Medicare Payment Reductions for Diagnostic Cardiovascular, Imaging and Ophthalmology Proceduresvascular, Imag

Section 3134 of the Affordable Care Act added Section 1848(c)(2)(K) of the Social Security Act which specifies that the Secretary shall identify potentially misvalued codes by examining multiple codes that are frequently billed in conjunction with furnishing a single service. As a further step in implementing this provision, Medicare is making a change to the MPPR on the PC and TC of certain diagnostic imaging procedures and to the TC of diagnostic cardiovascular and ophthalmology procedures.

See below for details:

                                               

Application of the Multiple Procedure Payment Reduction (MPPR) on Imaging Services to Physicians in the Same Group Practice 

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7747.pdf

Currently, the MPPR applies only when an individual physician furnishes multiple services to the same patient, in the same session, on the same day. The Centers for Medicare & Medicaid Services (CMS) is expanding the MPPR of imaging services by applying it to physicians in the same group practice (same Group National Provider Identifier (NPI)) who furnish multiple services to the same patient, in the same session, on the same day.

The MPPR on certain diagnostic imaging services applies to Professional Component (PC) and Technical Component (TC) services. It applies to both PC-only services, TC-only services, and to the PC and TC of global services. Full payment is made for each PC and TC service with the highest payment under the Medicare Physician Fee Schedule (MPFS). Payment is made at 75 percent for subsequent PC services furnished by the same physician group, to the same patient, in the same session, on the same day. Payment is made at 50 percent for subsequent TC services furnished by the same physician group, to the same patient, in the same session, on the same day. The individual PC and TC services with the highest payments under the MPFS of globally billed services must be determined in order to calculate the reduction.

The complete list of codes subject to the MPPR on diagnostic imaging can be found in Attachment 1 of CR7747, which is available on the CMS website at:

http://www.cms.gov

Multiple procedure payment reduction on the technical component of diagnostic cardiovascular and ophthalmology procedures

The MPPRs on diagnostic cardiovascular and ophthalmology procedures apply when multiple services are furnished to the same patient on the same day. The MPPRs apply independently to cardiovascular and ophthalmology services. The MPPRs apply to TC only services, and to the TC of global services.

For cardiovascular services, full payment is made for the TC service with the highest payment under the MPFS. Payment is made at 75 percent for subsequent TC services furnished by the same physician or physician group to the same patient on the same day.

For ophthalmology services, full payment is made for the TC service with the highest payment under the MPFS. Payment is made at 80 percent for subsequent TC services furnished by the same physician or physician group to the same patient on the same day.

The MPPRs do not apply to professional component (PC) of diagnostic cardiovascular and ophthalmology services.

The complete lists of codes subject to the MPPRs on diagnostic cardiovascular and ophthalmology procedures are in Attachments 1 and 2 of CR 7848 respectively. CR 7848 can be found on the CMS website at:

http://www.cms.gov

Billing Hint:
Medicare is applying the MPPR to physicians in the same group practice who furnish multiple services to the same patient, in the same session, on the same day. Medicare will assume procedures furnished on the same date of service were furnished in the same session unless the provider uses modifier 59 to indicate multiple sessions, in which case the reduction does not apply.  If multiple sessions did occur, explicit and detailed documentation will be required in case of an audit of the billed services.

Fee Schedule Information:

To accommodate implementation of this new proposal for certain bill types, the 2013 Medicare physician fee schedule will include the following changes:

1. A new multiple procedure (Field 21) value of ‘6’ will denote diagnostic cardiovascular services subject to the MPPR methodology.

2. A new multiple procedure (Field 21) value of ‘7’ will denote diagnostic ophthalmology services subject to the MPPR methodology.

Explanation of Benefits Information:

When payments are reduced due to the MPPR, you will receive a claim adjustment reason code of 59 (Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia,) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.) and group code CO (contractual obligation).

 For further information and questions, please contact your carrier or A/B MAC .

Claim Scrubber Optimizes Radiation Therapy Claims Reimbursement

Coding claims is tricky.

Radiation oncology billing is especially difficult because of the planning and staging processes that occur prior to treatment. On a bad day a coder can create future problems that are difficult to remedy.  Fortunately, Iridium Suite offers a safety net to help you avoid the pitfalls of improper coding.

A claim scrubber is a built-in editor, like spell check, except it is automatic. Iridium Suite medical system software features a scrubber that has many capabilities, so a biller can be confident that many billing violations will be caught by the claim scrubber before the claim is generated.  The claim scrubber is present and active in the background during billing work, whether during the importing of charges from outside systems (such as record and verify systems or EMR's/EHR's) or while manually coding charges.

Here are a few examples of the functions of Iridium Suite’s claim scrubber:

The claim scrubber offers suggestions for converting old, outdated codes to newer ones, or requests permission to add a modifier to an E & M (evaluation and management) code that conflicts with other codes billed the same day, such as 99204 with 77263.  The biller has the option of re-evaluating the code and overriding the warning edit or allowing the scrubber to change it.

The claim scrubber sets a warning status on service lines that may be correctly coded but which conflict with other services according to NCCI (National Correct Coding Initiative) edits. A pop-up window shows the NCCI conflict and rule regarding the services billed. The biller has the option of choosing to override the warning status or the biller can change the date on the service that is being billed to avoid the conflict. The service line may also be deleted and a more appropriate service can be coded.

 
PQRI/PQRS is a potential ‘miss’ on any patient having Medicare or Medicaid.  If a medical practice activates the PQRS scrubber, then the scrubber is configured to automatically request that the physician sets up PQRS measures for each patient whose treatment qualifies for PQRI. The claim scrubber also recognizes which billing codes are potential PQRS denominators and automatically suggests the PQRS numerator codes that should be added to the claim. The biller simply accepts these suggestions and the claim scrubber automatically adds the proper PQRS charge codes to the claim.

In addition, the Iridium Suite claim scrubber makes every radiation oncology biller’s life better by automatically adding up the patient’s daily treatments and applying the management code 77427 with its corresponding dates. This feature is a fantastic time saver and ensures that this often-forgotten code is billed out properly.

Iridium Suite’s claim scrubber is only one of the many ideally designed tools integral for the best radiation oncology medical practice billing software available. It saves time and money and prevents potential errors that delay receipt of your claim reimbursement.

EDI Functionality In Medical Electronic Billing

Electronic data interchange (EDI) is the structured transmission of data between organizations by electronic means. It is used to transfer electronic documents or business data from one computer system to another computer system, i.e. from a medical practice to an insurance payer.

                                                

A Physician billing system should utilize the following three common EDI functions: submission of Electronic Claims, utilization of Real Time Eligibility (RTE) and receipt of Electronic Remittance Advices (ERA's). Lets look at each one of these further.

• Electronic Claims replace the standard HCFA 1500 paper claim forms that are printed and mailed to the payer. The claims are batched in the medical billing software and then transmitted in an electronic format directly to the payer or to a clearinghouse. If a clearinghouse is used, they serve as the middle man for all the EDI transactions. Unlike with paper claims where you have no way to verify receipt by the payer, electronic claims can be tracked through each stage of the process, from receipt by the clearinghouse to the acknowledgement and acceptance by the payer. Additionally, electronic claims are pre-screened for certain errors with notices being sent back to the medical practice within days for quick correction and resubmittal. Due to their formatting, electronic claims are much more quickly processed by the payer, reducing the wait for reimbursement in some cases from weeks to days.
  
  
• The Real Time Eligibility function in the medical billing software allows the medical practice to verify patient insurance coverage before services are rendered. The details provided in the RTE response also confirm or provide other valuable data such as, patient address, health insurance identification number and group number, and effective dates of coverage. All of this information eliminates denials for lack of coverage and provides great assistance in submitting clean claims that will be processed quickly.
  
  
• Electronic Remittance Advices are the electronic equivalent of a paper Explanation of Benefits (EOB). The medical billing software imports the ERA from the payer or clearinghouse and often can adjudicate the payments automatically in the indicated patient's accounts. Amounts that are designated Contractual Obligations are written off, patient responsibilities such as co-pays and deductibles are allocated to the patient balance, and other open balances are applied to any appropriate additional payers. Even information regarding denials is attached to the designated services with complete details allowing medical office staff to research and choose the best action in order to resolve the denial with the payer.

If your medical system software is not utilizing all of these functions, it may be time to look for a better solution, Iridium Suite by Medical Business Systems.

                                        

Five Ways to Capture More Claim Money

Often the handling of accounts receivable is considered distasteful, something that can be ignored or should be handled by somebody else.  Too often the calls don’t get made to insurance companies, the appeals don’t go out, or the resolution of denials is put off.  Even though it may be difficult to find time to perform these tasks, they are an integral part of every successful medical practice.

It is crucial to have a plan for working your accounts receivables.  Follow these suggestions below to get your cash flow going:                                          

• Setting aside the time and assigning the accounts receivable task to one person is the most logical option.  This assures a focused attempt to resolve problems and may reveal erroneous patterns in billing that are missed by several people handling the receivables ‘on the fly’ or ‘when they have time’.
• Most insurance companies have made information quickly available online through their secure websites.  Often an EOB or check that has been missed may be found online and entered in the accounting software without picking up the phone.  The website can also offer more detailed information regarding claim denials.  Additionally many insurance websites offer direct email to quickly access customer service with any questions.
• Each insurance company has an appeal process that must be adhered to in order to get the attention directed to your claim. Keep an appeal file with details (also available on websites) so that the information is quickly available. When an appeal letter is written, keep a copy on the computer and use it to easily change only the patient information and date, thereby saving additional time and keeping the format needed by the insurance company.
•  If there is no other way around making the occasional phone call to an insurance company, they often have an IVR (Instant Voice Response) telephone number where you can retrieve all the information needed regarding claims and eligibility. To accomplish this task quickly, make sure all the details are at your fingertips prior to making the call. If you must speak to a ‘live’ person, get as much information as possible at the time of the call to avoid repeat calls.
•  Finally, if there is no time to squeeze these tasks into any staff schedules, check into hiring outside personnel that will concentrate on this important job. Make sure they have the communication skills and availability to give feedback when necessary so that recurrent findings or problems can easily transfer back to billers or medical staff. 

Staying involved with accounts receivables is a win-win solution for medical offices, patients and insurance companies.  

                                            

Medical practice billing software such as Iridium Suite also offers extensive practice management reporting to effectively oversee the financial health of your practice.  You will be able to stay organized and maximize claim reimbursement.