code.

Medicare entertained a request from P-Stim in their May 29, 2013 HCPCS Meeting. Agenda item #6 Stated; Topic/Issue:Request to establish a new Level II HCPCS code to identify a miniaturized device designed to administer auricular point stimulation treatment over several days. Trade name: PSTIM. Applicant’s suggested language: “P-STIM: percutaneous auricular neurostimulator with 3 needles; used for before and after measurements of sympathovagal balance”. According to the requester, the P-STIM is a miniaturized device designed to administer auricular point stimulation treatment over several days. Point stimulation by the P-STIM is mainly used to treat pain. The P-STIM is a wearable device this is designed to administer continuous pulses of a low-level electrical current at the ear over several days. Electrical pulses are emitted though three selectively positioned acupunctures needles. The P-STIM is worn for four days on and three days off and is removed by the patient on the fourth day. The average patient usually requires 1-12 weeks of treatment. According to the requester, the patient population for which the device is clinically indicated is patients who suffer from diagnosis as: migraine, chronic pain (lower back or otherwise), shingles, fibromyalgia, refractory neuropathy, central sensitization disorders and PTSD. The decision was; A national program operating need was NOT identified by Medicare, Medicaid, or the private insurance sector to establish a code to identify this device. Based preliminary benefit category analysis, we believe that there would be NO Medicare payment for these items.

Major Medical Coverage:

Non-coverage of the services may be found in their Acupuncture policies, complementary and alternative medicine or, if specifically addressed, like with the “Blues”, in a policy for “CRANIAL ELECTROTHERAPY STIMULATION (CES) AND AURICULAR ELECTROSTIMULATION”. Others, like Health Net, for example, just include the service under their non-payable “investigational procedures” listing.

Opinion on the use of CPT implant code 64555 for the procedure and E1399 for the electrodes.

In reviewing the literature and rationale from the company, we see that they are making a “leap” to now declare the unit to be a “percutaneous electronic nerve stimulator” (PENS) and applicable to the coverage provisions and coding applicable to those units INCLUDING the implant procedure code 64555 Percutaneous implantation of neurostimulator electrodes; peripheral nerve.

We must again take exception with the rationale, based both on the coding and on the “off label” use that exceeds the FDA approval of the unit as an electro-acupuncture device to stimulate appropriate auricular acupuncture points.

We must also take exception that the electrodes are “implanted” when the FDA 510(k) approval specifically states “The P-Stim™ device connects to 3 inserted acupuncture needles with caps and wires.”

Typically carriers interpret “implant” as being a surgical procedure way beyond an “insertion” of needles.

Last, we must object to assuming that the implant is to the “nerve(s)” since the approval also specifies that the use of the “stylus” is to identify the appropriate auricular acupuncture points.

Academy Conclusion On Proper Coding: Based on the available evidence, the Academy finds that the representative claims that “P-stim is reimbursed by Medicare and Most Major Medical Plans” and should be billed under the 64555 code are inaccurate.

The Academy therefore suggests the following as “applicable” to the P-Stim™

CPT:

97813 Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
97814 Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure)

HCPCS: Is the Most specific.

S8930 Electrical stimulation of auricular acupuncture points; each 15 minutes of personal one-on-one contact with the patient.
- (Developed and became effective April 1, 2012.)

There is no specific supply code for the unit(s) and therefore you would use E1399 with a description of “P-Stim electro-acupuncture device”.

In our opinion, billing for application of the unit under 64555 is NOT appropriate and such reporting should be restricted to 64999 with an accurate description of the procedure to avoid any misrepresentation to the carrier. We remind everyone that the fact you billed using an approximate fit code which was paid, does NOT mean you billed it correctly. For example, Medicare will pay the codes you billed because they are valid codes and they are assuming those are the procedures you performed. Your PAIN will come with audit when your notes do NOT support a surgical implant.

We also feel proper billing for the supplies (unit kits) should be reported under the E1399 NOS supply code or CPT general supply code 99070, with an accurate description of “electro-acupuncture device” including the unit name. Most carriers will expect you to submit an invoice with the claim.

We feel any other coding scenarios would be a misrepresentation of the service performed, subject to recovery upon carrier audit and possible allegations of fraud or abuse.

Again, our opinion here is on the “Coding” ONLY and not the quality or efficacy of the actual equipment, technology or potential therapeutic benefit to the patient.

Members should consider the potential benefit to the patient within the reality of a “non-covered service” and provide the patient with applicable notice of personal liability.

Prepayment Audits of E&M 99205 / 99215 start in June.

Posted on June 3, 2014July 12, 2014 by kellyausiello

CMS look National CERT data showed projected rises in improper payments for outpatient E&M services for 2013 with CPT codes 99205 and 99215 being in the top 15 codes identified for improper payment. Previous review of high level outpatient E&M services resulted in high error rates because services were frequently billed at a higher level than could be supported for medical necessity by the medical record.

Audit Results: The overall percentage of services recoded or denied for CPT 99205 was 78.66%. The overall percentage of services recoded or denied for CPT 99215 was 78.50%. The key reasons services were denied are as follows:

Failure to respond to the request for documentation
Documentation was missing a provider signature
Insufficient or missing documentation
The medical record did not support the coverage requirements forservices of nonphysician personnel furnished incident to physician’s services billing
Documentation did not support a separately identifiable E&M service performed in addition to procedure billed for the same date of service (inappropriate use of modifier 25)

The key reasons services were recoded to a lower level E&M service are as follows:

The medical record failed to support the medical necessity of the highest level of outpatient E&M service
For new patient E&M service CPT 99205, all 3 key components (comprehensive history, comprehensive examination, and high complexity medical decision making) were not supported at the level billed
The provider selected the level of E&M using time as the controlling factor, but the medical record failed to differentiate physician time devoted to face-to-face counseling with the beneficiary from the time dedicated to history and physical examination; or the record failed to provide sufficient detail about the coordination of care or counseling provided to justify the level of E&M billed

The majority of the services billed as CPT 99205 were recoded one or two levels, and the majority of the services for CPT 99215 were recoded one level. Based on the results of this widespread audit, prepayment review of CPT 99205 and CPT 99215 will resume for Part B claims in Illinois, Minnesota and Wisconsin beginning June 2014.

CMS Supervision Rules

Posted on June 3, 2014July 12, 2014 by kellyausiello

You should always insure that your written policies identify the level of supervision required in the Medicare fee schedule for specific tests AND your State regulations on performance so you are consistently in compliance. While Medicare may permit a service under “general supervision” of a physician, your State regulations may require specific certifications to operate the testing equipment. We see this frequently with the technical components for radiation regulations and neuro testing procedures.
That being said, general Medicare regulations require all diagnostic x-ray and other diagnostic tests to be furnished under at least a general level of physician supervision with some tests more restricted and require either direct or personal supervision.

General supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually perform the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician. (Supervision Indicator 1)

Direct supervision in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed. (Supervision Indicator 2)

Personal supervision means a physician must be in attendance in the room during the performance of the procedure. (Supervision Indicator 3)
Indicators

1 Procedure must be performed under the general supervision of a physician.
2 Procedure must be performed under the direct supervision of a physician.
3 Procedure must be performed under the personal supervision of a physician.
6 Procedure must be performed by a physician or by a physical therapist (PT) who is certified by the American Board of Physical Therapy Specialties (ABPTS) as a qualified electrophysiologic clinical specialist and is permitted to provide the procedure under State law.
6a Supervision standards for level 66 apply; in addition, the PT with ABPTS certification may supervise another PT but only the PT with ABPTS certification may bill.
7a Supervision standards for level 77 apply; in addition, the PT with ABPTS certification may supervise another PT but only the PT with ABPTS certification may bill.
9 Concept does not apply.
21 Procedure must be performed by a technician with certification under general supervision of a physician; otherwise must be performed under direct supervision of a physician.
22 Procedure may be performed by a technician with on-line real-time contact with physician.
66 Procedure must be performed by a physician or by a PT with ABPTS certification and certification in this specific procedure.
77 Procedure must be performed by a PT with ABPTS certification or by a PT without certification under direct supervision of a physician, or by a technician with certification under general supervision of a physician.

CPT-HCPCS Hyaluronan Coding

Posted on June 1, 2014July 12, 2014 by kellyausiello

This article becomes effective on and is being used by MA plans as well at this time.

The following directions are provided for billing the drug codes for Hyalgan products.

HCPCS code J7322 has been deleted and replaced with HCPCS code J7325 (hyaluronan or derivative, Synvisc or Synvisc-ONE for intra-articular injection, 1 mg) effective for dates of service on or after 01/01/2010.
If an aspiration and an injection procedure are performed at the same session, bill only one unit for CPT code 20610.
The appropriate site modifier (RT or LT) must be appended to CPT code 20610 to indicate if the service was performed unilaterally and modifier (50) must be appended to indicate if the service was performed bilaterally.
The appropriate site modifier (RT or LT) must be appended to the drug code to indicate if the service was performed unilaterally or bilaterally. The drug must be reported on a separate claim line for each knee or shoulder treated using the appropriate site modifier, RT or LT. Claims without a modifier will be returned to the provider unprocessed.
Use “EJ” modifier on drug codes to indicate subsequent injections of a series. Do not use this modifier for the first injection of each series. A series is defined as the set of injections for each joint and each treatment. Injection of the left knee or shoulder is a separate series from injection of the right knee or shoulder.