National HIV Testing Day

June 27^th has been designated by the US Department of Health and Human Services to be National HIV Testing Day.

Since the discovery of the Human Immunodeficiency Virus in the 1980’s, HIV has affected numerous millions of people in the United States alone.   The CDC estimates more than 1.1 million people in the United States are living with HIV infection currently and about 50,000 new cases are diagnosed each year.

The CDC also reports that almost 1 in 5 (18.1%) of infected individuals are unaware of their infection.  As with any disease, the ideal way to fight the spread of HIV is with early detection.  It allows those who are diagnosed to initiate treatment as soon as possible, increasing survival chances and quality of life. This also helps to eliminate the chance of unknowingly spreading the disease to others.  

Healthcare professionals should take this opportunity to encourage high risk individuals to be screened for HIV.  Information on testing that is geared to provider education is provided on the aids.gov website.

For patients, a screening location finder can be found on the CDC website by clicking here or also at http://aids.gov/.

The table below lists basic on the Medicare coverage for HIV Screening.  Please consult the CMS Preventive Services website for complete detailed information.

Service	Procedure Code(s)	Coverage	Frequency
HIV Screening	G0432-Infectious agent by EIS technique G0433-Infectious agent by ELISA technique G0435-Infectious agent by rapid antibody test	Any beneficiaries at increased risk for HIV infection or pregnant.	Annually for high risk beneficiaries.  Three times per pregnancy.

Discharge Planning as Part of Community-Based Care Transition Program (CCTP)

CMS encourages Home Health Agencies, Hospices, Hospitals, Inpatient Psychiatric Facilities, Long-Term Care Facilities, and Swing Beds to review the guide on “Discharge Planning”(ICN 908184) found in the Medical Learning Network section of CMS.  This 20 page publication provides valuable detailed information for any provider of service involved in the patient discharge process.
CMS data suggests almost 20% of hospitalized Medicare patients are readmitted within 30 days of their discharge. This amounts to approximately 2.6 million beneficiaries being affected and costs the Medicare program an estimated $26 billion every year.

                                              

In an attempt to curb this expense, the CMS Innovation Center established by the Affordable Care Act has created the Community-Based Care Transition Program (CCTP).  The ACA has earmarked up to $500 million for the CCTP that was launched in 2011 and will run for 5 years.

                                   

The program starts with the basic principle that the healthcare community should work together to
improve quality of patient care.

                                             

The goal is to ultimately reduce hospital readmissions by a minimum of 20 % which would translate to a savings of $5.2 billion a year.  This represents a significantly larger amount than the initial cost to CMS for the program.

                                                

Data for 2012 suggests the program is already working by preventing an estimated 70,000 readmissions.

                                                

Enrolled participants, referred to as Community-based organizations (CBOs) now numbering over 100, will work with hospitals to coordinate patient care transitions.  If you would like to see who is participating in your area, you can select this link to access the CMS interactive map: http://innovation.cms.gov/initiatives/map/index.html?modelPass=CCTP

                                      

Care transitions as referred to in this program, relate to hospital inpatients that are being discharged to their home, a nursing home, or other care facility.  CBOs will use care transition services to identify risk factors that produce readmissions and coordinate the necessary actions to lessen the effect of those factors.

                                                                             

CBOs will be required to provide:

Care transition services that begin no later than 24 hours prior to discharge

Timely, culturally and linguistically competent post-discharge education to patients

NOTE:  This education is crucial so that patients understand potential additional health problems that may develop or a deteriorating condition.

Timely interactions between patients and post-acute and/or outpatient providers

Patient centered self-management support and information specific to the beneficiary’s condition

A comprehensive medication review and management

NOTE: This includes any appropriate counseling and self-management support.

                              

The CBOs will be paid an all-inclusive rate per eligible discharge based on the cost of care transition services provided at the patient level and of implementing systemic changes at the hospital level. CBOs will only be paid once per eligible discharge in a 180-day period of time for any given beneficiary.

                                           

Performance and effectiveness of the CBOs will be gauged by the evaluation contractor and the implementation and monitoring contractor.  Quality and utilization measures will consist of 30-day all cause readmission rates, and will also monitor 90-and 180-day readmission rates, mortality rates, observation services, and emergency department visits.  One major goal of the CCTP is to develop effective approaches to care interventions that will improve the quality of care while decreasing readmissions.  This transparency of the COB’s should ensure accurate evaluations of both successes and shortcomings of this program.

Please follow this link to the CMS site for full details on this program:
http://innovation.cms.gov/initiatives/CCTP/

Medicare: What is a Duplicate?

Each Medicare claims processing system contains criteria to evaluate all claims received for potential duplication.  The claims can be placed into two categories: exact duplicate or suspect duplicate.  Each category is processed uniquely by the Medicare contractor.

CMS has recently updated the Medicare Claims Processing Manual, Chapter 1, Section 120: “Detection of Duplicate Claims” based on change request (CR) 8121.

An exact duplicate claim is denied or rejected, if missing applicable modifiers, automatically by the claims processing system.

For exact duplicate denials, professional providers do have appeal rights, but institutional and DME providers do not.

If a claim is deemed suspect by the initial system review, the claim is suspended for further review by the Medicare contractor.

If suspect duplicate is denied after review, all providers have right to appeal.

 Due to the nature of the service, some claims may only appear to be duplicates.  Proper coding of the service with the applicable condition codes or modifiers will identify the claim as a separate payable service, not a duplicate.  An example could be modifiers “LT” and “RT” for bilateral procedures.

 By utilizing an advanced Medical Practice Management Billing Software like Iridium Suite from Medical Business Systems, duplicate claims submissions are easily prevented.  A configurable Claim Scrubber as found in Iridium Suite will check each service entered and alert the user immediately if the same service is already on record.  This gives the user the opportunity to determine if the service is a true duplicate or if the service qualifies for an appropriate addition of a modifier.

See the information below for details on the process Medicare utilizes to identify duplicate claims.

Provider of Service	Exact Duplicate	Suspect Duplicate
Institutional	Claim matches identically on the following data: 1. Health insurance claim (HIC) number 2. Type of bill 3. Provider identification number  4. From date of service 5. Through date of service 6. Total charges (on the line or on the bill) 7. HCPCS,  CPT-4, or procedure code/modifiers	Claim matches on the following data: 1. Beneficiary information 2. Provider identification 3. Same date of service or overlapping dates of service
Professional	Claim matches identically on the following data: 1. HIC number 2. Provider number 3. From date of service 4. Through date of service 5. Type of service 6. Procedure code 7. Place of service 8. Billed amount	The criteria for identifying suspect duplicate claims submitted by physicians and other suppliers vary according to the type of billing entity, type of item or service being billed, and other relevant criteria.
DME	Claim matches identically on the following data: 1. HIC number 2. From date of service 3. Through date of service 4. Place of service 22 5. HCPCS 6. Type of service 7. Billed amount 8. Supplier	The criteria for identifying suspect duplicate claims submitted by physicians and other suppliers vary according to the type of billing entity, type of item or service being billed, and other relevant criteria.

You can find the official instruction, CR 8121, issued to your FI, carrier, A/B MAC, RHHI, or DME MAC by clicking here.

Do you know MUE?

Working in medical billing is like being in a bowl of alphabet soup. 

One of the probably less common acronyms is MUE:  Medically Unlikely Edit.
Read below to find out what an MUE is, and why you should care.

A medically unlikely edit (MUE) is an automated claim processing edit that compares the number of units submitted for a procedure code against the designated maximum units that are typically reported for that code on the vast majority of appropriately reported claims.

 The edit is applied to services billed by a single provider/supplier to a single beneficiary on the same date of service.

The MUE program was developed by CMS in an effort to reduce the paid claims error rate for Medicare claims that result from various circumstances such as:

·         clerical entries
·         incorrect coding based on:

o   anatomic considerations

o   procedure code descriptors

o   procedure coding instructions

o   established CMS policies

o   nature of a service/procedure

o   unlikely clinical treatment

You can locate a listing of most MUE values on the CMS website:  http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.htmlon

CMS does not publish MUE values for some codes. Some MUE values are confidential and may not be published.

 CMS fiscal intermediaries and Part A/Part B Medicare administrative contractors (A/B MACs) process claims with the fiscal intermediary shared system (FISS).  They adjudicate MUEs against each line of a claim rather than the entire claim. If a procedure code is reported more than once, each line with that code is separately adjudicated against the MUE. They will deny the entire claim line if the unit of service (UOS) on the claim line exceeds the MUE value for the procedure code listed on the claim line.

For Example CPT Code 77300 is submitted on one service line for 11 units, if the MUE is 10, then all 11 are denied, instead of a just denying the one unit over the limit.

When there is a need to report medically reasonable and necessary units of service in excess of an MUE value modifiers can be used to report the same code on separate lines of a claim will enable a provider/supplier to report medically reasonable and necessary units of service in excess of an MUE value.

The modifiers noted below will accomplish this purpose.

• 76 -- Repeat procedure by same physician

• 77 -- Repeat procedure by another physician

• Anatomic modifiers (e.g., RT, LT, F1, F2, 50)

• When is it appropriate to bill modifier 50?

• 91 -- Repeat clinical diagnostic laboratory test

• 59 -- Distinct procedural service (Note: Modifier 59 should be utilized only if no other modifier describes the service.)

Effective April 1, 2013, CMS converted some claim line MUEs to date of service (DOS) MUEs.  The total units of service (UOS) from all claim lines for a HCPCS/CPT code with the same date of service will be summed and compared to the MUE value.  Claims denied based on DOS MUEs may be appealed usingsimilar processes to claim line MUE denials.  CMS does not publish which codes have DOS MUEs.  Since all UOS for a HCPCS/CPT code on all claim lines with the same date of service are summed, reporting additional UOS on separate claim lines with a HCPCS/CPT modifier will not result in payment of UOS in excess of the MUE value.

Key Medicare Benefits for Men’s Health

For those providers servicing Medicare beneficiaries, Men’s Health Awareness Week is a good time for you to re-familiarize yourself with the wide range of covered preventive services.  Identifying risk factors and utilizing screening tests for early detection can mean the difference between life and death. 

As demonstrated by the chart below, several of leading causes of death in males age 65 and over in the United States, are routinely linked to preventable and /or highly treatable causes.  This data was reported by Centers for Disease Control and Prevention for 2009.   

The table below lists the covered service detailing eligibility requirements and other useful billing information:

   

  

Service	Procedure Code(s)	Coverage	Frequency
Abdominal Aortic Aneurysm Screening	G0389-U/S exam AAA Screening	Any beneficiaries with certain risk factors and a referral resulting from an IPPE visit.	Once in a lifetime
Alcohol Misuse Screening and Counseling	G0442-Annual screening, 15 min. G0443-Brief face-to-face behavioral counseling for misuse, 15 min.	For screening: all beneficiaries. For misuse, furnished by PCP: all competent beneficiaries.	G0442-Once annually G0443-4 times per year
Annual Wellness Visit (AWV)	G0348-Initial Visit G0349-Subseqeunt Visit	Any beneficiary that has been effective for Part B for at least 1 year.	G0348- Once in a lifetime G0349- Once annually
Colorectal and Prostate Cancer Screenings	G0104-Flexible Sigmoidoscopy or G0106-Barium Enema G0105-Colonoscopy (high risk) or G0120-Barium Enema G0121-Colonoscopy (not high risk) G0328-Fecal Occult Blood Test immunoassay 82270- Fecal Occult Blood Test by peroxidase activity.	Any beneficiary aged 50 or over who are at normal or high risk for developing Colo-rectal cancer.	G0328/82270-Once annually G0104-Once every 4 years or 120 months after G0121 G0121-Once every 10 years or 48 months after G0104 or every 24 months for high risk G0106/G0120-Once every 48 months or 24 months for high risk.
Cardiovascular Disease Screenings	80061-Lipid Panel 82465-Cholesterol 83718-Lipoprotein 84478-Triglycerides	Any beneficiaries w/o signs or symptoms of cardiovascular disease	Every 5 years
Depression Screening	G0444-Annual screening, 15 min.	Any beneficiary as furnished by PCP with proper support staff.	Once annually
Diabetes Screening	82947-Blood Glucose; quantitative 82950-Glucose;post-glucose dose 82951-Glucose;3 specimen tolerance test	Any beneficiaries with risk factors or diagnoses with pre-diabetes.	Once annually if no pre-diabetes.  Twice annually with pre-diabetes.
HIV Screening	G0432-Infectious agent by EIS technique G0433-Infectious agent by ELISA technique G0435-Infectious agent by rapid antibody test	Any beneficiaries at increased risk for HIV infection or pregnant.	Annually for high risk beneficiaries.  Three times per pregnancy.
Immunizations (Seasonal Influenza, Pneumococcal, and Hepatitis B)	90654-90657, 90660-90662, Q2034-Q2039-Influenza Virus Vaccine/ G0008 administration 90669-90670,90732-Pneumococcal Vaccine/ G0009-Administration 90740,90743-90744, 90746-90747-Hepatitis B Vaccine/G0010 administration	Influenza and Pneumococcal: all beneficiaries. Hepatitis B:i any beneficiaries at intermediate or high risk for	Influenza- Once per season. Pneumococcal- Once in a lifetime. Hepatitis B- Scheduled dosages as required.
Intensive Behavioral Therapy for Cardiovascular Disease	G0446-IBT to reduce cardiovascular disease risk; individual, face-to-face, bi-annual, 15 min.	Furnished by PCP: Male beneficiaries aged 45-79-encouraging aspirin use, adults aged 18 or older- screening for hypertension, adults with risk factors- promoting a healthy diet	Once annually
Intensive Behavioral Therapy for Obesity	G0447-Behavioral counseling, face-to-face, 15 min.	Beneficiaries with BMI greater than or equal to 30 kg/m2, furnished by PCP.	One visit per week in first month. One visit every 2 weeks, months 2-6. One visit per month, months 7-12.
Prostate Cancer Screening	G0102-Digital rectal exam G0103-Prostate Specific Antigen test	All male beneficiaries aged 50 and older.	Once annually
Tobacco Use Cessation Counseling	G0436-Counseling for the asymptomatic patient; intermediate >3min. up to 10 min. G043-Couseling for the asymptomatic patient; intensive, > 10 min.	All outpatient and inpatient beneficiaries.	Two cessation attempts per year: attempt =  max of four sessions, up to eight sessions in 12 months.

For More Information:

• MLN Preventive Services Educational Products for Health Professionals

• CMS Prevention website

• CMS Immunizations website

• MLN National Provider Calls and Events website

• Men’s Health Month website