Wednesday, March 19, 2014

Health Insurance Exchange Confusion Hinders Patient Sign Ups

HHS Secretary Kathleen Sebelius testified before the House Ways and Means Committee on March 12 that there will be no more tweaking in the of the individual mandates under the Affordable Care Act (ACA).  This after the White House announced the extension of exemptions on the basis of hardship.

A list of those hardships, reported by the Wall Street Journal, includes more than a dozen ways that Americans could qualify, including homelessness, having utilities shut off, and having a very low income in a state that did not expand its Medicaid program. Sebelius also refused to say whether the White House goal of signing up 7 million people will be met by the March 31 deadline, when open enrollment ends. Thus, the deadline for open enrollment will not be extended, according to Sebelius, despite lack of any clear data on the number of people who have both signed up and actually paid their premium. Individuals without coverage by the deadline will face a penalty at tax time, which will likely be deducted from any anticipated tax refund next year. Any way you look at it, the hope of the White House that individuals will actually buy into the private purchase of health plans seems largely misplaced.  A great deal of the problem lies in the confusing array of plans that can be purchased through the exchanges. First, a purchaser must figure out what is being offered. Often termed “metal” plans: bronze, silver, gold and platinum, one would seemingly need to possess an advanced college degree simply to understand the choices.  The lower-premium plans, are the “bronze" plans, which carry higher initial copayment responsibilities.  This may at first seem attractive to a lower wage earner.  However, such a plan would actually benefit a higher-income individual, who could afford the 40 percent copayment.  The platinum plan, which costs more in premiums but carries a 10 percent initial copayment, would seem to be better suited to a person who lacks resources to pay nearly half of his initial healthcare expense from his own savings.  Recognizing the problem faced by lower wage earners, there are three alternative silver plans for lower income earners, which the website Obamacare 411 explains as follows:  “These three alternative health insurance plan options are only available for people that have the lower incomes.  The three health insurance plans have lower out-of-pocket expenses for people that are enrolled in the health insurance plan.  Basically, what this all means is that even though you are buying a silver tier plan; you are actually being given a better health insurance plan.
  • 100 percent to150 percent of the federal poverty level (FPL) = 94 percent AV, better than average platinum plan
  • 150 percent to 200 percent of FPL = 87 percent AV, better than average gold plan
  • 200 percent to 250 percent of FPL = 73 percent AV, better than average silver plan
If you have difficulty following this, you see my point.  One thing people do universally seem to understand:  “What is this going to cost me?”  The answer should open more than a few eyes: All plans cap out of pocket expenses at about $6,350 for an individual, and $12,700 for a family in 2014. This means for an individual in good health, who must pay for coverage without a subsidy, the annual out of pocket expense could be well over $14,000, even with the least expensive plan.  The next question on a consumer’s mind will likely be: “What happens if I just give up and hope I don’t get sick?”  Naturally, without insurance the same individual would be liable for the entire cost of any unexpected care. But Americans have proven more than willing to accept this risk.  If a person does not choose to comply with the individual mandate before the March 31 deadline, he will face a tax bill of between $95 and $285, if I understand the rules and exemptions correctly. Finally, the largest problem facing the White House is the Republican message: “Vote against Democrats, and this all goes away.” It doesn’t, but explaining that, would be complicated.

Article  By Martin Merritt from Physicians Practice

Medical Practices Struggle to Collect Payments Due to New Payer Tactics

Over the past month or so, we've seen so many side effects from insurance companies both opting in to provide insurance through the health insurance exchanges and opting out.  Those that opted in are losing a lot of money right now due to the low number of enrollees.  Those that opted out are also losing a lot of money because they lost several of their clients when they dropped them from enrollment. 

Here's how those side effects are trickling down to medical practices: 1. Insurance companies that typically paid you within 15 days to 20 days are now holding onto that money and making more money in interest on it, leaving your cash flow suffering.  I'm also finding that they you are not paying until you call asking where that money is. 2. Insurance companies are dropping claims stating, “We never received those dates” when the two dates before and the two dates after, all within the same batch, have been paid.  This is resulting in your billing department having to follow up on all claims older than 30 days. 3. Insurance companies are creating narrow networks and patients are having difficulty finding in-network providers.  This means that many of your patients may have to pay out of network rates.  They not only have high deductibles, they also have high premiums. 4. Insurance companies are hiring outsourced auditors to review every single claim they have paid you.  If they find one error, they're coming after that money.  I once had to write a refund check for 4 cents.  Yes, 4 cents.  This can be devastating to your bank account. Essentially, these changes mean that your practice will be more and more strapped for basic cash flow.  Payroll, expenses, administrative time chasing this money down, are all a drain to your business.   Your businesses accounts receivable should be considered an asset until it starts costing your more to obtain that money than you are paid for that claim.  Here are some tips you can implement right now to help you get through this new “norm.” 1. Be sure your billing staff is calling on claims older than 30 days to 45 days if you are typically paid sooner. 2. Your billing department should have access to your clearinghouse website and be able to prove that all claims were sent on time. 3. Start keeping a list of alpha-prefixes or some type of identifier that shows it's a newer plan and you are perhaps not in network. When calling and verifying, do not assume you are in network.  Ask the rep: “Are we in network with this plan?” and if you are not, ask for out of network benefits.  I'm also seeing that many specialties are not a plan benefit, so even if you are in network, your specialty may not be covered.  In this case, you will need to turn the patient into a cash paying patient. 
Keep your eye on your accounts receivable and your bank account.  It is imperative that you own this area of your business in this volatile insurance fiasco.

Article By  from Physicians Practice

DMEPOS Fee Schedule - 2014 April Update Medicare/Noridian

DMEPOS Fee Schedule - 2014 April Update

MLN Matters® Number: MM8645
Related Change Request (CR) #: CR 8645
Related CR Release Date: March 11, 2014
Effective Date: April 1, 2014
Related CR Transmittal #: R2902CP
Implementation: April 7, 2014

Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Part A/B Medicare Administrative Contractors (MACs), Hospice and Home Health (HHHMACs), and Durable Medical Equipment MACs (DME MACs) for DMEPOS items or services paid under the DMEPOS fee schedule.

Provider Action Needed 
The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 8645 that alerts providers and suppliers that CMS issued instructions updating the DMEPOS fee schedule payment amounts. Be sure your billing personnel are aware of these changes.

CMS updates DMEPOS fee schedules on a quarterly basis, when necessary, in order to implement fee schedule amounts for new and existing codes, as applicable, and apply changes in payment policies. The quarterly update process for the DMEPOS fee schedule is located in the "Medicare Claims Processing Manual", Chapter 23, Section 60, which is available at This link will take you to an external website. on the CMS website.

Key Points of CR8645

Splints, Casts and Certain Intraocular Lenses (IOLs) 
The following are the HCPCS codes for splints, casts, and certain IOLs added to the DMEPOS fee schedule file:
  • A4565, Q4001, Q4002, Q4003, Q4004, Q4005, Q4006, Q4007, Q4008, Q4009, Q4010, Q4011, Q4012, Q4013, Q4014, Q4015, Q4016, Q4017, Q4018, Q4019, Q4020, Q4021, Q4022, Q4023, Q4024, Q4025, Q4026, Q4027, Q4028, Q4029, Q4030, Q4031, Q4032, Q4033, Q4034, Q4035, Q4036, Q4037, Q4038, Q4039, Q4040, Q4041, Q4042, Q4043, Q4044, Q4045, Q4046, Q4047, Q4048, Q4049, V2630, V2631, V2632.
As written in the MLN Matters® Article MM8523 (Change to the Reasonable Charge Update for 2014 for Splints, Casts, and Certain Intraocular Lenses) at This link will take you to an external website., for dates of service on or after April 1, 2014, payment for splints, casts and IOLs inserted in a physician's office will be made using national fee schedule amounts.
For splints and casts, codes A4565 and Q4001-Q4049 are used when supplies are indicated for cast and splint purposes and:
  • Payment is in addition to the payment made under the physician fee schedule for the procedure for applying the splint or cast. Per the regulations at 42 CFR Section 414.106, national fee schedule amounts for 2014 for these items were developed using 2013 reasonable charges updated by the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June 2013, which is 1.8 percent; and 
  • For each year subsequent to 2014, the fee schedule amounts will be updated by the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June of the preceding year, reduced by the productivity adjustment as described in Section 1886(b)(3)(B)(xi)(II) of the Social Security Act.
For intraocular lenses (codes V2630, V2631 and V2632), payment under the DMEPOS fee schedule is only made for lenses implanted in a physician's office:
  • For payment of IOLs inserted in a physician's office furnished from April 1, 2014, through December 31, 2014, regulations at 42 CFR Section 414.108 require national fee schedules be established based on the Calendar Year (CY) 2012 national average allowed charges updated by the percentage increase in the consumer price index for all urban consumers (United States city average) for the 24-month period ending with June 2013, which is 3.5 percent;
  • For each year subsequent to 2014, the fee schedule amounts will be updated by the percentage increase in the consumer price index for all urban consumers (United States city average) for the 12-month period ending with June of the preceding year, adjusted by the productivity adjustment as described in Section 1886(b)(3)(B)(xi)(II) of the Act; and 
  • For IOL codes V2630 and V2631, national fee schedules amounts have been established using the fee schedule amounts for comparable code V2632 since there is insufficient allowed charge data for use in calculating the fee schedule amounts.
Subject to coinsurance and deductible rules, Medicare payment for these items is to be equal to the lower of the actual charge for the item or the amount determined under the applicable fee schedule payment methodology.
Payment Category Reclassification of Certain DME  
Effective for dates of service on or after April 1, 2014, certain HCPCS codes for DME are reclassified from the payment category for inexpensive or other routinely purchased DME to the payment category for capped rental items, to align with the regulatory definition of routinely purchased equipment found at 42 CFR Section 414.220(a)(2).
These changes were determined through rulemaking (CMS-1526-F) and as written in the MLN Matters® Article MM8566 titled Rescind/Replace Reclassification of Certain Durable Medical Equipment from the Inexpensive and Routinely Purchased Payment Category to the Capped Rental Payment Category, available at MLN/MLNMattersArticles/Downloads/MM8566.pdf This link will take you to an external website. on the CMS website.
As part of the April 2014 update to the DMEPOS fee schedule, the methodology used to calculate fee schedule amounts for capped rental items has been used to establish new fee schedule amounts for the following HCPCS codes:
  • A4639, A7025, E0117, E0144, E0198, E0300, E0620, E0656, E0657, E0740, E0762, E0764, E0849, E0855, E0856, E0984, E0986, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1010, E1014, E1029, E1030, E1161, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1700, E2227, E2310, E2311, E2312, E2313, E2321, E2322, E2325, E2326, E2327, E2328, E2329, E2330, E2351, E2373, E2374, E2376, E2377, E2378, E2500, E2502, E2504, E2506, E2508, E2510, K0607, K0730.
Consistent with the capped rental payment methodology, only Rental Amounts (RR) will appear on the fee schedule file for the above codes, effective April 1, 2014, and:
  • The HCPCS codes transitioning to the capped rental payment category with corresponding KC, KF or KE modifiers will continue to have rental amounts associated with these modifiers on the fee schedule file;
  • The capped rental fee schedule amount is calculated based on ten percent of the base year purchase price increased by the covered item update; 
  • This is the fee schedule amount for rental months one through three. Beginning with the fourth month, the fee schedule amount is equal to 75 percent of the fee schedule amount paid in each of the first three rental months; and
  • All of the payment rules for capped rental items, including guidelines regarding continuous use and transfer of title to the beneficiary following 13 months of continuous use, apply to these codes, effective for claims with dates of service on or after April 1, 2014.
Also effective April 1, 2014, MACs will process and pay claims for capped rental wheelchair accessories on a lump sum purchase basis when used with complex rehabilitative power wheelchairs (wheelchair base codes K0835 – K0864). In this case, the supplier must give the beneficiary the option of purchasing these accessories at the time they are furnished. The purchase fee schedule amount for capped rental accessories furnished in this manner is equal to the rental fee (for months one through three) multiplied by ten. If the beneficiary declines the purchase option, the supplier must furnish the accessory on a rental basis and payment will be made in accordance with the capped rental payment rules.
Specific Coding and Pricing Issues
As part of this update, effective April 1, 2014, HCPCS code L8680 is not included on the 2014 DMEPOS fee schedule file and the coverage indicator is revised to "I" to show it is not payable by Medicare. Note that:
  • For neurostimulator devices, HCPCS code L8680 is no longer separately billable for Medicare because payment for electrodes has been incorporated in CPT code 63650 Percutaneous implantation of neurostimulator electrode array, epidural. 
  • CMS established non-facility practice expense inputs for CPT code 63650 in the Medicare Physician Fee Schedule Final Rule (published November 27, 2013). As a result, practitioners should not report electrode(s) using code L8680 in conjunction with a lead implantation procedure furnished in any setting for Medicare.  
  • Also, this change for code L8680 will be available on the HCPCS Quarterly Update website at This link will take you to an external website. on the CMS website.
Additional Information
The official instruction, CR8645, issued to your MAC regarding this change is available at This link will take you to an external website. on the CMS website.
Last Updated Mar 14, 2014

Vitamin B 12 Injection LCD Retirement - Effective March 7, 2014 Medicare/Noridian

Vitamin B 12 Injection LCD Retirement - Effective March 7, 2014

The following Local Coverage Determination (LCD) has been revised under contractor numbers 01111 (California), 01211 (Hawaii and Territories), 01311 (Nevada), 01911 (Former NO-CA, HI and Territories).

Medicare Coverage Database (MCD) Number/Contractor Determination Number: L33502
Policy Name: Vitamin B 12 Injection
Effective Date: 03/07/2014

NOTE: LCDs are retired due to lack of evidence of current need(s) for the education and/or edits or in some cases because the material is addressed by a National Coverage Determination (NCD), a coverage provision in a CMS interpretative manual, another LCD or an article.  Retirement does not mean that medical necessity has changed or that the LCD no longer reflects appropriate criteria. The guidance in the retired LCD may be helpful in assessing medical necessity.
To access the Noridian Retired LCDs from our website, follow the instructions below.
  • Go to
    • The End User Agreement for Providers will appear if you have not recently visited the website. Select "Accept" (if necessary).
  • Select the state/contract of interest. This link will redirect you to the state specific listing of retired LCDs on the CMS MCD.
Last Updated Mar 14, 2014

Wednesday, March 12, 2014

The Disturbing Confessions of a Medical Scribe
 Article Courtesy of

The disturbing confessions of a medical scribe

As a medical scribe working with a large, well-known scribe company, unnamed to protect my job, it makes me proud reading all the articles published about how much having a scribe benefits a physician, especially in the emergency department. I enjoy my job immensely and I am grateful for the opportunity to learn and engage in patient care. However, as a pre-medical student working next to several other doctor-hopefuls in a high stress environment, being a scribe frustrates me on an ethical level.
Let’s examine the structure and reasoning that has made medical scribe programs so successful. When EMR systems were first introduced, there was resistance, but it gave way to the push for efficiency. The biggest benefit of EMRs is easy: risk management. By allowing for documentation of every little part of a patient’s care, EMRs significantly decrease the risk of mistakes slipping through the cracks. It allows for better defense of the physician’s medical decisions, even months down the line.
For example, a physician I worked with was asked to go to court for a patient who had been assaulted by her boyfriend. The patient had been seen several months ago in the ED. Few physicians would be able to remember all the details of an encounter so long ago. His testimony was therefore entirely based on the medical chart, written by me and approved by him. The EMR allowed for comprehensive, detailed documentation of test results, discussions with the patient, and interactions with the police.
Unfortunately, such comprehensive medical records take time and effort to write. Physicians complain that they were becoming little more than data entry specialists, dedicating large portions of the time they should be spending with patients to clicking buttons. In comes the scribe. Usually students or recent graduates interested in becoming a medical provider, we become the physician’s right hand. Scribes are purported to decrease physician burnout considerably and increase ED efficiency. Better documentation also leads to better billing, so hospitals make more money. The physicians I work with, in a hospital who has been using scribes for over 3 years now, have all been grateful for the program.
Sounds great, right? The winning combination of EMRs and scribes. The road to increased efficiency, increased Press-Ganey scores, increased billing accuracy, increased fraud, increased profits for the administration. Happiness abounds.
How many of you missed the “increased fraud”?
Medical billing is based off charting and documentation, and that can have different levels. Level 5 charts are billed the most, when the provider offers the higher level of care. Ideally, EMRs make documentation more accurate, allowing for more level 5 charts for medical coding and billing. But when all it takes is a few buttons to increase your billing, how many physicians submit to small temptations and conveniences?
In Epic’s CareConnect, a widely used EMR, there is a small button that, when pushed, indicates the physician has counseled the patient to stop smoking. It adds a small amount ($20-30) to the billing, and the physician makes a little more.
I’ve been told by physicians, “If the patient is an active smoker, just click that button about the counseling.” Most of the time, the patient is counseled. Sometimes though, they aren’t. But if that button isn’t pressed, eventually, it comes back onto me.
“I told you to press it, so just press it.” At which point, I protest, “But you didn’t counsel them.”
The physician responds, “You probably just weren’t paying attention.” Or “It’s okay, just click it anyways.” As a “good” scribe, I don’t say anything and I click the button.
Similarly, physicians can make “macros” which auto populate certain parts of the chart, such as the physical exam. It’s nice and saves time, and it is usually accurate. It ensures that there are enough areas input for the physical exam for the chart to be level 5. But sometimes, the physicians don’t do everything their macro says they’ve done. In those cases, I go in and take out the inaccurate information. Sometimes, I’m told to just leave it, that I must have missed when they did it.
How do I know it’s not me? Because as the physician’s right hand, I have been with them the entire shift, even during any breaks they take. I have paid incredibly close attention to everything they say or do so my charts are as complete as possible. That’s my job. I know they did not counsel the patient. I know they did not ask for social history. I know they did not listen to the patient’s heart rhythm or breath sounds. I know every time I “just leave it,” I am lying in a medical document.
I don’t blame the physicians. The pressure on physicians from the administration is incredible. If a physician only charts what they has done, that means their charts sometimes don’t reach level 4 or 5. When that happens too often, administration comes down, and they’re told to write better charts. They lose money when their charts get down coded.
So what do they do? They click a few extra buttons for that higher level chart, because they’re seeing so many patients in a shift and it’s that much easier to just click a few buttons than double the time in a patient’s room when there are other acute patients waiting. Considering how much debt physicians are straddled with as a result of the insane cost of medical education, it’s clear why that extra $20 per patient counseled is so easy.
These are small, tiny transgressions. In the grand scheme of things, it probably does not matter that that the patient did not actually get counseled about smoking cessation. But small things add up and in the end, the burden of all this comes back onto the patient. More importantly, if thousands of small lies are okay and never brought to light, how many bigger lies are out there, hidden by convoluted billing, poor memories, and a healthcare system that lacks any semblance of transparency?
I will never regret being a scribe — as I prepare to apply to medical school, I know my experience as a scribe will be a core piece of my application. I am lucky to have this opportunity. I am also a person with bills to pay, and I don’t want to lose my job. As a “good” scribe, I understand that the chart I am writing is ultimately a reflection of the physician, and therefore at the end of the day, I will write whatever the physician wants me to write. It isn’t my job to say no. Whether or not it’s my responsibility to is undecided.

The author is an anonymous medical scribe.

Cerumen Removal - CPT 69210 Noridian/Medicare

Cerumen Removal - CPT 69210

Effective in 2014, the American Medical Association (AMA) CPT manual identifies CPT code 69210 (removal impacted cerumen requiring instrumentation, unilateral) as a unilateral procedure. CMS has determined that, regardless of unilateral or bilateral, 69210 will remain bilateral and will allow only one unit per date of service billed. Appending modifier 50 is not acceptable.
The work Relative Value Unit (RVU) was maintained at 0.61.

For further details, consult the Federal Register/Volume 78, No. 237 / Tuesday, December 10, 2013/Rules and Regulations 74341(14) Cerumen Removal (69210) at This link will take you to an external website..
Last Updated Mar 07, 2014

ICD-10 Limited End to End Testing with Submitters Noridian/Medicare

ICD-10 Limited End to End Testing with Submitters

MLN Matters® Number: MM8602
Related CR Release Date: February 21, 2014
Related CR Transmittal #: R1352OTN
Related Change Request (CR) #: CR8602
Effective Date: July 7, 2014
Implementation Date: July 7, 2014

Provider Types Affected
This MLN Matters® Article is intended for physicians, other providers, and suppliers who submit claims to Medicare Claims Administration Contractors (Durable Medical Equipment Medicare Administrative Contractors (DME MACs), A/B Medicare Administrative Contractors (A/B MACs), and/or Home Health and Hospices (HH & H MACs) for services provided to Medicare beneficiaries.

What You Need to Know
This article is based on Change Request (CR) 8602 which instructs providers and clearinghouses on how to volunteer to be chosen for ICD-10 End to End testing with Medicare in July 2014. Potential testers must complete the volunteer form on the MAC website by March 24, 2014.

The International Classification of Disease, Tenth Revision, (ICD-10) must be implemented by October 1, 2014. While system changes to implement this project have been completed and tested in previous releases, the industry has requested the opportunity to test with the Centers for Medicare & Medicaid Services (CMS).
Change Request (CR) 8602 will allow for a small subset of Medicare claims submitters to test with MACs and the Common Electronic Data Interchange (CEDI) contractor to demonstrate that CMS systems are ready for the ICD-10 implementation. This additional testing effort will further ensure a successful transition to ICD-10.
To facilitate this testing, CR8602 requires MACs to do the following:
  • Conduct a limited end to end testing with submitters in July 2014. Test claims will be submitted July 21-25, 2014.
  • Each MAC (and CEDI with assistance from DME MACs) will select 32 submitters to participate in the end-to-end testing. The Railroad Retirement Board (RRB) contractor will select 16 submitters.) Testers will be selected randomly from a list of volunteers. At least five, but not more than ten of the testers will be a clearinghouse, and submitters should be a mix of provider types.
  • By March 7, 2014, the MACs and CEDI will post a volunteer form to their website to collect volunteer information with which to select volunteers. The form will provide information to verify that volunteers are ready to test, meet the requirements to test, and collect needed data about the tester (how they submit claims, what type of claims will be tested, etc.). Volunteers must submit the completed forms to the MACs and CEDI by March 24, 2014.
  • By April 14, 2014, the MACs and CEDI (for the DME MACs) will notify the volunteers that they have been selected to test and provide them with the information needed for the testing, such as:
    • How to submit test claims (for example, what test indicators should be set);
    • What dates of service may be used for testing;
    • How many claims may be submitted for testing (Test claims volume is limited to a total of 50 claims for the entire testing week, submitted in no more than three files);
    • Request for National Provider Identifiers (NPIs) and Health Insurance Claim Numbers (HICNs) that will be used in testing (no more than 5 NPIs and 10 HICNs per submitter);
    • Notice that if more than 50 claims are submitted, they may not be processed;
    • Notice that claims submitted with NPIs or HICNs not previously submitted for testing, likely will not be completed; and
    • Notice of potential Protected Health Information (PHI) on test remittances not submitted (and instructions to report PHI found to the MAC).
    • MACs and CEDI (for the DME MACs) will collect information from the selected test volunteers to request the HICNs, NPIs, and Provider Transaction Access Numbers (PTANs) the testers will use during the testing. The forms for this information must be completed and returned to the MAC/CEDI by May 2, 2014. If these forms are not returned by May 2, the tester may lose the opportunity to test.
    • CEDI will instruct suppliers to submit claims with ICD-10 codes with Dates of Service (DOS) 10/1/2014 through 10/15/2014. They may also submit claims with ICD-9 codes with DOS before 10/1/2014.
    • MACs will instruct testers to submit test claims with ICD-10 codes with DOS on or after 10/1/2014. They may also submit test claims with ICD-9 codes with DOS before 10/1/2014.
    • MACs and CEDI will be prepared to support increased call volume from testers during the testing window, and up to 2 weeks following the receipt of the Electronic Remittance Advices (ERAs) from testing. MACs and CEDI will provide information to the testers on who to contact for testing questions. There may be separate contacts for front end questions and remittance questions.
    • MACs will post an announcement about the testing to their websites.
Additional Information
The official instruction, CR 8602, issued to your MAC regarding this change may be viewed at This link will take you to an external website. on the CMS website.
Last Updated Mar 10, 2014