Road to 10: The Small Physician Practice's Route to ICD-10 From CMS

CMS has created “Road to 10” to help you jump start the transition to ICD-10.

 

Built with the help of small practice physicians, “Road to 10” is a no-cost tool that will help you:

• Get an overview of ICD-10
• Explore Specialty References by selecting a specialty
• Click the BUILD YOUR ACTION PLAN box to create your personal action plan

To get started and learn more about ICD-10, navigate through the links on the left side of the page. If you’re ready to start building an action plan, select the BUILD YOUR ACTION PLAN box after you follow the link below:

http://www.roadto10.org/

Specialties include: Family Practice, Pediatrics, OB/GYN, Cardiology, Orthopedics, Internal Medicine and other.

Improve Clinical Documentation for ICD-10

By Rhonda Buckholtz, CPC, CPMA from Physicians Practice

With less than a year left before the "go-live" date for ICD-10, industry focus is turning more and more to clinical documentation improvement (CDI), as it will be even more vital to every facility. -

Under ICD-10’s more rigorous specificity requirements, physician documentation will need to meet the higher standard as well. If your practice is fully prepared for ICD-10 in every other aspect, but clinical documentation has not improved, accurate coding and proper payment will not be possible.

A recent study of more than 20,000 audits of physicians’ clinical documentation revealed that only 63 percent of current documentation is sufficient for ICD-10’s specificity levels. Keep in mind, the insufficient documentation found in these audits often represented a larger percentage of at-risk revenue. For example, in one larger assessment, findings indicated seven of the most commonly used diagnosis codes accounted for 93 percent of the facility’s revenue.

Here are a few examples of where documentation changes will likely be needed:

Diabetes documentation must include:
• Type of diabetes
• Body system affected
• Complication or manifestation
• If a patient with type 2 diabetes is using insulin, a secondary code for long term insulin use is required

Neoplasms documentation must include:
•Type:Malignant (Primary, Secondary, Ca in situ)
Benign
Uncertain
Unspecified behavior
• Location(s) (site specific)
• If malignant, any secondary sites should also be determined
• Laterality, in some cases

Asthma documentation must include:
• Severity of disease:
Mild intermittent
Mild persistent
Moderate persistent
Severe persistent
• Acute exacerbation
• Status asthmaticus
• Other types (exercise induced, cough variant, other)

These are only a few examples of the more specific documentation requirements.

To avoid an increase in denied claims under ICD-10, perform an ICD-10 readiness assessment. Here's how:

Start by running a report in your computer system and sorting it by diagnosis code. Next, take your top 10 most commonly used diagnoses and run another report of patients that had those diagnoses appended to them. Pull 10 to 20 charts for your most commonly used diagnosis code. Review the ICD-10-CM guidelines (if there are any) for the chapter in which the diagnosis is located. Then, review the notes for diagnosis only. Look at the history and the assessment, and see how much can be coded under ICD-10-CM.

Based on the documentation, determine how many of these notes:
• Could be coded under ICD-10-CM
• Need more specific information to code
• Had to be coded to an unspecified code

Each provider in your facility should review these findings so they understand what documentation is needed to support this specific diagnosis in ICD-10. Then, move on to the next diagnosis on your top 10 list, and keep evaluating until your list is complete.

The facility should have a target percentage for the assessments and schedule future readiness evaluations, even if the goal is reached along the way.

How often these evaluations take place will depend on the number of providers at your facility, the number of different specialties, the type of specialties (some are seeing more changes in ICD-10 than others), and how providers perform. To ensure a smooth transition and a minimal impact on revenue, these assessments should become part of the regular audit process even after implementation of ICD-10. 

Courtesy of: Physicians Practice http://www.physicianspractice.com/blog/improve-clinical-documentation-icd-10?cid=fbP2Buckholtz120413

Back to School: Identify How ICD-10 Will Affect Your Practice

In order to be fully prepared for the October 1, 2014, ICD-10 transition, you need to know exactly how ICD-10 will affect your practice. Although many people associate coding with submitting claims, in reality, ICD codes are used in a variety of processes within clinical practices, from registration and referrals to billing and payment.
The following is a list of important questions to help you think through where you use ICD codes and how ICD-10 will affect your practice. By making a plan to address these areas now, you can make sure your practice is ready for the ICD-10 transition.

• Where do you use ICD-9 codes? Keep a log of everywhere you see and use an ICD-9 code. If the code is on paper, you will need new forms (e.g., patient encounter form, superbill). If the code is entered or displayed in your computer, check with your EHR and/or practice management system vendor to see when your system will be ready for ICD-10 codes.
• Will you be able to submit claims? If you use an electronic system for any or all payers, you need to know if it will be able to accommodate the ICD-10 version of diagnoses and hospital inpatient procedures codes. If your billing system has not been upgraded for the current version of HIPAA claims standards—Version 5010—you will not be able to submit claims. Check with your practice management system or software vendor to make sure your claims are in the HIPAA Version 5010 format and that your system or software can include the ICD-10 version of diagnoses and hospital inpatient procedures codes.
• Will you be able to complete medical records? If you use any type of electronic health record (EHR) system in your office, you need to know if it will capture ICD-10 codes. Look at how you enter ICD-9 codes (e.g., do you type them in or select from a drop down menu) and talk to your EHR vendor about your system’s capabilities for ICD-10. If your EHR system does not capture ICD-10 codes and you use another terminology (SNOMED), you will still need ICD-10 codes to submit claims.
• How will you code your claims under ICD-10? If you currently code by look up in ICD-9 books, purchase the ICD-10 code books in early 2014. Take a look at the codes most commonly used in your office and begin developing a list of comparable ICD-10 codes. Alternatively, check your software for an ICD-10 look up functionality.
• Are there ways to make coding more efficient? For example, develop a list of your most commonly used ICD-9 codes and become familiar with the ICD-10 codes you will use in the future; and invest in a software program that helps small practices with coding.

Want more information about ICD-10?
Visit the CMS ICD-10 website for the latest news and resources to help you prepare for the October 1, 2014, deadline. Sign up for CMS ICD-10 Industry Email Updates from CMS.

Courtesy of: Centers for Medicare & Medicaid Services (CMS) Weekly Digest Bulletin

New Measures in Pay-for-Performance Programs

Pay for performance, or P4P as it is more commonly known, is not a new concept and some plans have been using this type of initiative with providers for a decade or more. Those providers that participate in Medicare's Physician Quality Reporting System (PQRS) — which uses a combination of incentive payments and payment adjustments to promote reporting of quality information — as well as those participating in large Blues plans, will be most familiar with this model.

The shift What is new is the shift away from P4P as a "bonus" structure and a shift toward an "earning" structure. That is, the extent to which payers are incorporating P4P into their payment strategies means that a portion (or percentage) of providers' revenue is "earned" through meeting P4P targets or measures.  These new models are referred to as "value-based," shifting away from straight fee-for-service payments to some combination of performance- and fee-based compensation, which puts some of the financial risk on providers. The hope is this type of compensation model will improve the quality of care, reduce medical costs over time, and improve patient outcomes. So you can think of the newer P4P models as Pay for outcomes, or P4O.  Under Medicare  The Affordable Care Act expands P4P efforts in hospitals through the establishment of a Hospital Value-Based Purchasing Program begun last year, where hospitals are rewarded for how well they perform on a set of quality measures, as well as on how much they improve in performance relative to a baseline.  The healthcare law also extends the Medicare PQRS program through 2014. However, beginning in 2015 the incentive payments go away, and physicians who do not satisfactorily report quality data will see their payments from Medicare reduced. This marks the real beginning of P4O, in my view, due to the setting of a "quality care" baseline against which the ability to earn will then be tied.

By commercial payers For commercial payers, value-based contracts are springing up around Patient-Centered Medical Homes (PCMHs) and accountable care organizations (ACOs). However, new and negotiated contracts for generalized services — that is, practices that are not technically a PCMH or ACO — are now typically being crafted with P4P/P4O components that allow practices to "earn" additional dollars or year-to-year increases in multi-year contracts through meeting specific measures and targets.  Theses measure are typically HEDIS-based (Healthcare Effectiveness Data and Information Set) which is a widely used set of performance measures developed and maintained by the National Committee for Quality Assurance (NCQA). Many of these measures are focused on high-cost conditions such as heart disease, diabetes, high blood pressure, as well as preventive measures like immunizations and medication management. New and changed measures for 2014 include breast- and cervical-cancer screenings.

 Commercial payers utilizing P4P measures typically have a combination of HEDIS-type "quality" measures as well as "self-reported" measures, where practices can report on items such as EHR implementation and use, and status in achieving NCQA programs such as Patient-Centered Medical Home (PCMH), diabetes, heart/stroke, and back pain recognition programs. In addition to NCQA measures, there is substantial investment underway by the Agency for Healthcare Research and Quality (AHRQ) and other public policy organizations to identify further evidence-based medicine practices that could be used for measurement. And the National Quality Forum (NQF) is leading focused efforts to collect and normalize data, and endorse additional performance measures.

Article By Susanne Madden of physicians Practice http://www.physicianspractice.com/physician-compensation/new-measures-pay-performance-programs?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=31102013

Update to the Provider Remittance Advice Impacts as a Result of the Jurisdiction E Part B MAC Transition

Noridian has identified an impact to the content of the provider remittance advices as a result of the transition of pending workload from Palmetto Government Benefit Authorizers (PGBA) to Noridian.

Providers may notice the Glossary, Group, Reason, MOA, Remark and Adjustment Codes section of their remittance may contain verbiage that does not match the services provided.  The group codes and liability assigned to payments and denials may also be incorrect.

One example providers may notice is for claims that previously displayed CO-45 (Charge exceeds fee schedule/maximum allowable or contracted/legislated fee Arrangement) for payment.  These paid claims may incorrectly display on the remittance as a PR-150 (Payer deems the information submitted does not support this level of service).  As of 9/20/2013, this has been updated in Noridian's system. Please be aware that remittances generated on or after 09/20/13 may still show the incorrect verbiage depending on the status of the claim when the system was updated.

Noridian is currently working to correct history and provide corrected remittance advices to impacted providers.  Additional updates will be provided when they are available.

10/22/13 Update: Noridian has completed updating a large part of claims history that contained incorrect provider remittance advice messages.  We continue to work to update any remaining claims with incorrect messages.

Corrected provider remittance advices for all claims that were part of the history correction are expected to be generated in the next few weeks.  Further information regarding the dates and generation of the remittances will be provided when they are available.

Last Updated Oct 24, 2013

The Evolution of Government Intrusion on the Medical Profession

By Martin Merritt from Physicians Practice

This week found me sitting alone in our law firm library, preparing to defend a physician before the Texas Medical Board. In an era of electronic research, both legal and medical, it is rare to find anyone, (other than me), in the library. I not only enjoy flipping through real pages; some of which were bound and placed on these shelves 70 years ago, I enjoy getting momentarily sidetracked from my original mission.

I picked up this habit as kid reading the World Book Encyclopedia. Regardless of what I might be looking for, I would always stop and absorb eight to ten articles, just to learn about some historical fact I didn’t know existed.  

This week, flipping through historical reports of medical ethics cases, many dating to the 1950s, I began to see a clear picture of something I wasn’t expecting to find.  Virtually every federal regulatory concern currently plaguing the modern practice of medicine also existed in some form in the 1950s.

Comparable to Medicare RAC and external audits; physicians were losing their practices for improper charting and documentation. However, these losses usually pertained to life-and death matters, such as the prescription of narcotics. “Off-label promotion,” similar to the fen-phen scandal, usually concerned mundane, unapproved uses of common household remedies.

For example, a physician in the 1950s lost his license for charging patients $49 each for a treatment to remove gallstones using olive oil. (The board found that the oil, mixed with stomach acid, actually produced “soap balls,” not gallstones, as the physician improperly claimed.)

“Bundling and unbundling” issues were also present sixty years ago when a physician was disciplined by the board for routinely including fee-for-services charges that were already billed to the patient as part of the hospital’s charges.

Time and again, modern coding, charting and regulatory issues “pop” from the pages of history. Some cases represent quaint precursors to FTC “advertising” regulations. These appear as ethics disputes over the size of the lettering appearing on a physician’s office window, to questions about the exact line between acceptable public service promotion and impermissible advertising.

Half a century ago, one party was notably absent from the dusty pages of medical ethics cases: the federal government. There is a reason for this. Until the post-Civil War period of reconstruction, no federal laws governed a person’s conduct in any way. Slowly, beginning with the regulation of racially motivated murder, and laws pertaining to civil rights violations, Title 42 of the United States Code (containing laws related to civil rights and health and human services), began to grow in size and scope.

Today, in addition to racial offenses (42 U.S.C. §1983); Stark Law (42 U.S.C. 1395nn); the Anti-kickback Statute, (42 USC § 1320a–7b); HIPAA (42 U.S.C. § 300gg); and the Medicare law (42 U.S.C. 1395) are located in the growing Title 42 of the United States Code.

Many fear, and rightly so, that as healthcare insurance exchanges offered at healthcare.gov become fully operational, the federal takeover of the practice of medicine will soon be complete.

In the not-too-distant future, the common law principle, “A physician and patient are free to contract for services in any way they see fit,” will seem just as quaintly anachronistic as limits on the size of lettering on a physician’s office window.

Courtesy of Physicians Practice http://www.physicianspractice.com/blog/evolution-government-intrusion-medical-profession?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=22102013

Six ICD-10 Questions for Your Medical Claims Clearinghouse

By Lucien W. Roberts courtesy of Physicians Practice

It's September, and you've been busy since February preparing for ICD-10. No? Well, fortunately you still have 12 months to get ready. One key partner in your preparations should be your medical claims clearinghouse.

One of the things I learned from the HIPAA 5010 transition was that it hurt cash flow in way too many practices. I had the chance to observe two practices that had the same practice management system, the same payers, but different clearinghouses. One practice was a month down on cash flow well into the spring; the other had no cash flow disruption at all.

A very few clearinghouses made the 5010 transition seamless for practices; accepting both 4010- and 5010-formatted claims and then converting them, as necessary, on a payer-by-payer basis.  I never appreciated the value of a reliable clearinghouse partner until the 5010 transition.

So how does that lesson apply to the ICD-10 transition? As with 5010, your practice's cash flow will be at risk during the ICD-10 transition. Here are six questions to ask your clearinghouse as you prepare your practice for ICD-10.

1. Our practice suffered a disruption of cash flow during the 5010 transition. What will you do differently with ICD-10 to prevent a repeat performance?

(This is an optional question for practices that suffered during the 5010 transition. If you do not like the answer you get, consider moving to a clearinghouse whose 5010 performance was stronger.)

2. Would you please run a report of claims rejections and denials by ICD-9 code?

(And while you're at it, please provide guidance on how to prevent these errors.)

3. Would you run a similar report by payer?

(Such a report will give you a good basis for meeting with your key payers and discussing their ICD-10 conversion plans.)

4. Please run a report that identifies the "generic" codes each provider uses regularly.

(Generic ICD-9 codes (like 250.00 for Type II diabetes) are most likely to be denied by payers going forward. These codes should be your first priority as you commence ICD-9 to ICD-10 mapping.)

5. Could you share advice on mapping my superbill from ICD-9 to ICD-10?

(Coding remains each provider's responsibility. However, your clearinghouse may be helpful in this critical exercise.)

6. Could you share the progress of your discussions with my practice management vendor and my payers? When can we start sending test claims?

(Mapping from ICD-9 to ICD-10 is not an exact code-for-code proposition. Prudent practices will map — test — refine — test — refine their coding well before they submit their first real ICD-10 claim on Oct. 1, 2014.)

Post ICD-10 performance evaluation

TK Software of Carmel, Ind., is one clearinghouse whose clients were unaffected by the 5010 transition. TK Software's managing partner, Matt Behringer, shared their post-ICD-10 plans: "A post ICD-10 performance evaluation is critical," Behringer says. "Your clearinghouse should be able to create reports that show encounters, dollars billed, dollars rejected, and/or denied [claims] per day for each provider, pre- and post-ICD-10."

I agree. Ongoing cash flow in an ICD-10 world will require diligence and corrective education in the days and months following Oct. 1, 2014. A reliable clearinghouse partner helps, but it remains incumbent upon practices to begin their ICD-10 preparations now.

Article by: Lucien W. Roberts, III, MHA, FACMPE, is a consultant and a former practice administrator. For the past 20 years, he has worked in and consulted with physician practices in areas such as compliance, physician compensation, negotiations, strategic planning, and billing/collections. He can be reached at Lucien.roberts@yahoo.com.

Article courtesy of http://www.physicianspractice.com/icd-10/six-icd-10-questions-your-medical-claims-clearinghouse?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=19092013

How Practices Can Recover From a Bad EHR Implementation

By Erica Sprey from Physicians Practice

You and your management team have practiced due diligence throughout the selection and implementation of your new EHR. You've done everything by the book. So what's wrong?

Melding technology and people is a complex process, involving many moving parts.

Is your clinical team talking to your IT support team? Is it responding in an appropriate way? Do you have a strong project leader?

Carolyn Hartley is president and CEO of Physicians EHR, Inc., a Cary, N.C.-based consultancy that assists practices in EHR selection through
detailed implementation and preparedness for quality incentives.  Hartley also serves as consultant to the 62 Regional Extension Centers operated under HHS.

Physicians Practice recently spoke with Hartley about her Medical Group Management Association Annual Conference presentation, "Seven Symptoms of a Troubled EHR Implementation and What to Do About It." Her session is scheduled for Monday, Oct. 7.

Q: Why is it that so many practices have troubles with EHR implementation?

A: We don't get calls from practices that say, "Boy, I love my EHR." We get calls from people who are so angry, that their practice is just about ready to implode. One of [our] physicians said, "Purchasing a system is like having a car delivered to you in a box. There's a car in there if you can figure out how to put together the pieces, but we forgot to include the manual."

Q: There's a lot written about interoperability as many systems don't work together. For example, hospitals are using one system and practices are using another. Do you feel that this is part of the problem?

A: You know, the message from the vendors changes almost every year, on why [practices] should purchase systems. Two years ago, the message was, "You have to buy our system if you want to be interoperable with all the other people in your community." Now the message is "Guess what? We are willing to work with anybody." The problem is you have to have a middle-ware. And by that I mean an algorithm or list of components — first name, last name — [that] when combined creates the patient's identity. We don't have a standard for that yet.

Q: So, practices have bought a system and they are not particularly happy with it — what are the signs of a bad implementation?

A: No.1 in our book is finger pointing. [We hear] "The vendor didn't tell us that," or, "We have one EHR system and one [practice management] system from the same company, and I'm telling you, there are things that are dropping, and we don't know where to go for help."

Another is finger pointing from within, and that is the most dangerous one. We try to get into these as quickly as possible, when the physicians are just mad at each other. If they are mad at each other, then the practice is ripe for getting sold. It's ripe for having key people leave the practice.

Q: What are some things that people can do to recover from this?

A: Well, the good news is that an EHR can be stabilized. There are best practices and they provide a pathway for stability and profitability. We're kind of the bee that's pollinating the forest. We're saying, "Guess what? This worked with these guys in nephrology with this particular system." But we need to take a look at what's best in that practice. Because one of those physicians has figured it out.

Q: Can you talk to me about stabilizing the practice/vendor relationship?

A: Vendors generally know how the system works. …There's a huge rush to get so much market share during meaningful use incentives. So we have this massive market acquisition to say, "Get my system in place." But there wasn't enough backup to support those installs. The vendors know, going forward, they've got to stabilize their clients. Because they are facing anywhere from 35 percent to 75 percent of users at risk of going to a different system.

I coach the regional extension centers [RECs]. They've tried to be consistent in selecting the [EHR] systems. They tried to vet the systems for their primary-care providers. They also responded to the vendors saying, "We're good for primary care." But those vendors are also kind of costly. So, if those primary-care physicians had to go outside of the REC recommendation, and many of them did [because of cost constraints], they go outside and purchase something that is more affordable for them. Now, as we are going into Stage 2 [requirements] of meaningful use and [some] certified vendors cannot meet [requirements for Stage 2] … You have to be a pretty ambitious vendor in order to meet those requirements. So, some of them have huge user databases, [and] they are going to continue. But those that don't have a huge database have to figure out, "What am I going to do in 2014?"

Article by Erica Sprey, courtesy of: http://www.physicianspractice.com/mgma13/how-practices-can-recover-bad-ehr-implementation?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=04102013

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

 

 

What Practices Need to Do Now to Prepare for HIPAA Omnibus Changes

The September 23, 2013, deadline for when covered entities such as physician practices must be in compliance with the HIPAA Omnibus Final Rule is quickly approaching. The rule marks the most sweeping changes to the HIPAA Privacy and Security Rules since they were first implemented.

While the final rule brings about many changes, there are three in particular that likely warrant the most attention from practices now. The following column identifies those changes and provides practical guidance to meet the new requirements.

Change 1: The definition of what a "breach" is has been modified.
What it means: Under the old law, a breach was an event that "compromises the security or privacy of the protected health information (PHI) such that the use or disclosure poses a significant risk of financial, reputational or other harm to the affected individual." Under the new rule, the definition of a breach is expanded to include even just the "risk" of impermissible use or disclosure of PHI. For example, if you have patient records on a thumb drive and that drive is lost, if the records are not password-protected or encrypted, that will be considered a breach even if the data is never accessed by anyone. An incident report should be filed with your HIPAA officer. If you lose a laptop but can prove the computer is encrypted and nobody is able to access the information without a secure ID, thus indicating a low probability of the PHI becoming compromised, you will not have committed a breach.
What practices should do: Perform a complete risk assessment in an effort to minimize security holes and prevent possible breaches. Three of the most common causes of breaches are stolen laptops, lost or stolen external hard drives or thumb drives, and sending PHI through unsecured email.
Change 2: The definition of a "business associate" (BA) has been completely reworded.
What it means: A BA is essentially a company or any person who is not a member of the workforce for the covered entity but has access to PHI. This would include contractors and now, under the new rule, subcontractors under the BA. 
What practices should do: Review all BA agreements to see if they need to be revised or replaced. With older agreements, a BA could potentially include a clause that says the BA cannot be held liable for PHI breaches. Now, a BA can be held directly liable. BAs can still try to include the clause to remove themselves and their subcontractors from liability, but a practice would be wise to object to such a request and a BA will lack a strong argument for the clause's inclusion. An example of when a BA might be liable: If an IT company has an off-site data backup and somebody steals the backup device, the BA can be found personally liable for breach of all of the health records on that device. An example of when a subcontractor might be liable: If the IT company were to bring in a subcontractor to run network cable and electric lines in a new service center, that subcontractor would then be considered a BA and potentially liable since it could have access to PHI.Since all BAs are more stringent under the new HIPAA security laws, BAs themselves need to now remain HIPAA compliant.
Change 3: HIPAA audits will happen more frequently, fines will be substantially higher, and auditors will be incentivized to find security problems.
What it means: Periodic HIPAA audits by HHS were already authorized and underway, but covered entities can expect them to happen more frequently once the new rule is enacted.In addition, fines associated with penalties due to HIPAA violations will become significantly higher and essentially without a limit.Finally, auditors will receive what amounts to a "kickback" for each security violation discovered during an audit, which incentivizes auditors to dig deep and find any and all holes. 
What practices should do: The best practice is to perform at least quarterly risk assessments. This will help ensure security hole fixes put in place are working and holding and identify other potential problems. If you can indicate to an auditor that you performed a risk assessment, identified a problem, and have a plan in place to fix it, the auditor is more likely not to consider the problem an issue unless it remains unresolved. Many covered entities rely upon an external company to perform such risk assessments. These companies are not only skilled in identifying security problems and issues often overlooked by covered entity staff members, they have the knowledge and ability to take care of requirements such as creating policies and procedures for administrative safeguards, setting up employee training and changing all IT systems so they have a data backup plan, specific user names, and password policies in place.
Larger organizations may consider hiring someone to handle these responsibilities, but this may be cost prohibitive. For smaller organizations, it's often more cost-effective to hire a company to handle all of these tasks and help ensure year-round compliance.
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Article By Nelson Gomes and Michael Daly of Physicians Practice http://www.physicianspractice.com/blog/what-practices-need-do-now-prepare-hipaa-omnibus-changes?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=10092013

What Health Insurance Exchanges Mean for Physicians

Congress enacted the Affordable Care Act (ACA) to provide the means for uninsured Americans to purchase healthcare coverage.  Despite many legal battles and slipped deadlines, the new healthcare insurance exchanges — also known as marketplaces — will begin open enrollment on Oct. 1, 2013. The law provides for three options: one, where states will create and run their own exchanges; two, where they will create a hybrid exchange run by both the state and federal government; and three, where the federal government creates and runs the exchanges for states that have opted out. Coverage through the plans begins on Jan. 1, 2014.

Aside from great reservations expressed by many states, there are a number of unanswered questions where physicians and their practices are concerned. In part because so many states were reticent to fund and undertake the creation of a state-based exchange, progress to date varies widely. As of May 10, 2013, 25 states have been conditionally approved to operate some type of state-based exchange, according to The Center for Consumer Information & Insurance Oversight (CCIO).

And, because each state exchange is unique, the number and type of insurance companies that participate in the exchanges will be singular to each state.

So, what does this mean for physicians and their practices?

Sarah Dash, a faculty member at the Health Policy Institute at Georgetown University, says "fundamentally the exchange plans are just insurance plans. …The market is organized for the purpose of the consumer gaining easier access to those insurance plans. So, to some extent, it is the same thing." Since many people put off seeing the doctor because they are uninsured and can't afford the cost, experts have suggested that there will be a flood of sicker patients once the exchanges provide health insurance. Dash calls it "pent up demand." However, she is not convinced that this will be the case. She points out that the premise of the reform law's "insurance mandate" was to provide a good mix of healthy younger patients with older, potentially sicker patients. Owen Dahl, a practice management consultant based in The Woodlands, Texas, also believes that practices won't be deluged with new patients — but for a different reason. He says people who don't have insurance now are generally those who don't understand how it works and can't afford to pay for it.  "If I've been going to the emergency room for 15 years to get my care, [patients will say] 'Oh look, I've got this insurance, well I'm still going to go to the emergency room,'" says Dahl. He thinks that it will take time for people to change their behavior, which means practices will have plenty of time to prepare for newly insured patients. There is also trepidation among physicians that plans offered on the insurance exchanges will not pay well. As it is nearly impossible to predict reimbursement rates until the exchanges are fully established and patients are enrolled, it is perhaps a wasted effort for practices to dwell on this aspect. Dahl feels that plans offered on the exchanges may behave like managed-care plans. He says that it is likely that exchange plans will be offered by the major payers such as Blue Cross. "As far as the rates are going to be concerned, I think the best-case situation we could expect would be Medicare rates," he says. While that could mean lower revenues for practices, there are other aspects of the reform law which may be to their advantage. Dash says that "the point of the ACA is not to just give people an insurance card. It's to give people an insurance card that they can use. By that I mean, if the cost sharing is too high [in the forms of copays and deductibles], certainly that could be a deterrent."  She argues that through the law, patients will have access to tax subsidies and cost-sharing subsidies that should make it easier for patients to pay their bills. Certainly these changes will bring added administrative burdens to practices, but in many cases, they have already begun to implement new processes and quality improvements required by programs like Patient-Centered Medical Homes. Dahl advises practices "Do not panic." He says that while the business of medicine is most certainly changing, it won't happen overnight. "The important thing is for doctors to think about [the law] and to be prepared for that, but not react," he says.

Article By Erica Sprey - See more at: http://www.physicianspractice.com/blog/what-health-insurance-exchanges-mean-physicians#sthash.oenrJwFk.dpuf

"New" CMS-1500: WCMS-1500CS-12 Date of Implimentation Unknown (as of August 2013)

1500 Health Insurance Claim Form Change Log 6/17/2013 
The following is the list of changes between the 1500 Claim Form 08/05 version and the 02/12 version.

 

Header: The barcode was removed.

Header: The language “PLEASE DO NOT STAPLE IN THIS AREA” was removed from the left-hand side.

Header: The rectangle with “1500” was added in black ink to the left-hand side.

Header: The title “HEALTH INSURANCE CLAIM FORM” was moved from the lower, right-hand side to the left-hand side.

Header: The language “APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05” was added to the left-hand side.

Header: The language “TEST VERSION – NOT FOR OFFICIAL USE” was added to the right-hand side. This language will be removed when the form is approved by OMB.

Box 1: “TRICARE” was added above “CHAMPUS”.

Box 1: Under CHAMPVA, “VA File #” was changed to “Member ID#”.

Box 17a: The box was split in half length-wise.

Box 17a: This area was shaded. This box will accommodate other ID numbers.

Box 17a: Two vertical lines were added. This field will accommodate a two byte qualifier for other ID numbers.

Box 17b: This field was added.

Box 17b: Two vertical lines were added with the “NPI” label. This field will accommodate the NPI number.

Box 21: The lines after the decimal point in items 1, 2, 3, and 4 were extended to accommodate four bytes.

Box 24: The line with the alpha indicators was removed. The alpha indicators were moved next to the respective titles in the title fields.

Box 24: The line numbers to the left of Box 24 were increased in size and centered with each line.

Box 24: Each of the six lines were split length-wise and shading was added to the top portion of each line. This area is to be used for the reporting of supplemental information.

Box 24: Vertical line separators on each of the six lines have been removed from the shaded area,               except for the lines before Boxes 24I and 24J.

Box 24C: “Type of Service” was removed. This field is now titled “EMG”.

Box 24D: The field became wider by three bytes.

Box 24D: Shading was added vertically between “CPT/HCPCS” and “MODIFIER”.

Box 24D: Vertical lines were added in the unshaded “MODIFIER” section to accommodate four                  sets of two bytes.

Box 24E: The title was changed from “DIAGNOSIS CODE” to “DIAGNOSIS POINTER”.

Box 24E: The field was decreased by three bytes.

Box 24G: This field was increased by one byte.

Box 24H: This field was decreased by one byte.

Box 24I: The title was changed from “EMG” to “ID. QUAL.”.

Box 24I: A horizontal line was added length-wise across the field separating the shaded and unshaded portions of the field.

Box 24I: The label “NPI” was added in the unshaded portion of the field.

Box 24J: The title was changed from “COB” to “RENDERING PROVIDER ID. #”. 1500 Claim                            Form Change Log – 11/29/05

Box 24J: A dotted horizontal line was added length-wise across the field separating the shaded and unshaded portions of the field. The NPI number is to be reported in the unshaded field. An other ID number can be reported in the shaded field.

Box 24K: This field, “RESERVED FOR LOCAL USE”, was removed.

Box 32: Boxes 32a and 32b were added at the bottom.

Box 32a: This field was added to accommodate reporting of the NPI number and is indicated by the shaded label of “NPI”.

Box 32b: This shaded field was added to accommodate the reporting of other ID numbers.

Box 33: Parentheses were added after the title to indicate the location for reporting the telephone number.

Box 33: Boxes 33a and 33b were added at the bottom.

Box 33a: The title of this field was changed from “PIN#” to “a.”.

Box 33a: A shaded label of NPI was added to the box to indicate the reporting of the NPI number.

Box 33b: The title was changed from “GRP#” to “b.” to accommodate the reporting of other ID numbers.

Box 33b: The field was shaded.

Footer: The language “NUCC Instruction Manual available at: www.nucc.org” was added to the left-hand side.

Footer: The OMB approval numbers were removed and the language “OMB APPROVAL                 PENDING” was added. The numbers will be added after approval has been received by OMB.

Back: The following language was added in the last line at the bottom of the form: “This address     is for comments and/or suggestions only. DO NOT MAIL COMPLETED CLAIM  FORMS TO THIS ADDRESS.”

 

Courtesy of HMBA

The Affordable Care Act and Model 4 Bundled Payments for Care Improvement

Jurisdiction 1 Part B

The Affordable Care Act and Model 4 Bundled Payments for Care Improvement 

MLN Matters® Number: MM8070
Related Change Request (CR) #: 8070
Related CR Release Date: June 27, 2013
Effective Date: July 1, 2013
Related CR Transmittal #: R1251OTN
Implementation Date: July 1, 2013

Note: This article was revised on July 26, 2013, to reflect a revised Change Request (CR). The CR added Part B MAC responsibility to the CR's business requirement 18.3. The release date, transmittal number and link to the CR was also changed. All other information remains the same.

Provider Types Affected This MLN Matters® Article is intended for hospitals, physicians, and non-physician providers participating in the Model 4 Bundled Payments for Care Improvement (BPCI) initiative and submitting claims to Medicare contractors (Fiscal Intermediaries (FIs) and A/B Medicare Administrative Contractors (MACs))
for services to Medicare beneficiaries.

What You Need to Know This article provides an overview of Medicare’s implementation of the Model 4 Bundled Payments for Care Improvement initiative. General program information is provided along with separate sections containing information of special interest to hospitals and physicians and non-physician providers. It addresses issues related to readmissions, claims crossover, remittance advice, and claims submission, among others. This pilot program is being conducted under the Centers for Medicare & Medicaid Services (CMS) Innovation Center’s model testing authority. The program is slated to be implemented in October 2013.

Background The Affordable Care Act provides a number of new tools and resources to help improve health care and lower costs for all Americans. Bundling payment for services that patients receive during a single episode of care, such as heart bypass surgery or a hip replacement, is one way to encourage doctors,
hospitals, and other health care providers to work together to better coordinate care for patients, both when they are in the hospital and after they are discharged. Such initiatives can help improve health, improve quality of care, and lower costs.

CMS is working in partnership with providers to develop models of bundling payments through the BPCI initiative. On August 23, 2011, CMS invited providers to apply to help test and develop four different models for bundling payments. Model 4, one of these four models, is discussed in this article. In Model 4, the episode of care is defined as the acute care hospital stay and includes inpatient hospital services, Part B services furnished during the hospitalization, and hospital and Part B services for related readmissions.

Information in this article is based on the change requests implemented for Bundled Payments for Care Improvement Model 4, including CRs 7887, 8070, and 8196.

General BPCI Model 4 Information
Beneficiary Eligibility In order to be eligible for Model 4, the beneficiary must meet the following requirements:

• Beneficiary is eligible for Part A and enrolled in Part B;
• At the time of admission, beneficiary either (a) has at least 1 day of utilization left and that day is also a day of entitlement or (b) has at least one lifetime reserve day remaining;
• Beneficiary does not have End-Stage Renal Disease;
• Beneficiary is not enrolled in any managed care plans;
• Beneficiary must not be covered under the United Mine Workers; and
• Medicare must be the primary payer.

If the beneficiary does not meet all of these requirements, the following codes will be assigned to rejected or cancelled NOAs:

• Claims Adjustment Reason Code (CARC) B5: Coverage/program guidelines were not met or were exceeded.
• Remittance Advice Remarks Code (RARC) N564: This patient did not meet the inclusion criteria for the demonstration project or pilot program.

Model 4 Bundled Payment Provision Hospitals that participate in the BPCI Model 4 initiative will receive a prospectively established bundled payment for agreed upon Medicare Severity Diagnosis Related Groups (MS-DRGs).

• This will not apply to claims that are paid on a transfer per-diem basis.
• This payment will include both the DRG payment for the hospital and a fixed amount for the Part B services anticipated to be rendered during the admission.

Separate payment for providers’ professional services rendered during the inpatient hospital stay will not be made.

• Participating Model 4 hospitals receiving a Model 4 payment will be responsible for paying providers who would otherwise be paid separately for professional services under the Physician Fee Schedule (PFS).
• Claims from physicians will be processed as no-pay claims if they occur between the inpatient hospital admission and discharge date in order to prevent duplicate payment of physicians under the bundled payment.

Co-payments, Co-insurance, and Deductibles

• The regular Part A deductible, including the Part A blood deductible, and daily coinsurance amounts (when applicable) will continue to be applied to the claim.
• The fixed Part B portion of the negotiated bundled payment will first be applied to the Part B deductible, if applicable.
• A fixed Part B copayment will be applied to the claim. This will be the responsibility of the beneficiary and will be calculated as an approximation of what the Part B coinsurance would have been in the absence of Model 4.
• Both the copayment and the deductible to be paid by the beneficiary for the Part B services will appear on the MSN along with the Part A deductible and any applicable coinsurance.

Appeals Payments made under Model 4 have no rights of appeal, except in the case of calculation errors.

• RARC N83: No appeal rights. Adjudicative decision based on the provisions of a demonstration project.

Information for Hospitals

Notification of Admission (NOA) Hospitals participating in this initiative should submit a Notice of Admission (NOA) when a beneficiary expected to be included in the model is admitted. Timely filing of the NOA allows subsequent Part B claims submitted before the hospital claim to be properly processed as “no-pay” claims, which indicates
that payment for these claims are to be included in hospital payments under Model 4. By extension, these Part B claims will then be included timely on weekly Part B reports provided to the hospital to be used in calculating payments for Part B providers.

• Hospitals will be paid a $500 payment upon submission of the NOA and will receive the balance of the prospectively established bundled payment when the hospital claim is processed.
  • RARC N568: Initial payment based on the Notice of Admission (NOA) under the Bundled Payment Model IV initiative.
  • If the patient ultimately does not qualify for a Model 4 prospective payment based on the MS-DRG ultimately assigned to their inpatient stay, or if the NOA is cancelled, the $500 NOA payment will be recouped.
  • Medicare systems will initiate a “look back” into the claims history records upon receipt of a canceled NOA to identify Model 4 BPCI claims- i.e., Part B physician or other professional claims - which were processed as "no pay" as a result of the NOA being opened. If such claims were processed, the Medicare contractor will adjust the claims automatically and remit payment for services rendered based on regular Medicare Fee-for-Service claims processing rules.
  • Hospitals must submit the final claim within 60 days of the beneficiary’s hospital admission or submit an interim claim during that time period to demonstrate that the beneficiary is still an inpatient. Otherwise, the beneficiary will be considered not subject to episode payment and the $500 will be recouped.
    • The following codes will be assigned when a Model 4 claim matches an NOA for admission date and beneficiary, but not provider.
      • CARC 208: National Provider Identifier - Not matched
      • RARC N562: The provider number of your incoming claim does not match the processed Notice of Admission (NOA) for this bundled payment
  • The following codes shall be assigned when an NOA is cancelled because a matching claim is not received within 60 days. A match consists of beneficiary, admit date, and provider.
    • CARC 226: Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete
    • RARC N560: This pilot program requires an interim or final claim within 60 days of the Notice of Admission. A claim was not received

Readmissions Model 4 hospitals will not be paid for readmissions that occur to the same hospital (i.e., another admission with a date of admission within 30 days of discharge of the Model 4 stay) under this model unless the MS-DRG assigned to that readmission is expressly excluded as unrelated to the MS-DRG assigned to the original admission.

• Unrelated readmissions have been defined by CMS, and a list of DRGs defining unrelated readmissions has been provided for each included MS-DRG to every Model 4 participating hospital. This list can also be found on the Bundled Payments collaboration site, accessible to Model 4 Awardees.
• Related readmissions to a hospital other than the original treating hospital, as well as payments for physicians’ services during related readmissions to hospitals other than the original treating hospital, will be reconciled retrospectively by a BPCI payment reconciliation contractor and payment will be recouped, as applicable, by the Model 4 awardee.
• If claims for a Model 4 anchor admission and a readmission are submitted out of order, the readmission claim will be canceled and must be resubmitted to receive payment. The following codes will be used in this situation:
  • CARC 249: This claim has been identified as a readmission.
  • RARC N561: The bundled payment for the episode of care includes payment for related readmissions. You may resubmit your claim to receive a corrected payment.

Payment Rate Updates and Adjustors Payment rates may be updated as often as quarterly to allow for ongoing updates to Medicare payment rates, including regular recurring changes made to the Physicians Fee Schedule (PFS) and Inpatient Prospective Payment System (IPPS). Indirect Medical Education (IME) and Disproportionate Share Hospital (DSH) payments, as well as outlier payments and hospital capital payments to Model 4 hospitals will be calculated based on the non-discounted base DRG payment that would have been made in the absence of the model. This is true for both anchor admissions and related readmissions to the Model 4 hospital. In the case of readmissions, these payments will be denoted by the following:

• CARC 249: This claim has been identified as a readmission.
• RARC N524: Based on policy this payment constitutes payment in full.

Other applicable payment adjustors will also be calculated based on the base DRG that would otherwise have applied to the case, as opposed to the prospectively established amount paid through this initiative, which will be higher as it includes payment for Part B services in addition to the base DRG
payment.

Information for Physicians and Non-Physician Providers
Claims Submission and Processing Physicians and non-physician practitioners shall submit claims for dates of service during an episode of care included in Model 4 BPCI as usual.

Physicians and non-physician practitioners shall be required to accept assignment for all claims covered under the Model 4 BPCI payment.

For those Part B services rendered during a Model 4 admission or a related readmission to that Model 4 hospital, Medicare will process claims as no-pay. In processing no-pay professional claims, Medicare will assign the following:

• CARC 234: This procedure is not paid separately.
• RARC N67: Professional provider services not paid separately. Included in facility payment under a demonstration project. Apply to that facility for payment, or resubmit your claim if: the facility notifies you the patient was excluded from this demonstration; or, if you furnished these services in another location on the date of admission or discharge from a demonstration hospital. If services furnished in a facility not involved in the demonstration on the same date the patient was discharged from or admitted to a demonstration facility, you must report the provider ID number for the non-demonstration facility on the new claim.

Physicians submitting claims should take care not to include on the same claim services that are both within the dates (admission and discharge) of a Model 4 BPCI episode and outside the dates of the episode. If such claims with both Model 4 and non-Model 4 services are received, Medicare contractors will reject the claims and advise the physician to separate the services and rebill. The following remittance messages will be used in this situation:

• CARC 239: Claim spans eligible and ineligible periods of coverage. Rebill separate claims.
• RARC N61: Rebill services on separate claims.

Incentive Payments Bonus or incentive payments calculated by CMS, such as HPSA bonus payments, will not be affected by physician or non-physician practitioner participation in the Bundled Payments initiative.

Participation Declination Physicians have the right to decline participation in this program. Declination will be indicated by including a HCPCS modifier on each claim. Further details will be provided at a future date.

Readmissions Part B services provided during a related readmission to the original treating hospital will not be paid separately. If Part B claims were processed prior to receipt of the hospital's readmission claim, Medicare will take steps to recover payments to the physician.

• CARC A1: Claim/Service Denied; and
• RARC N68: Prior payment being cancelled as we were subsequently notified this patient was covered by a demonstration project in this site of service. Professional services were included in the payment to the facility. You must contact the facility for payment. Prior payment made to you by the patient or another insurer for this claim must be returned within 30 days.

Claims Crossover In association with this initiative, CMS will make changes to allow for the reporting of two new Claim Adjustment Reason Codes (CARCs) within the 2320 Claim Adjustment Segment (CAS), so that supplemental payers can more easily determine these amounts when adjudicating Medicare Health Insurance Portability and Accountability Act (HIPAA) 837 institutional Coordination of Benefits (COB)/crossover claims.

• CARC 247 will be defined as “Part B deductible on a Part A claim.”
• CARC 248 will be defined as “Part B coinsurance on a Part A claim.”
• An adjusted RARC M137 will be defined as “Part B coinsurance under a demonstration project or pilot program.

This initiative will also result in the reporting of a new value code within the 2300 Health Care nformation Codes (HI) Value Information (qualifier BE) portion of outbound HIPAA 837 institutional COB/crossover claims.

Additional Information
The official instruction, CR8070, issued to your Medicare contractor regarding this change may be viewed at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1251OTN.pdf on the CMS website. In addition, CR8196 is available at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1189OTN.pdf and CR7887 is available at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1240OTN.pdf on the CMS website.

Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2012 American Medical Association.

Courtesy of : Palmetto GBA http://www.palmettogba.com/palmetto/providers.nsf/ls/J1B~9A5Q6C6034?opendocument&utm_source=J1BL&utm_campaign=J1BLs&utm_medium=email

4 J code Options Help you Determine Strep Throat Diagnoses: ICD-9 to ICD-10

Wait for lab results before assigning the final code.

ICD-9 coding: When using the ICD-9-CM code set, you report 034.0 (Streptococcal sore throat) if the patient suffers from streptococcal laryngitis. The ICD-9 manual also directs you to 034.0 if the patient suffers from streptococcal tonsillitis or pharyngitis.

ICD-10 changes: When ICD-10 becomes effective in October 2014, you won't have a simple catch-all code for streptococcal throat infections. Instead, ICD-10 will differentiate between streptococcal laryngitis, pharyngitis and tonsillitis, so your documentation will need to specify type. The four diagnosis choices will be:

• J02.0 (Streptococcal pharyngitis)
• J03.00 (Acute streptococcal tonsillitis, unspecified)
• J03.01 (Acute recurrent streptococcal tonstillits)
• J04.0 (Actue laryngitis)

Code j04.0 requires you to use an additional code to report the infections agent. For strep, that code would be B95 (Streptoccoccus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere), with the exact code depending on the nature of the streptococcus.

Documentation tip: Don't report the strep throat diagnosis code unless your physician receives confirmation from a lab test (either rapid strep or throat culture) indicating that the patient tested positive for a streptococcal throat infection. If you don't have a positive lab test confirming strep throat, you should simply report the diagnosis codes for the symptoms (such as sore throat, fever, etc).

Vital: Your documentation must include a copy of the laboratory report confirming that the patient had strep throat before you select your diagnosis code.

The family physician will ned to clearly note which type of throat condition the patient has, so you can code accordingly to whether the pateint's streptococcal infection affected the larynx, pharynx or the tonsils.

In addition, if the patient suffers from streptococcal tonstillits, you will have to further delineate whether he is experiencing an unspecified or recurrent acute condition. If you use, J03.01 (recurrent), your documentation must confirm that the patient has suffered from the condition in the past.

Coder tips: Make sure that you print the new strep throat codes on your superbills prior to ICD-10 implementation, and let your practicioners know that they will need to differentiate between streptococcal laryngitis, phyryngitis, and tonstillits.

Courtesy of: The Coding Institute: Family Practive Coding Alert

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.

What you can do to prepare for the transition from Medicare claims administrator Palmetto to Noridian

What you can do to prepare your practice for the transition from Medicare claims administrator Palmetto to Noridian?
The transition from Medicare claims contractor Palmetto GBA to Noridian takes place on September 16, 2013 (Part B). During the transition, Noridian is encouraging providers that submit electronic claims to take advantage of an ‘early boarding’ opportunity.
Early boarding will allow providers to connect to Noridian’s EDI Support Services gateway prior to the transition. Noridian will act as a clearinghouse, collecting claims, performing basic front-end editing and then sending the claims to Palmetto GBA for processing and payment.
Providers that use a vendor to submit claims do not need to take any action. Your vendor will be working with Noridian directly to connect. However, providers should check with vendors to ensure this is occurring and encourage them to make contact with Noridian if it is not.
If you bill directly, you can take the necessary steps to ‘board early’ by reading an article published online by Noridian titled: Noridian Jurisdiction E (JE) Early Boarding Has Begun.
The Centers for Medicare and Medicaid Services also asks that physicians check to make sure that their National Provider Identification (NPI) numbers are updated in the National Plan and Provider Enumeration System (NPPES) are up to date and consistent with information in the Provider Enrollment, Chain and Ownership System (PECOS). According to Noridian, the number one reason for problems during similar transitions is inaccurate NPI data in the NPPES system. Updates can be made on the NPPES website.
Noridian has also set up "Meet and Greet" workshops throughout the state. The California Medical Association (CMA) encourages practices to take advantage of this opportunity to meet Noridian staff and learn about the transition, including what will and will not change with the transition from Palmetto to Noridian.
To stay up to date on the latest news related to the Noridian transition, see CMA's Medicare Transition webpage at www.cmanet.org/medicare-transition.

This article courtesy of: http://www.cmanet.org/news/detail/?article=what-you-can-do-to-prepare-your-practice-for

House bill would stop ICD-10 mandate

Legislation introduced in the U.S. House would prohibit the Dept. of Health and Human Services from mandating that physicians use ICD-10 diagnosis codes beginning Oct. 1, 2014.

The bill, the Cutting Costly Codes Act of 2013, would stop the required transition to new diagnosis code sets by physicians who are billing for medical services, verifying patient eligibility, obtaining pre-authorizations, documenting patient visits, and conducting both public health reporting and quality reporting. The mandated switch to the 68,000-code system had been established in a 2009 regulation. HHS announced in 2012 that its implementation deadline had been delayed by one year to 2014.

The American Medical Association wrote an April 26 letter to Rep. Ted Poe (R, Texas) in support of his legislation. Physician practices must bear the cost of training, software upgrades and testing of the new system. The projected cost of ICD-10 implementation ranges from $83,290 to more than $2.7 million per practice, the AMA letter stated.

“The timing of the ICD-10 transition could not be worse, as many physicians are currently spending significant time and resources implementing electronic health records into their practices,” the AMA said. “Physicians are also facing present and future financial burdens in the form of penalties if they do not successfully participate in multiple Medicare programs already under way, including e-prescribing, EHR meaningful use, the physician quality reporting system and value-based modifier programs.”

The House legislation also would authorize the Government Accountability Office to study ICD-10 and recommend ways to mitigate upgrade disruptions within the health care system.

 

This article courtesy of: http://www.amednews.com/article/20130513/government/130519980/10/?utm_source=rss&utm_medium=&utm_campaign=20130708

 

ICD-10 DEADLINE OCT 1, 2014

The ICD-10 Transition: An Introduction

The ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. This fact sheet provides background on the ICD-10 transition, general guidance on how to prepare for it, and resources for more information.

About ICD-10

ICD-10-CM/PCS (International Classification of Diseases, 10th Edition, Clinical Modification /Procedure Coding System) consists of two parts:

 

1. ICD-10-CM for diagnosis coding

 

2. ICD-10-PCS for inpatient procedure coding

ICD-10-CM is for use in all U.S. health care settings. Diagnosis coding under ICD-10-CM uses 3 to 7 digits instead of the 3 to 5 digits used with ICD-9-CM, but the format of the code sets is similar.

 

ICD-10-PCS is for use in U.S. inpatient hospital settings only. ICD-10­ PCS uses 7 alphanumeric digits instead of the 3 or 4 numeric digits used under ICD-9-CM procedure coding. Coding under ICD-10-PCS is much more specific and substantially different from ICD-9-CM procedure coding.

 

The transition to ICD-10 is occurring because ICD-9 produces limited data about patients’ medical conditions and hospital inpatient procedures. ICD-9 is 30 years old, has outdated terms, and is inconsistent with current medical practice. Also, the structure of ICD-9 limits the number of new codes that can be created, and many ICD-9 categories are full.

 

Who Needs to Transition

ICD-10 will affect diagnosis and inpatient procedure coding for everyone covered by Health Insurance Portability Accountability Act (HIPAA), not just those who submit Medicare or Medicaid claims. The change to ICD-10 does not affect CPT coding for  outpatient procedures.

 

Health care providers, payers, clearinghouses, and billing services must be prepared to comply with the transition to ICD-10, which means:

• All electronic transactions must use Version 5010 standards, which have been required since January 1, 2012. Unlike the older Version 4010/4010A standards, Version 5010 accommodates ICD-10 codes.
• ICD-10 diagnosis codes must be used for all health care services provided in the U.S., and ICD-10 procedure codes must be used for all hospital inpatient procedures. Claims with ICD-9 codes for services provided on or after the compliance deadline cannot be paid.

 

Transitioning to ICD-10

It is important to prepare now for the ICD-10 transition. The following are steps you can take to get started:

 

• Providers – Develop an implementation strategy that includes an assessment of the impact on your organization, a detailed timeline, and budget. Check with your billing service, clearinghouse, or practice management software vendor about their compliance plans. Providers who handle billing and software development internally should plan for medical records/coding, clinical, IT, and finance staff to coordinate on ICD-10 transition efforts.
• Payers – Review payment policies since the transition to ICD-10 will involve new coding rules. Ask your software vendors about their readiness plans and timelines for product development, testing, availability, and training for ICD-10. You should have an implementation plan and transition budget in place.
• Software vendors, clearinghouses, and third-party billing services – Work with customers to install and test ICD-10 ready products. Take a proactive role in assisting with the transition so your customers can get their claims paid. Products and services will be obsolete if steps are not taken to prepare. 

 http://www.cms.gov/Medicare/Coding/ICD10/index.html