New CMS-1500 Medi-Cal (California Medicaid) Guide for Use Beginning January 6, 2014

Medi-Cal has created a New CMS-1500 Medi-Cal Guide to show providers the fields that have changed on the new 02/12 version of the CMS-1500 claim form. Information submitted in the fields will be the same as information submitted previously on the old 08/05 version of the claim form.

Providers can refer to the CMS-1500 Completion or CMS-1500 Completion for Vision Care section in the appropriate Part 2 provider manual for claim completion instructions by field number. Side-by-side comparisons of the current and upcoming claim fields are available in the New CMS-1500 Medi-Cal Guide, which can be downloaded from the new Claim Form Updates page of the Medi-Cal website.

Old and New Claim Versions: Dates of Use
Beginning January 6, 2014, the Medi-Cal claims processing system will be able to accept and process the new 02/12 version of the CMS-1500. The old 08/05 version of the CMS-1500 will continue to be accepted and processed also, but only for three months, through March 31, 2014. Beginning April 1, 2014, only claims submitted on the 02/12 version will be accepted and processed.

Provider Manual Update Plan
The CMS-1500 claim form has been revised to accommodate the ICD indicator that will be required on claims in 2014 with the ICD-10-CM code rollout. Rather than update the entire provider manual to announce claim updates and then next year release the manual pages again with ICD-10 information, Medi-Cal has determined to approach provider manual updates as follows:

• To serve the immediate need for claim completion instructions, the CMS-1500 Completion and CMS-1500 Completion for Vision Care manual sections will be updated. The sections are slated for release in the December 2013 Medi-Cal Update bulletins. A set of instructions for completing the new 02/12 version of the CMS-1500 will be added at the front of each section. The older 08/05 instructions will be retained at the back of the section.
• Claim field names in the provider manual will continue as they appear on the 08/05 version of the CMS-1500. For example, Reserved for Local Use field (Box 19) will be retained and not changed to Additional Claim Information field (Box 19) until later in 2014.
• Billing examples will be retained, as is, in the 08/05 version of the CMS-1500.
• If it is determined that claim instructions must be updated before ICD-10-related manual pages are released in 2014, an analysis will be performed to decide if select manual pages should be updated and released.

The above cost-saving approach will allow several hundred manual sections to be updated only once.

Courtesy of: http://files.medi-cal.ca.gov/pubsdoco/Claims/Articles/claims_21966.asp?utm_source=iContact&utm_medium=email&utm_campaign=Medi-Cal%20NewsFlash&utm_content=21966

Medi-Cal & Telehealth (California Medicaid)

Medi-Cal & Telehealth

The Department of Health Care Services (DHCS) considers telehealth a cost-effective alternative to health care provided in-person, particularly to underserved areas. Telehealth is not a distinct service, but a way that providers deliver health care to their patients that approximates in-person care. The standard of care is the same whether the patient is seen in-person or through telehealth.

DHCS’s coverage and reimbursement policies for telehealth align with the California Telehealth Advancement Act of 2011 and federal regulations. State law defines telehealth as “the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care while the patient is at the originating site and the health care provider is at a distant site.” This definition applies to all health care providers in California, not just Medi-Cal providers.

Medi-Cal also complies with federal regulations for telehealth, which are the same for Medicaid as they are for Medicare. Medicaid regulations authorize telehealth using “interactive communications” and asynchronous store and forward technologies. Interactive telecommunications must include, at a minimum, audio and video equipment permitting real-time two-way communication, according to the Centers for Medicare and Medicaid Services.

Medi-Cal pays for current Medi-Cal benefits appropriately provided via telehealth:
 • Selected Evaluation and Management (E&M) services for patient visit and consultation.
 • Selected psychiatric diagnostic interview examination and selected psychiatric therapeutic services.
 • Teledermatology by store and forward.
 • Teleophthalmology by store and forward.
 • Transmission costs (up to 90 minutes per patient, per day, per provider).
 • Originating site facility fee.
 • Interpretation and report of X-rays and electrocardiograms performed via telehealth.

Please see the Medi-Cal Provider Manual: Telehealth for more information.

For additional information about Medi-Cal’s coverage and reimbursement telehealth policies, as well as resources for providers, please see the Telehealth Resources page.

For questions about submitting a claim for services provided by telehealth, please call the Telephone Service Center (TSC) at 1-800-541-5555.

Providers may email questions about Medi-Cal telehealth policy to Medi-Cal_Telehealth@dhcs.ca.gov.

Update – ACA Increased Medi-Cal Payments for Primary Care Physicians (California MediCaid)

The Department of Health Care Services (DHCS) plans to implement increased fee-for-service Medi-Cal payments for primary care physicians in late October 2013.

 

The Patient Protection and Affordable Care Act (ACA), as amended by House Resolution 4872-24 Health Care and Education Reconciliation Act of 2010, Section 1202, requires that payments to primary care physicians be increased to the Medicare equivalent for certain Evaluation and Management and Vaccine Administration services.

 

These increased payments are contingent upon pending Centers for Medicare & Medicaid Services (CMS) approval of a DHCS State Plan Amendment (SPA). The increased payments are retroactive for dates of service on or after January 1, 2013.

 

The first interim payment will be issued in October. A final settlement of payment owed but not reimbursed by the interim payment will be issued as early as February 2014.

 

The increased payments are not automatic. Providers must attest to their eligibility, but DHCS estimates that less than half of eligible providers have self-attested. Completing your attestation prior to CMS approval of the SPA and system updates will ensure you receive increased payments as soon as possible. Visit the Medi-Cal ACA Program Page on the Medi-Cal website for more information or to submit a self-attestation form.

 

You should complete your attestation form as soon as possible.

Attestation form link: https://www.medi-cal.ca.gov/acaattest/acaattestmenu.aspx

 

 

Health Insurance Exchange Information for Physicians and Patients

A primary mission of the Affordable Care Act is to provide universal health coverage through the creation of health insurance exchanges or marketplaces. The triad of employer-sponsored coverage, marketplace insurance exchanges, and expanded Medicaid coverage should cover most Americans under 65 years old, with some exceptions.

Unfortunately, there will be coverage gaps for low-income people who fall between certain income levels and live in states where the Medicaid expansion was rejected, according to Jennifer Tolbert, director of state health reform for the Kaiser Family Foundation.

Tolbert is charged with monitoring state implementation of the Affordable Care Act and the establishment of state insurance exchanges for Kaiser. She recently discussed in a webinar some consumer-based elements of the law that are also helpful for medical practices to understand and communicate with current or potential new patients.

Consumers will be able to shop and enroll in new insurance plans through the federal government's website (www.healthcare.gov), or their own state's website if available, beginning Oct. 1, 2013. Open enrollment will continue through Mar. 31, 2014, with the option of enrolling after that date if a qualifying event occurs.

Coverage through the marketplaces and the expanded Medicaid program (where approved by individual states) will begin Jan. 1, 2014, when insurance market rules also go into effect. That is also when the individual mandate to have insurance coverage begins.

The exchanges will offer a choice between four plans (figures are for single coverage; family coverage would be double):

• Bronze – typical deductible $5,000 / typical coinsurance 30 percent
• Silver – typical deductible $2,000 / typical coinsurance 20 percent
• Gold – typical deductible $0 / typical coinsurance 20 percent
• Platinum – typical deductible $0 / typical coinsurance 10 percent

They will also offer a catastrophic plan for people up to age 30, with a typical deductible of $6,350 and no coinsurance. While these levels of cost sharing may seem prohibitive, most consumers will be eligible for federal subsidies and tax credits.

The cost of premiums will vary by state and locality; and also by age. Consumers who wish to get a ballpark estimate of the costs of different plans can use the Health Insurance Subsidy Calculator provided by Kaiser.

For example: A 40-year-old pre-school teacher making $30,750 — or 250 percent to 300 percent of the federal poverty level —  would be required to pay 8 percent to 9.5 percent of her income for healthcare premiums on the exchange. Her subsidized cost for the Silver Plan would be $2,633 annually. (The unsubsidized annual cost would be $3,857.)

All of the plans offered on the health insurance exchanges are mandated to offer "essential health benefits," said Karen Pollitz, a senior fellow on health reform and private insurance for Kaiser:

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services, including behavioral health treatment
6. Prescription drugs
7. Rehabilitative and wellness services, and chronic disease management
8. Pediatric services, including oral and vision care

There are multiple health-reform resources available online through Kaiser and Healthcare.gov that would be helpful additions to your own medical practice website; even if your own patients don't need this information, most everyone has a family member who may benefit from knowing the facts, e.g. a young adult child who does not receive health insurance from her workplace, or perhaps a single professional who does freelance work or is self-employed.

As leaders in the health community, it is important for physicians to be knowledgeable about the coming changes in health insurance coverage. It also allows physicians to make informed choices about the types of new insurance they will participate in, and the numbers of new patients they take into their practices.

Article By Erica Sprey, Courtesy of Physicians Practice http://www.physicianspractice.com/blog/health-insurance-exchange-information-physicians-patients?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=17092013

California State Medicaid Will Discontinue Use of ZS Modifier as of December 31, 2013

Public Comment Forum: HIPAA Code Conversion for Local Modifier ZS 

As part of the continuing effort to comply with the federally mandated Health Insurance Portability and Accountability Act (HIPAA), the following change is slated to be effective for dates of service on or after December 1, 2013: 
The Department of Health Care Services (DHCS) will discontinue use of local modifier ZS, which is used to bill for the full professional (26) and technical (TC) components of a procedure. 

This article provides information about a public comment forum for this change. 

Claim Completion
Providers will be instructed to use one of the following scenarios when submitting a claim for split- billable procedures or services: 

Scenario 1: The facility and physician each bill for their respective component of the service with modifiers 26 or TC. Each provider/facility submits their own claim with one line of service and the appropriate modifier (26 or TC) designating the service they provided. 

Scenario 2: Full Fee Billing – The physician bills for both the professional and technical components and subsequently reimburses the facility for the technical component, according to their mutual agreements. The physician submits a CMS-1500 claim form and completes two separate claim lines as follows: The first line contains the split-billable procedure code and one of the two modifiers (26 or TC). The second line contains the same procedure code and the corresponding modifier (26 or TC).

Scenario 3: Standard Billing – The facility bills for both the technical and professional components and reimburses the physician for the professional component, according to their mutual agreements. The facility submits a UB-04 claim form and completes two separate claim lines as follows: The first line contains the split-billable procedure code and one of the two modifiers (26 or TC). The second line contains the same procedure code and the corresponding modifier (26 or TC). 

TAR Completion
Providers will be instructed to use one of the following scenarios when submitting a Treatment Authorization Request (TAR) for split-billable procedures or services: 

Scenario 1: One TAR and one provider for both the professional (26) and technical (TC) components of service. The TAR must be submitted with two lines of service. The first line must have the CPT-4 code and one of the two modifiers (26 or TC). The second line must have the same CPT-4 code and the corresponding modifier (26 and TC). 

Scenario 2: One TAR and two different providers for the professional (26) and technical (TC) components of service. One of the providers submits the TAR on behalf of both providers of the two components of service (26 and TC). Both providers use the same TAR for claim submission. The TAR is submitted with two lines of service. The first line must have the CPT-4 code and one of the two modifiers (26 or TC). The second line must have the same CPT-4 code and the corresponding modifier (26 and TC). 
This is the preferred method for two different providers. 

Scenario 3: Two TARs and two different providers for the professional (26) and technical (TC) components of service.
Each provider submits their own TAR with one line of service and the appropriate modifier designating the service (26 or TC) they provided or will provide. 

Comment Period
Notice is hereby given that DHCS will conduct written public proceedings, during which time any interested person or such person’s duly authorized representative may present statements, arguments or contentions relevant to the action described in this notice. 

There has been a correction to the start date of the comment forum, which was previously posted as September 15, 2013. The comment forum will begin September 16, 2013, and end at 4:00 PM on October 30, 2013. The proposed changes will be available by clicking the “Public Comment Forum Coming: HIPAA Code Conversion for Local Modifier ZS” line in the NewsFlash area of the Medi-Cal website. This link will direct providers to the “Medi-Cal Comment Forum” where they can view the article. Providers may call the Telephone Service Center (TSC) at 1-800-541-5555 or visit the Medi-Cal website if they have questions or need additional information.

Courtesy of : http://files.medi-cal.ca.gov/pubsdoco/forum_21767_1.asp

Health Insurance Exchanges: Good News, Bad News for Physicians

USA Today recently reported that people have been signing up for health insurance exchanges for in excess of expected levels.

Staff writer Kelly Kennedy reports that a survey of each of the 50 states yielded 19 states reporting estimates for how many of their uninsured residents they expect will buy through the exchanges. The reported 8.5 million would far outstrip the federal government's estimate of 7 million new customers for all 50 states under the Affordable Care Act (ACA).

In the short term, this is great news for physicians' practices. This statistic means there will be 8.5 million new paying customers. This is even better news for physicians in states which have refused to expand Medicaid to the level mandated by the reform law, commonly termed "Obamacare."

Prior to the law, many states were permitted to set their own limits for Medicaid eligibility. Alabama, for example, reportedly disqualified a family from Medicaid eligibility if the family earned 25 percent of the federal poverty level (about $6,000 per year for a family of four). Under the reform law, states would have been required to expand Medicaid roles to conform to a new national standard of 133 percent of the federal poverty level (about $31,300 per year for a family of four). On June 28, 2012, the U.S. Supreme Court upheld the constitutionality of most of the ACA in the case National Federation of Independent Business v. Sebelius. However, the Court held that states cannot be forced to participate in the law's Medicaid expansion under penalty of losing their current Medicaid funding. Therefore, patients in states which did not expand Medicaid roles to include these "newly eligible" patients are able to purchase federally subsidized private plans through health insurance exchanges, which is the subject of the USA Today article.

This is good news for physicians’ practices, because Medicaid simply doesn’t pay very well (so low in fact, about one-half of all physicians would refuse to accept a new Medicaid patient).) Private plans which are subsidized by the government would almost certainly provide reimbursement rates which are above the rock-bottom rates for Medicaid patients. Open enrollment begins October 1, 2013, and coverage is set to begin January 1, 2014.

Before we all get too drunk on all this free government Kool-Aid, recall that the Kool-Aid isn’t "free." The reform law was enacted because the Medicare trust fund could not afford to pay for all the aging baby boomers set to turn 65 in the next few years.

The idea behind the law was to save Medicare by forcing more healthy Americans into the system through individual mandates, employer mandates, expansion of Medicaid for the poorest Americans, and providing health insurance exchanges for those who are just above the level needed to qualify for Medicaid. But how is this supposed to help save the Medicare trust fund? Obviously, by cutting future Medicare reimbursement rates.  But on what part of "planet crazy" does it make sense for the government to pick up the tab of the cost for all the newly insured, (which was supposed to save the system from failing, because the government is broke)?

In her book, "Your Doctor is Not In," Jane Orient draws the analogy between our nation’s healthcare model and the one created by Ptolemy, which contained multi-layered epicycles to explain the universe. "Wheeling and whirring, the Ptolemaic universe could be turned to predict almost any observed planetary motion — and when it failed, Ptolemy fudged the data to make it fit," Orient writes.

Here, the Obama Administration is so desperate to make the healthcare reform law work, any solution that will keep the wheels whirring, is perfectly acceptable. By the time anyone figures out it is a bad model, the president will be working on a location for his presidential library, and paying for healthcare will be the next administration’s problem.

Article By Martin Merritt http://www.physicianspractice.com/blog/health-insurance-exchanges-good-news-bad-news-physicians

COMMON SETS OF CODES USED TO BILL FOR EVALUATION AND MANAGEMENT SERVICES

When billing for a patient’s visit, select codes that best represent the services furnished during the visit. A billing specialist or alternate source may review the provider’s documented services before the claim is submitted to a payer. These reviewers may assist with selecting codes that best reflect the provider’s furnished services. However, it is the provider’s responsibility to ensure that the submitted claim accurately reflects the services provided.

The provider must ensure that medical record documentation supports the level of service reported to a payer. The volume of documentation should not be used to determine which specific level of service is billed.

In addition to the individual requirements associated with the billing of a selected E/M code, in order to receive payment from Medicare for a service, the service must also be considered reasonable and necessary. Therefore, the service must be:

• Furnished for the diagnosis, direct care, and treatment of the beneficiary’s medical condition (i.e., not provided mainly for the convenience of the beneficiary, provider, or supplier); and
• Compliant with the standards of good medical practice

The two common sets of codes that are currently used for billing are: Current Procedural Terminology (CPT) codes and International Classification of Diseases (ICD) diagnosis and procedure codes.

CURRENT PROCEDURAL TERMINOLOGY CODES
Physicians, qualified non-physician practitioners (NPP), outpatient facilities, and hospital outpatient departments report CPT codes to identify procedures furnished in an encounter. CPT codes are used to bill for services furnished to patients other than inpatients and for services being billed on claims other than inpatient claims. Therefore, CPT codes should be used to bill for E/M services provided in the outpatient facility setting and in the office setting.

INTERNATIONAL CLASSIFICATION OF  DISEASES DIAGNOSIS AND PROCEDURE CODES 
The use of ICD-9-Clinical Modification (CM) diagnosis and procedure codes is limited to billing for inpatient E/M services on inpatient claims. All other provider types should continue to use CPT codes to bill for E/M services.

The compliance date for implementation of the International Classification of Diseases, 10th Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/ PCS) is for services provided on or after October 1, 2014, for all Health Insurance Portability and Accountability Act covered entities. ICD-10-CM/PCS is a replacement for ICD-9-CM diagnosis and procedure codes. The implementation of ICD-10-CM/PCS will not impact the use of CPT and alpha-numeric Healthcare Common Procedure Coding System codes.

All providers billing for inpatient services provided to inpatient beneficiaries will use ICD-10-CM diagnosis codes instead of ICD-9-CM diagnosis codes for services furnished on or after October 1, 2014.

 ICD-10-CM/PCS will enhance accurate payment for services rendered and facilitate evaluation of medical processes and outcomes. The new classification system provides significant improvements through greater detailed information and the ability to expand in order to capture additional advancements in clinical medicine. 

ICD-10-CM/PCS consists of two parts: 

• ICD-10-CM – The diagnosis classification system developed by the Centers for Disease Control and Prevention for use in all U.S. health care treatment settings. Diagnosis coding under this system uses 3 – 7 alpha and numeric digits and full code titles, but the format is very much the same as ICD-9-CM; and
• ICD-10-PCS – The procedure classification system developed by the Centers for Medicare & Medicaid Services for use in the U.S. for billing inpatient hospital claims for inpatient services ONLY. The new procedure coding system uses 7 alpha or numeric digits while the ICD-9-CM coding system uses 3 or 4 numeric digits.

Courtesy of: CMS http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html

Selecting the Right E&M Codes at Your Medical Practice

The focus on educating providers and coders on the selection of evaluation and management (E&M) services has increased over the years due to numerous factors, including: E&M codes make up the majority of procedures reported by physicians and mid-level providers; audits (e.g. OIG audit focus on E&M especially documentation using EHRs); and the fact that complexity of code selection can be confusing and ambiguous.     

Most of the education focuses on the three key components (history, exam, and medical decision making). Proper documentation of these elements is extremely important but we cannot lose focus on the most important criteria for E&M code selection, which is medical necessity. Codes should not be solely selected based on the volume of the documentation of the three key components, but the nature of the patient’s presenting problem and medical intervention required by the provider.

As more and more physicians implement EHRs, there is an increase in the volume of documentation. EHRs are very useful tools if used appropriately, but can be abused to create pages of useless information that does not pertain to the date of service or the patient’s complaint for the encounter. We often see this with the review of systems and past, family, and social history components when elements from a previous encounter are carried forward. When you see the same information documented for the patient each time she is seen, it makes you wonder if the information is obtained each time or a system default. If it is obtained each time, is the information pertinent to the presenting problem?

An effective way to incorporate the focus on medical necessity of the service into your E&M training is to relate it to the provider’s typical patient. When a patient presents to the office, the provider can usually tell quickly how sick the patient is. The patient’s complaint for the day will dictate the questions the provider asks regarding the patient’s presenting problem. This information makes up the history component of the encounter.

Next, the provider examines the patient. The provider should exam all body areas and/or organ systems that are pertinent. Some providers may prefer to perform an eight-system exam for each patient but it might not be medically necessary. For example, a patient presents with an earache. An eight-system exam may not be warranted depending on the last time the patient was seen. If the patient was seen recently for a complete physical and is presenting for only an evaluation of the earache, the complete exam might not be necessary. However, if the patient has not been seen in over a year, the provider will take the opportunity to address the presenting problem(s) and perform a complete exam for preventive measures or conditions the patient may have. Sometimes a patient will present for one problem and “oh by the way” something else is also bothering them.

The medical decision making component includes the provider’s assessment, data collected (e.g. diagnostic tests), and treatment plan. Once the exam is complete, the provider will determine what tests are needed if any. When ordering tests, providers must document the reason for the test. If a definitive diagnosis has not been determined, the reason for the tests will be the patient’s signs and symptoms. Although differential diagnoses are not reported, they should be included in the documentation to support the severity of the patient’s condition.

If the patient is presenting with a headache and the provider is ruling out neurological conditions, it should be included in the documentation. The treatment plan should be documented. It can include medications prescribed, therapies ordered and/or procedures needed.

In addition to using the CMS documentation guidelines for E&M education, incorporate the nature of the presenting problems found in the CPT® E&M coding guidelines. Although the nature of the presenting problem is not one of the three key components, it helps the provider understand the types of conditions that qualify for the different levels of E&M. Focus your education on the patient’s condition, work needed to treat the patient, and the proper documentation to support the services rendered.

Article written By Raemarie Jimenez, CPC- See more at: http://www.physicianspractice.com/blog/selecting-right-em-codes-your-medical-practice#sthash.Z26Zg8gz.dpuf

Public Comment Forum Upcoming Changes: HIPAA Code Conversion for Local Modifier ZS (Medi-Cal, California State Medicaid)

As part of the continuing effort to comply with the federally mandated Health Insurance Portability and Accountability Act (HIPAA), the following change is slated to be effective for dates of service on or after December 1, 2013:

The Department of Health Care Services (DHCS) will discontinue use of local modifier ZS, which is used to bill for the full professional (26) and technical (TC) components of a procedure.

This article provides information about a public comment forum for this change.
Claim Completion
Providers will be instructed to use one of the following scenarios when submitting a claim for split-billable procedures or services:

Scenario 1: The facility and physician each bill for their respective component of the service with modifiers 26 or TC.
Each provider/facility submits their own claim with one line of service and the appropriate modifier (26 or TC) designating the service they provided.

Scenario 2: Full Fee Billing – The physician bills for both the professional and technical components and subsequently reimburses the facility for the technical component, according to their mutual agreements.
The physician submits a CMS-1500 claim form and completes two separate claim lines as follows:
The first line contains the split-billable procedure code and one of the two modifiers (26 or TC). The second line contains the same procedure code and the corresponding modifier (26 or TC).

Scenario 3: Standard Billing – The facility bills for both the technical and professional components and reimburses the physician for the professional component, according to their mutual agreements.
The facility submits a UB-04 claim form and completes two separate claim lines as follows:
The first line contains the split-billable procedure code and one of the two modifiers (26 or TC). The second line contains the same procedure code and the corresponding modifier (26 or TC).

TAR Completion
Providers will be instructed to use one of the following scenarios when submitting a Treatment Authorization Request (TAR) for split-billable procedures or services:

Scenario 1: One TAR and one provider for both the professional (26) and technical (TC) components of service.
The TAR must be submitted with two lines of service. The first line must have the CPT-4 code and one of the two modifiers (26 or TC). The second line must have the same CPT-4 code and the corresponding modifier (26 and TC).

Scenario 2: One TAR and two different providers for the professional (26) and technical (TC) components of service.
One of the providers submits the TAR on behalf of both providers of the two components of service (26 and TC). Both providers use the same TAR for claim submission. The TAR is submitted with two lines of service. The first line must have the CPT-4 code and one of the two modifiers (26 or TC). The second line must have the same CPT-4 code and the corresponding modifier (26 and TC).

This is the preferred method for two different providers.

Scenario 3: Two TARs and two different providers for the professional (26) and technical (TC) components of service.
Each provider submits their own TAR with one line of service and the appropriate modifier designating the service (26 or TC) they provided or will provide.

Comment Period
Notice is hereby given that DHCS will conduct written public proceedings, during which time any interested person or such person’s duly authorized representative may present statements, arguments or contentions relevant to the action described in this notice.
The comment forum will begin September 15, 2013, and stays open a minimum of 45 days. The proposed changes will be available by clicking the “Public Comment Forum Coming: HIPAA Code Conversion for Local Modifier ZS” line in the NewsFlash area of the Medi-Cal website. This link will direct providers to the “Medi-Cal Comment Forum” where they can view the article. Providers may call the Telephone Service Center (TSC) at 1-800-541-5555 or visit the Medi-Cal website if they have questions or need additional information.

Courtesy of: Dept. of Health Care Services Medi-Cal http://files.medi-cal.ca.gov/pubsdoco/newsroom/newsroom_21767.asp?utm_source=iContact&utm_medium=email&utm_campaign=Medi-Cal%20NewsFlash&utm_content=21767

3 Easy Ways to Increase Your Medical Practice Revenue by 25%

There are a hundred ways to streamline workflow and improve revenue in a medical practice. It’s hard to pick just a few, but in this guide, that’s just what we have done.

Here are three simple suggestions that any practice should be able to implement that can generate an increase of at least 25% revenue.

And they cost little or nothing to implement.

1. Make Money on Prescription Refills
Prescribing is a big deal for most practices. Many report the greatest percentage of in-bound phone calls to their practices are prescription related. Either the patient is asking for prescription refills or pharmacy personnel are seeking approval to fill a script. Have you ever considered how much this process is costing your practice? Have you ever asked, “How can we be compensated for this time?”
Who makes money when prescriptions are filled? Perhaps the more important question is who does not make money on prescription refills. Today, most commonly, the pharmacist is benefiting the most from the prescription renewal process. Sure, the pharmaceutical manufacturers are also making revenue from the sale. Unfortunately, the biggest loser in this process is the medical practice. But it doesn’t have to be this way.
How much does the prescription refill process cost your practice? Every patient or pharmacist contact for a prescription refill creates a cost to the practice. What is the overhead cost in your practice for the following functions? • Taking a message • Pulling a fax off the fax machine • Pulling a chart • Provider reviewing the chart • Authorizing the refill • Calling or faxing in the prescription
Even if your practice has automated some of these functions, there still is a cost, and it is important for you to calculate it.
Is it possible to transform this cost into revenue? The temptation is to believe that the prescription refill process is just a cost of doing business. It doesn’t have to be this way! The fact is that a prescription policy can generate additional revenue for the practice and offset that cost.
This policy outlines how refill and other prescription requests are handled. It should include a follow-up period for chronic disease patients. Generally, they should be seen every 90 days for evaluation and review of medications. It can be billed as 99213 with an average reimbursement of about $70.00. Also, consider including something in the policy for patients who call with acute symptoms and are “experts” at self-diagnosis. They may call and request that a prescription be called in without a visit. Your policy should focus on eliminating prescribing in these cases and getting those patients in for an appointment, ideally the same day. If you have mid-level providers, they can perform these types of services. Make sure all staff are well-versed in the prescription policies and that those policies are clearly conveyed to patients. If needed, you can create talking points for staff to help them with the change.
The average practice can spend anywhere from $4.00 to $15.00 for every single prescription refill event.

2. Use Your Schedule to Maximize Visits
Time really is money for most healthcare providers so your goal should be to see as many patients as possible each day. Unfortunately, physicians historically haven’t been good at using their schedules to generate income. So your front office staff needs to learn to be strategic in their scheduling process because every unfilled appointment represents a loss of income.
Analyze Your Patient Mix Are they primarily fee-for-service (FFS) or capitated? FFS patients pay for services one-by-one where capitated patients have a set fee that has been paid for services performed.
Fill your schedule based on the mix of patients. If you have 70% FFS and 30% capitated your schedule should reflect that, and you should triage patients accordingly as well. Try to schedule capitated patients only in your blocked capitated spaces while leaving same day and extended hours open for FFS patients. Don’t book capitated patients in the same-day slots unless necessary. You don’t want to lose the revenue from FFS patients, and they may go elsewhere if they can’t get in to see you promptly.
Categorize Your Visits You have many types of visits. Some take longer than others. A new patient visit takes a lot longer than an established patient. Acute patients are different than visits for preventive care.
Do an analysis of the types of appointments you have. Once you have identified those visits, look at how much time each visit takes and what resources need to be scheduled. You can then customize your scheduler with your practice resources (providers, rooms, equipment, etc.) and place appointments at times of the day where it makes the most sense.
For example, put longer, new patient visits at the end of the day while shorter visits can be placed earlier in the day.
If you can schedule by resource, you can also book more than one patient for the same or overlapping time slots. Having more control over your scheduling helps you get more patients each day and helps you improve their experience by reducing wait times.
Developing the perfect schedule for your practice may take some work and even some trial and error but in the end, you’ll find it’s worth it.
Consider Double-Booking According to Medicaid, one in three patients doesn’t show up. Other studies suggest 25-50% of follow up patients cancel or don’t show. Look at your schedule to identify groups of patients who are most likely to cancel or not show up. Consider double-booking those types of patients or appointments. Also, consider changing the way you discuss some of these types of visits with patients. For example, say “See you in five days” and have the patient schedule a follow up versus “Call us if you aren’t feeling better.”
Create a Cancellation/No-Show Fee Patients who cancel appointments or surgeries at the last minute can be a huge drain on your practice’s cash flow. Since you are already streamlining your schedule, consider also implementing a strategy to prevent unexpected holes to minimize the impact of last minute cancellations and no shows on your medical practice.
Set a cancellation policy, and be sure it’s communicated to every patient. Ideally, this takes the form of a document that new patients sign when they first come to the practice. Afterward, make it a point to discuss your policy at the time of booking subsequent appointments or surgery, and when reminder calls or emails go out to patients.
In the cancellation policy, many practices require patients to cancel their appointment at least 24 hours before their scheduled appointment time. For surgeries, the required notice time can be even longer. For those patients who do not comply, consider charging a late cancellation fee.
Collecting cancellation fees can be achieved much more easily than you think when your office is set up to bill for cancellations and accept credit card payments. By creating a cancellation code, you can bill the patient using electronic statements. The day of the cancellation or no-show, process a patient statement and direct the patient to pay online by credit card. Enabling patients to pay online can increase patient payments and speed the turnaround on those payments whether it is for the cancellation fee or for standard co-pays and deductible payments.
3 Easy Ways to Keep Your Practice on Schedule
It may be one of the biggest challenges in a medical practice—staying on schedule. Physicians get sidetracked with refill requests, reviewing labs, returning calls to patients. Patients take up more time than they are allotted. A registration person calls in sick and your front desk gets a little behind. There are a hundred reasons why you might get off track. But once it happens, it’s hard to get that time back. You may find that your practice is slightly behind for the rest of the day. Here are a few simple strategies that might help avoid bottlenecks or turn things around when they start to go south.
1. Easiest: Set clear guidelines for staff about not interrupting the physician with calls or questions between appointments unless it is a true emergency.  Establish a process for the physician to receive messages and manage tasks at specific times of the day—first thing each morning, at the end of the day, perhaps a break at midday. He or she can take care of refills or return calls during those appointed times.
2. Easier: Prioritize tasks for staff. Make sure your staff know what their top priorities are so that if they get busy they know what to let go of for the time being. Sometimes people are trying to do too much when they should just be focused on moving patients swiftly through their appointment. 
3. Easy: Do an analysis of your time management, including your scheduling process and task management. You may need to look at your days from nuts to bolts. Is your schedule inefficient? Maybe the problem is that your longest patient visits are at the wrong time of day and they are causing backups everywhere else. Perhaps your providers just aren’t managing their tasks well. Many practice management and electronic health record systems offer task management tools. If everyone isn’t using them to stay on top of tasks and priorities, now might be a good time to start.
In the end the most important things to remember when trying to keep things on track are making sure that everyone knows exactly what their role is, what their priorities are, and what they should do if things get busy.  Sometimes the problem is simply that people don’t know what to do next to keep things on track and they flounder.
According to Medicaid, one on three patients doesn’t show up.

3. Mine Your Data to Increase VolumeNow that your schedule can accommodate more patients, you need have to get the patients to make appointments. At no extra cost to you, you can mine the data in your medical billing software to market your practice and increase volume.
Reach Out to Your Patients According to the Medical Group Management Association, you should be spending 1-3% of your practice revenue on marketing. If you aren’t marketing your practice, reaching out to existing patients based on your own data is a good, and essentially free, way to start. If your initial efforts are successful then you can decide if it’s worth it to invest a little more to send mailers or do other marketing outreach.
Your practice management and medical billing software is full of information that you can use to increase patient volumes and revenue. Dig into your data and run reports to identify the following types of patients (depending on your practice): • Patients with chronic conditions like diabetes, hypertension, and heart disease who are due for a follow up appointment. • Patients who may be due for physicals, well-woman or well- child checks, and other preventive care. • Anyone who may need immunizations, including annual flu or pneumonia shots.
Once you identify patients you can contact for appointments, be sure you have a process in place to do the reminders via mail, email, text, or phone. Also, make sure you’ve completed step two above and your schedule is setup to accommodate an increase in patient volume.
Implement Staff Incentives By maximizing your schedule and reaching out to patients to make appointments, you’ve created more work for your staff. You might be inclined to say, “Hey, that’s their job.” But your staff is more likely to work hard to get those patients in the door if you set a clear goal for your increase in appointments and reward staff for achieving that goal.
For example, if you decide that the goal is to increase patient visits in the first quarter by 10%, offer a bonus of some kind if your practice reaches this goal. It could be gift cards or a party—whatever you think your staff would like. You can do straight cash bonuses if you think that will work best. Show your staff that their hard work is appreciated and that increases in patients and practice revenue will benefit everyone.
Tap Into Payer Incentives There may be some added bonuses to this process. Some payers are now offering incentives for certain preventive care actions or chronic care follow up. Because incentives can vary widely by payer, state and even specialty, you’ll need to contact payers to ask about incentives. Reaching out to patients, may help your practice to tap into free money from those health plans that are providing financial incentives for meeting quality indicators.
The End Result There are a lot of ways to streamline your practice functions, reduce costs, or increase revenue. But these three options can apply to almost any practice, cost little or nothing to implement, and are virtually guaranteed to increase your revenue.
Courtesy of: Kareo

DHCS announces Healthy Families transition to Medi-Cal Managed Care in rural counties (California)

The Department of Health Care Services (DHCS) announced Medi-Cal fee-for-service transition to Medi-Cal managed care is set to begin for 28 rural counties on September 1, 2013. The transition is to be implemented in phases in order to ensure the readiness of DHCS contracted health plans and to minimize any disruption in services to beneficiaries.
Phase 4 of the Healthy Families Program transition will begin on September 1, 2013, for the eight County Organized Health System (COHS) counties that include Del Norte, Humboldt, Lake, Lassen, Modoc, Shasta, Siskiyou and Trinity. DHCS is evaluating health plan readiness to minimize disruption of services and ensure continuity of care. Approximately 8,000 Healthy Families’ patients will be transitioned.
On November 1 2013, Phase 4b of the 27,000 Healthy Families Program beneficiaries will transition in Alpine, Amador, Butte, Calaveras, Colusa, El Dorado, Glenn, Imperial, Inyo, Mariposa, Mono, Nevada, Placer, Plumas, Sierra, San Benito, Sutter, Tehama, Tuolumne and Yuba counties.
Additional details are available on the expansion of Medi-Cal managed care here.
Details for the Healthy Families transition are available here.
Questions or comments for DHCS can be sent via email to DHCSHealthyFamiliesTransition@dhcs.ca.gov.

ICD-10 FAQ's and Medi-Cal (California Medi-Caid)

ICD-10: FAQs

1. What does International Classification of Diseases, 10th Revision (ICD-10) compliance mean?
   ICD-10 compliance means that all HIPAA-covered entities are able to successfully conduct health care transactions on or after October 1, 2014, using the ICD-10 diagnosis and procedure codes. ICD-9 diagnosis and procedure codes can no longer be used for health care services provided on or after this date.
2. Why is the ICD-10 transition necessary?
   ICD-10 is a provision of HIPAA, as regulated by the U.S. Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS). This federal mandate pertains to all HIPAA-covered entities.

   The transition from ICD-9 to ICD-10 is occurring for the following reasons:

   • ICD-9 codes have limited data about patient’s medical conditions and hospital inpatient procedures.
   • ICD-9 codes use outdated and obsolete terms and are not consistent with current medical practices.

   The structure of ICD-9 limits the number of new codes that can be created, and many ICD-9 categories are full. A successful transition to ICD-10 is vital to transforming our nation’s health care system.
3. Codes change every year, so why is the transition to ICD-10 any different from the annual code changes?
   ICD-10 codes are different from ICD-9 codes in several ways. Currently, ICD-9 codes are for the most part numeric and have three to five digits. ICD-10 codes are alphanumeric and contain three to seven characters. ICD-10 codes provide a higher level of description. However, like ICD-9 codes, ICD-10 codes will be updated every year.
4. Will ICD-10 replace Current Procedural Terminology (CPT) procedure coding?
   No. The transition to ICD-10 does not affect CPT coding for outpatient procedures. Like ICD-9 procedure codes, ICD-10 Procedure Coding System (PCS) codes are for hospital inpatient procedures only.
5. What is the implementation date for ICD-10?
   On October 1, 2014, medical coding in U.S. health care settings will change from ICD-9 code sets to ICD-10 code sets.
6. After the October 1, 2014, implementation date, when do I use ICD-9 versus ICD-10 on my claim?
   Please refer to the chart below, using the date specified in the date field, to determine the ICD code version to use.  If the value of the date field is before October 1, 2014, use ICD-9 to code the diagnosis. If the value of the date field is on or after October 1, 2014, use ICD-10.

   Claim Type	Claims	Date Field To Be Used For Determining ICD Code Version
   1	Pharmacy	Date of service
   2	Long Term Care (LTC)	Through date
   3	Inpatient	Through date
   4	Outpatient	From date
   5	Medical	From date

   In addition, all claims received on or after the ICD-10 compliance date will require a version indicator (ICD-9 = 9 or ICD-10 = 0).
7. Will there be a grace period for converting to ICD-10?
   No.
8. How is Medi-Cal addressing the implementation of ICD-10?
   Medi-Cal will be using a crosswalk solution in the legacy California Medicaid Management Information System (CA-MMIS). Medi-Cal has mapped all ICD-10 codes to corresponding ICD-9 codes by starting with the General Equivalence Mappings (GEMs) provided by the Centers for Medicare & Medicaid Services (CMS) and modifying the mappings to align with existing Medi-Cal policy. Claims will be run against the crosswalk to determine the ICD-9 value to process through the system.
9. What is a crosswalk solution?
   Medi-Cal has mapped all ICD-10 codes to corresponding ICD-9 codes starting with the General Equivalence Mappings (GEMs) and Reimbursement Mappings provided by the Centers for Medicare & Medicaid Services (CMS) and modifying the mappings to align with existing Medi-Cal policy. Claims that are submitted with ICD-10 starting October 1, 2014, will be run against this crosswalk to identify the appropriate ICD-9 code that will be used to process the claim.
10. Will an ICD-10 to ICD-9 crosswalk be published?
    Medi-Cal will not publish the crosswalk. However, the provider manuals will be updated with the ICD-10 codes as appropriate.
11. Who is affected by the transition to ICD-10? If I don’t deal with Medicare claims, will I have to transition?
    Everyone covered by HIPAA must transition to ICD-10. This includes providers and payers who do not deal with Medicare or Medicaid claims.
12. What if I don’t make the transition to ICD-10?
    For HIPAA-covered entities, transition to ICD-10 is not an option. Claims for all services and hospital inpatient procedures performed on or after the compliance deadline must use ICD-10 diagnosis and inpatient procedure codes. This change does not apply to Current Procedural Terminology (CPT) coding for outpatient procedures. Without ICD-10, providers will experience delayed payments or even non-payments; increased rejected, denied or pending claims; reduced cash flows and ultimately lost revenues.

    It is important to note, however, that claims for services and inpatient procedures provided before the compliance date must use ICD-9 codes.
13. Is Medi-Cal policy going to change with ICD-10?
    Medi-Cal will be updating the provider manuals to account for the change to ICD-10 in 2014. However, due to the size of the ICD-10 code set and limitations in the legacy MMIS policy will not change.
14. Will Medi-Cal accept claims with both ICD-10 and ICD-9 codes on the same claim form?
    No. Medi-Cal will accept claim forms containing only ICD-9 or ICD-10 codes.
15. If I transition early to ICD-10, will Medi-Cal be able to process my claims?
    The U.S Department of Health and Human Services (HHS) has mandated that all HIPAA-covered entities will transition to the use of ICD-10 on October 1, 2014, and early or late transitions will not be allowed. Medi-Cal will not be able to process claims using ICD-10 until October 1, 2014.
16. Are paper claims affected by the transition to ICD-10?
    Yes. All claim transactions, whether paper or electronic, except dental claims, will be required to be submitted using ICD-10 codes. 
17. What type of training will providers and staff need for the ICD-10 transition?
    Medi-Cal will be providing education about the use of ICD-10 for submitting claims to Medi-Cal. Providers are encouraged to visit the Medi-Cal website regularly throughout the course of the transition to access the latest information about education opportunities.

    In addition, ICD-10 resources and training materials may be available through the Centers for Medicare & Medicaid Services (CMS), many professional associations and societies, and software/system vendors.
18. Where can I get additional information about ICD-10?
    More information about ICD-10 is available on the ICD-10 page of the CMS website.

    
    

    Providers may also submit ICD-10-related questions to the ICD-10 mailbox at ICD-10Medi-Cal@xerox.com.

    This article courtesy of: Medi-Cal http://files.medi-cal.ca.gov/pubsdoco/hipaa/hipaa_icd10_faqs.asp