1 2011 3 rd Party Update In the 3 rd Party Area… What has happened in the last 12 months What to...

11

2011 32011 3rdrd Party Update Party Update

In the 3In the 3rdrd Party Area… Party Area…What has happened in the last 12 monthsWhat has happened in the last 12 months

What to expect in the next 12 monthsWhat to expect in the next 12 months

22

2011 32011 3rdrd Party Update Party Update HIPAA HIPAA (EDI)(EDI)

Claim Format Claim Format ICD-10-CMICD-10-CM PrivacyPrivacy

EHREHR PQRSPQRS eRxeRx WPS WPS CMSCMS

NoridianNoridian CEDICEDI

MedicaidMedicaid CodingCoding AOAAOA PotpourriPotpourri

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44

HIPAA EDI – Version 5010HIPAA EDI – Version 5010

The Health Insurance Portability and The Health Insurance Portability and Accountabiliy Act (HIPAA) electronic data Accountabiliy Act (HIPAA) electronic data interchange (EDI) federal regulations require interchange (EDI) federal regulations require that health data be transmitted in a that health data be transmitted in a standardized form. standardized form.

HIPAA is updating that transmission method HIPAA is updating that transmission method from HIPAA version 4010A1 to HIPAA version from HIPAA version 4010A1 to HIPAA version 5010 starting January 1, 2012.5010 starting January 1, 2012.

55


WHO:WHO: Any plan, clearinghouse or provider Any plan, clearinghouse or provider who transmits any health information in who transmits any health information in electronic form. electronic form. Includes changes to CMS-1500 claim forms.Includes changes to CMS-1500 claim forms.

WHY:WHY: The current format is unable to support The current format is unable to support ICD-10 and ICD-10 and pay for performance pay for performance (PQRS; eRx; EHR)(PQRS; eRx; EHR). .

WHENWHEN: Mandatory January 1, 2012. : Mandatory January 1, 2012.

66


WHAT TO DO:WHAT TO DO: Providers who use practice management and Providers who use practice management and

other applicable software programs should other applicable software programs should make sure that their software programs make sure that their software programs feature the updated Versions 5010 and D.0 feature the updated Versions 5010 and D.0 HIPAA transaction standards.HIPAA transaction standards.

IIt's likely that your practice management t's likely that your practice management software will need to be upgraded. software will need to be upgraded.

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WHAT TO DO:WHAT TO DO: To meet the January 1, 2012 implementation To meet the January 1, 2012 implementation

date, providers should begin testing Version date, providers should begin testing Version 5010 with their trading partners NOW. You 5010 with their trading partners NOW. You must test before January 1, 2012.must test before January 1, 2012.

Talk to your software vendor, clearinghouse, Talk to your software vendor, clearinghouse, or billing service NOW, and work together to or billing service NOW, and work together to make sure you'll have what you need to be make sure you'll have what you need to be ready. ready.

88


WHAT TO DO:WHAT TO DO: Contact your Medicare Administrative Contact your Medicare Administrative

Contractor MAC to inquire about their testing Contractor MAC to inquire about their testing protocols. protocols. WPS Medicare WPS Medicare

http://www.wpsmedicare.com/j5macpartb/departments/edhttp://www.wpsmedicare.com/j5macpartb/departments/edi_/i_/

Noridian (CEDI) Noridian (CEDI) http://www.ngscedi.com/5010/5010.htmhttp://www.ngscedi.com/5010/5010.htm

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WHAT TO DO:WHAT TO DO: Use 9-digit zip codes for billing provider Use 9-digit zip codes for billing provider

addressaddress Use 9-digit zip code for service facility Use 9-digit zip code for service facility

locations (POS)locations (POS) Lock box and post office boxes are not Lock box and post office boxes are not

acceptable billing provider addresses acceptable billing provider addresses

http://nebraska.aoa.org/prebuilt/noa/2011-05%203RD%20Party%20Newsletter.pdf

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HIPAA EDI – Version 5010HIPAA EDI – Version 5010Paper Claims:Paper Claims: CMS-1500 claim CMS-1500 claim

forms will also forms will also be alteredbe altered

Modification Modification proposals are proposals are now being now being consideredconsidered

1111

HIPAA EDI – Version 5010HIPAA EDI – Version 5010Resources for 5010 Versions 5010 & D.0 FAQs Now Available!

https://questions.cms.hhs.gov/app/answers/list/kw/5010 National Testing Day Message Now Available!

http://www.cms.gov/Versions5010andD0/Downloads/5010_National_Testing_Day_Message.pdf 5010/D.0 Errata requirements and testing schedule

http://www.cms.gov/Versions5010andD0/Downloads/Errata_Req_and_Testing.pdf Contact your MAC for their testing schedule

http://www.cms.gov/Versions5010andD0/Downloads/Reminder-Contact_MAC.pdf Have you done the following to be ready for 5010/D.0?

http://www.cms.gov/Versions5010andD0/Downloads/Readiness_1.pdf What do you need to have in place to test with your MAC?

http://www.cms.gov/Versions5010andD0/Downloads/Readiness_2.pdf Do you know the implications of not being ready?

http://www.cms.gov/Versions5010andD0/Downloads/Readiness_5010.pdf

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1313

HIPAA – ICD-9 to ICD-10HIPAA – ICD-9 to ICD-10

Starting October, 2013 you will be required to use ICD-10 diagnosis coding instead of ICD-9

ICD-10 Coding is completely different than ICD-9.

1414


https://www.cms.gov/ICD10/11b1_2011_ICD10CM_and_GEMs.asp

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http://www.revoptom.com/content/d/practice_management/c/14816/

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https://www.cms.gov/ICD10/Downloads/ICD-10QuickRefer.pdf

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1818

HIPAA Privacy UpdatesHIPAA Privacy Updates

Be sure to give every new patient your “Notice of Privacy Practices” (NPP) and have the acknowledge receipt in writing.

Be sure to post your NPP in an obvious location in your office.

If your office has a web site, you must post your NPP in an obvious location on you website.

1919


If you alter your NPP, be sure to give every patient a copy of the revised NPP and have them acknowledge receipt in writing.

On subsequent visits, remind patient that the NPP is available.

On subsequent visits, note in record whether NPP had previously be given and acknowledged in writing.

2020


Review your NPP with staff on a regular basis. (Dr. Quack receives HIPAA privacy questions which should be answered by the office’s NPP)

Review your HIPAA Office Manual yearly, and update as needed (names of employees, etc.)

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HIPAA Privacy UpdatesHIPAA Privacy Updates Find “Uses and Disclosures for Treatment, Payment,

and Health Care Operations,” which is at http://www.hhs.gov/ocr/privacy/hipaa/understanding/ coveredentities/usesanddisclosuresfortpo.html

Review the “Summary of the HIPAA Privacy Rule” at http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/ index.html

FAQs bys by category may be found at http://www.hhs.gov/hipaafaq/.

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2011 32011 3rdrd Party Update Party Update HIPAAHIPAA





2323

2011 Payments2011 Payments Payment based on 75 percent of their total Medicare

allowed charges submitted no later than two months after the end of the 2011 calendar year.

The maximum allowed charges used for a 2011 incentive payment are $24,000.

This means that the maximum incentive payment an EP can receive for 2011 is $18,000.

Incentive payments will not be made until the EP meets the $24,000 threshold in allowed Medicare charges.

2424

Attestation ResourcesAttestation Resources

CMS has resources to help you attest to having CMS has resources to help you attest to having met meaningful use requirements in order to met meaningful use requirements in order to receive your EHR incentive payment.receive your EHR incentive payment.

An An Attestation pageAttestation page, , http://www.cms.gov/EHRIncentiveProgramhttp://www.cms.gov/EHRIncentivePrograms/32_Attestation.asps/32_Attestation.asp, where participants in , where participants in the Medicare EHR Incentive Program can find the Medicare EHR Incentive Program can find important information on attestation. important information on attestation.

2525

Attestation ResourcesAttestation Resources The The Meaningful Use Attestation CalculatorMeaningful Use Attestation Calculator,,

http://www.cms.gov/apps/ehr/http://www.cms.gov/apps/ehr/ which allows EPs which allows EPs and eligible hospitals to check whether they have and eligible hospitals to check whether they have met meaningful use guidelines before they attest in met meaningful use guidelines before they attest in the system. The calculator prints a copy of each EP's the system. The calculator prints a copy of each EP's or eligible hospital's specific measure summary.or eligible hospital's specific measure summary.

The The Attestation User GuideAttestation User Guide for Medicare for Medicare http://www.cms.gov/EHRIncentivePrograms/Downloads/EP_http://www.cms.gov/EHRIncentivePrograms/Downloads/EP_Attestation_User_Guide.pdfAttestation_User_Guide.pdf , which provide step-by-step , which provide step-by-step guidance for EPs and eligible hospitals participating guidance for EPs and eligible hospitals participating in the Medicare EHR Incentive Program on navigating in the Medicare EHR Incentive Program on navigating the attestation system.the attestation system.

2626

Attestation ResourcesAttestation Resources Attestation WorksheetAttestation Worksheet for for

http://www.cms.gov/EHRIncentivePrograms/Downloads/EP_http://www.cms.gov/EHRIncentivePrograms/Downloads/EP_

Attestation_User_Guide.pdfAttestation_User_Guide.pdf , which allow users to fill out , which allow users to fill out their meaningful use measure values, so they have a their meaningful use measure values, so they have a quick reference tool to use while attesting. quick reference tool to use while attesting.

Attestation is currently open for all participants in Attestation is currently open for all participants in the Medicare EHR Incentive Program via the the Medicare EHR Incentive Program via the Medicare & Medicaid EHR Incentive Program Medicare & Medicaid EHR Incentive Program Registration and Attestation SystemRegistration and Attestation System https://ehrincentives.cms.gov/hitech/login.action .https://ehrincentives.cms.gov/hitech/login.action .

2727

EHR Approved SoftwareEHR Approved Software

ActivEHR™ 2011.1 by EMRlogic Systems Advantage EHR Version 10 by Compulink Business Systems Crystal Practice Management by Abeo Solutions Electronic Health Records (EHR) Version 7.6 by Medflow ExamWRITER Version 10 by Eyefinity/OfficeMate MaximEyes® SQL Electronic Health Records Version 1.1.0 by First

Insight Corporation Ocular Medical Records Version 11.0 by QuikEyes Practice Director by Williams Marketing RevolutionEHR Version 5.1.0 by Health Innovation Technologies

2828

EHR and FAQsEHR and FAQs

CMS has posted the latest EHR FAQs document on the CMS website. Go to

http://www.cms.gov/EHRIncentivePrograms/Downloads/FAQsRemediatedandRevised.pdf

CMS will continue to provide updates as new FAQs are added.

2929

2011 Attestation Q & A2011 Attestation Q & ADo you have questions about attestation?Do you have questions about attestation?Get answers to some of the most commonly asked questions about Get answers to some of the most commonly asked questions about

attestation.attestation. How will I attest for the Medicare and Medicaid Incentive Programs?How will I attest for the Medicare and Medicaid Incentive Programs? When can I attest?When can I attest? What can I do now to prepare for attestation?What can I do now to prepare for attestation? Where can I find user guides and other resources?Where can I find user guides and other resources? What will I need to login to the Attestation System?What will I need to login to the Attestation System? What is the EHR Certification Number?What is the EHR Certification Number? I am an Eligible Provider. Can I designate a third party to register and/or atI am an Eligible Provider. Can I designate a third party to register and/or at

test on my behalf?test on my behalf? When will I get paid?When will I get paid? How will I get paid?How will I get paid? Will CMS conduct audits?Will CMS conduct audits?

https://www.cms.gov/EHRIncentivePrograms/32_Attestation.asp

3030






3131

Medicare Reimbursement Adjustment Medicare Reimbursement Adjustment (penalty).(penalty).

2012 Medicare Payments docked 1%*2012 Medicare Payments docked 1%* 2013 Medicare Payments docked 1.5%2013 Medicare Payments docked 1.5% 2014 Medicare Payments docked 2%2014 Medicare Payments docked 2%

*It is still unknown whether or not the -1% 2012 payment adjustment applies to ODs

3232

Avoiding AdjustmentAvoiding Adjustment Must use approved eRx software as required by Must use approved eRx software as required by

MedicareMedicare Must report at least 25 unique eRx events for Must report at least 25 unique eRx events for

patients in the denominator of the measure before patients in the denominator of the measure before 12/31/11. (92000 or 99000 exam). 12/31/11. (92000 or 99000 exam).

ODs use “Claims-based reporting” of the electronic ODs use “Claims-based reporting” of the electronic prescribing measure. Report a successful e-Rx with prescribing measure. Report a successful e-Rx with G-code (G8553) for 2011 G-code (G8553) for 2011

3333

Avoiding the Medicare Avoiding the Medicare e-Prescribing “Adjustment” (penalty)e-Prescribing “Adjustment” (penalty)

You can get e-Rx credit for re-prescribing an Rx…but You can get e-Rx credit for re-prescribing an Rx…but you cannot get credit for giving a pharmacy you cannot get credit for giving a pharmacy permission to refill an Rx.permission to refill an Rx.You can get credit if you successfully e-Rx with your You can get credit if you successfully e-Rx with your approved e-Rx software, even if an intermediary approved e-Rx software, even if an intermediary changes your e-Rx to a Fax. changes your e-Rx to a Fax.

3434

Exemptions and ExceptionsExemptions and Exceptions To request an To request an exemptionexemption to the eRx Incentive to the eRx Incentive

Program and the payment adjustment, there are two Program and the payment adjustment, there are two “hardship codes” that can be reported via claims “hardship codes” that can be reported via claims should one of the following situations apply, plus an should one of the following situations apply, plus an exemption for not having prescribing privileges. exemption for not having prescribing privileges.

There are also two There are also two exceptionsexceptions

3535

ExemptionsExemptions

G8642 - The eligible professional practices in a G8642 - The eligible professional practices in a rural area rural area without sufficient high speed without sufficient high speed internetinternet access and requests a hardship access and requests a hardship exemption from the application of the exemption from the application of the payment adjustment under section 1848(a)(5)payment adjustment under section 1848(a)(5)(A) of the Social Security Act. (A) of the Social Security Act.

3636

ExemptionsExemptions

G8643 - The eligible professional practices in G8643 - The eligible professional practices in an area an area without sufficient available without sufficient available pharmacies for electronic prescribingpharmacies for electronic prescribing and and requests a hardship exemption from the requests a hardship exemption from the application of the payment adjustment under application of the payment adjustment under section 1848(a)(5)(A) of the Social Security Act section 1848(a)(5)(A) of the Social Security Act

3737

The final rule provides additional significant The final rule provides additional significant hardship exemption categories for 2011 for hardship exemption categories for 2011 for the 2012 eRx payment adjustment: the 2012 eRx payment adjustment:

(1) eligible professionals who (1) eligible professionals who register to register to participate in the Medicare or Medicaid EHR participate in the Medicare or Medicaid EHR Incentive Program and adopt certified EHR Incentive Program and adopt certified EHR technologytechnology;;

New ExemptionsNew Exemptions

3838

(2) eligible professionals who are unable to (2) eligible professionals who are unable to electronically prescribe electronically prescribe due to local, state, or due to local, state, or federal law or regulationfederal law or regulation; ;

(3) eligible professionals who have (3) eligible professionals who have limited limited prescribing activityprescribing activity;;

(4) eligible professionals who have insufficient (4) eligible professionals who have insufficient opportunities to report the e-prescribing opportunities to report the e-prescribing measure due to measure due to limitations of the measure’s limitations of the measure’s denominatordenominator..

New ExemptionsNew Exemptions

3939

ExExceptionsceptions Does not have prescribing privilegesDoes not have prescribing privileges. Note: (S)he . Note: (S)he

must report (G8644) at least one time on an must report (G8644) at least one time on an eligible claim prior to December 31, 2011;eligible claim prior to December 31, 2011;

Does not have at least 100 cases containing an Does not have at least 100 cases containing an encounter code in the measure denominatorencounter code in the measure denominator (92000 and 99000 exam codes)(92000 and 99000 exam codes)

4040

What to Do?What to Do?

Go to the CMS e-prescribing web siteGo to the CMS e-prescribing web site Click on “How to get Started” (left column)Click on “How to get Started” (left column)http://www.cms.gov/ERxIncentive/http://www.cms.gov/ERxIncentive/03_How_To_Get_Started.asp#TopOfPage03_How_To_Get_Started.asp#TopOfPage

4141

2010 eRx Payments2010 eRx Payments LELE will appear on the electronic remit. will appear on the electronic remit. CMS created a 4-digit code to indicate the type of CMS created a 4-digit code to indicate the type of

incentive and reporting year. For the 2010 eRx incentive and reporting year. For the 2010 eRx incentive payments, the 4-digit code is incentive payments, the 4-digit code is RX10RX10..

For example, eligible professionals will see For example, eligible professionals will see LE LE to to indicate an incentive payment, along with indicate an incentive payment, along with RX10RX10 to to identify that payment as the 2010 eRx incentive identify that payment as the 2010 eRx incentive payment.payment.

The paper remittance advice will read, “This is an eRx The paper remittance advice will read, “This is an eRx incentive payment.” The year will not be included in incentive payment.” The year will not be included in the paper remittance.the paper remittance.

4242

2010 eRx Payments2010 eRx Payments Who to Contact for QuestionsWho to Contact for Questions? Provider Contact ? Provider Contact

Center.Center. The The Contact Center DirectoryContact Center Directory is available at is available at http://www.cms.gov/MLNProducts/Downloads/Callhttp://www.cms.gov/MLNProducts/Downloads/CallCenterTollNumDirectory.zipCenterTollNumDirectory.zip

The QualityNet Help Desk is available Monday The QualityNet Help Desk is available Monday through Friday from 7:00 a.m. – 7:00 p.m. CST at through Friday from 7:00 a.m. – 7:00 p.m. CST at 1-1-866-288-8912866-288-8912 or via or via [email protected]@sdps.org. The . The help desk can also assist with program and measure-help desk can also assist with program and measure-specific questions.specific questions.

The following CMS resource is available to help The following CMS resource is available to help eligible professionals understand the 2010 eRx eligible professionals understand the 2010 eRx Incentive Payments, view Incentive Payments, view A Guide for Understanding the 2010 A Guide for Understanding the 2010 eRx Incentive Payment [PDF 57 KB]eRx Incentive Payment [PDF 57 KB], on the CMS website. , on the CMS website.

4343






4444

Nursing Home CodingNursing Home Coding1.1. Make sure there is a justifiable medical reason for the Make sure there is a justifiable medical reason for the

visit.visit.

2.2. If using E&M coding, make sure your documentation If using E&M coding, make sure your documentation justifies your 99307, 99308, or 99309 claim. justifies your 99307, 99308, or 99309 claim.

3.3. Don’t let your documentation look “cookie-cutter”. If Don’t let your documentation look “cookie-cutter”. If all your documentation looks alike, it raises question all your documentation looks alike, it raises question of authenticity.of authenticity.

4.4. 3. The AOA says an OD can use the 92xxx exam codes 3. The AOA says an OD can use the 92xxx exam codes when making nursing home visits, using the place of when making nursing home visits, using the place of service codes of 31 (skilled nursing facility) or, more service codes of 31 (skilled nursing facility) or, more likely, 32 (nursing facility).likely, 32 (nursing facility).

4545

Final Code must beFinal Code must beReasonable and NecessaryReasonable and Necessary

ConsideringConsidering• Chief Complaint/ Reason for visit / Chief Complaint/ Reason for visit /

Presenting ProblemPresenting Problem• HistoryHistory• Clinical findingsClinical findings• Decision Making RequiredDecision Making Required

4646

Must Sign Written Order for TestingMust Sign Written Order for Testing

WPS Medicare's Comprehensive Error Rate Testing (CERT) error findings for insufficient documentation accounted for 50% of all errors assessed.

The majority of these errors were due to the LACK OF A VALID PHYSICIAN ORDER for diagnostic services.

4747

CHANGES IN THE WPS OPTOMETRY LCD, EFFECTIVE JANUARY 1, 2011

The following CPT codes have been added to Table I for All Optometrists;

•76513•82962•83516•83520

925419254292544

99221-9922399231-9923399281-99283

9935099354993559935699357

9201892019922609227092287

4848


The following Codes have been added to Table II for The following Codes have been added to Table II for Optometrists with a therapeutic license; Optometrists with a therapeutic license;

652726527565286656006782567850

827858707087081872058780987809.

680209802068530688106884076529

4949


The following CPT codes, found in Table II, no longer require a -55 modifier;

67820 67938 680406876168801

5050






5151

Consolidated BillingConsolidated Billing

Medicare’s Consolidated BillingMedicare’s Consolidated Billing is when you bill the is when you bill the patient's SNF for materials, and some services, rather patient's SNF for materials, and some services, rather than Noridian or WPS. Applies when the patientthan Noridian or WPS. Applies when the patient

Had an inpatient hospital stay of 3 consecutive days or more. Has remaining Medicare Part A benefits His/her doctor decided daily skilled care is needed. The SNF has been certified by Medicare. The skilled services are needed due to hospital stay.

5252


Whenever you have a scheduled patient who is Whenever you have a scheduled patient who is residing in a SNF, prior to examination you residing in a SNF, prior to examination you should always ask the SNF if the patient is should always ask the SNF if the patient is currently covered under Medicare A.currently covered under Medicare A.

If so, you need to explain to the SNF about If so, you need to explain to the SNF about consolidated billing, since most are unfamiliar consolidated billing, since most are unfamiliar with the term or its consequences.with the term or its consequences.

5353


All post-op DME billing that would normally go All post-op DME billing that would normally go to Noridian must now go to the SNF.to Noridian must now go to the SNF.

The technical component of most ancillary The technical component of most ancillary testing must also go to the SNF. testing must also go to the SNF.

5454

Consolidated BillingConsolidated BillingTechnical component of the following codes must be Technical component of the following codes must be

billed to the SNFbilled to the SNF

92060 SPEC’L EYE EVAL. 92065 ORTHOPTICS 92081 VISUAL FIELDS 92082 VISUAL FIELDS 92083 VISUAL FIELDS 92133-4 DX IMAGING 92136 OPHTHALMIC BIOMETRY 92235 EYE EXAM WITH PHOTOS 92240 ICG ANGIOGRAPHY

92250 EYE EXAM WITH PHOTOS 92265 EYE MUSCLE EVALUATION 92270 ELECTRO-OCULOGRAPHY 92275 ELECTRORETINOGRAPHY 92283 COLOR VISION 92284 DARK ADAPTATION EYE

92285 EYE PHOTOGRAPHY 92286 INTERNAL EYE PHOTO

Excerpted From http://cms.hhs.gov/medlearn/file2pctc1.

5555


It is important that you work cooperatively with the SNF in these matters.

If either you or the SNF have questions about consolidated billing, you can find further information at the CMS website on consolidated billing: http://www.cms.hhs.gov/medlearn/snfcode.asp.

5656

Non-Participating Medicare Providers Non-Participating Medicare Providers CannotCannotBill or Charge Usual and Customary FeesBill or Charge Usual and Customary Fees..

The rules are….The rules are…. You do not have to see Medicare patients. You do not have to see Medicare patients. But, if you see ANY Medicare patients, federal But, if you see ANY Medicare patients, federal

law requires you to follow Medicare law requires you to follow Medicare guidelines. guidelines.

Non-Par providers must file claims for their Non-Par providers must file claims for their Medicare Patients.Medicare Patients.

Medicare Limiting ChargeMedicare Limiting Charge

5757

Non-Par providers must not Non-Par providers must not billbill more than the more than the Medicare limiting charge (last column on Medicare limiting charge (last column on Medicare Fee Schedule), under penalty of Medicare Fee Schedule), under penalty of federal law. federal law.

Non-par Providers Cannot Non-par Providers Cannot CollectCollect From From Medicare Patients & Medigap &/or Patient a Medicare Patients & Medigap &/or Patient a Total $ Amount More Than The Total $ Amount More Than The Medicare Medicare Limiting ChargeLimiting Charge

Excessive billing or failure to file claims will Excessive billing or failure to file claims will incur severe finesincur severe fines. .


5858


5959

A provider who violates the limiting charge is A provider who violates the limiting charge is subject to subject to

Assessments of up to $10,000 per violation Assessments of up to $10,000 per violation plus plus

Triple the amount of the charges in violation, Triple the amount of the charges in violation, and and

Possible exclusion from the Medicare Possible exclusion from the Medicare program. program.


6060

Medicare FeesMedicare Fees

You Cannot Charge Medicare Patients Extra You Cannot Charge Medicare Patients Extra FeesFees such as such as A Finance Charge A Finance Charge InterestInterest Other Similar Types Of Charges.Other Similar Types Of Charges.

6161

New ABN Required November 1stNew ABN Required November 1st

release date of 3/2011 printed in lower left hand corner

https://www.noridianmedicare.com/dme/forms/docs/cms-r-131.pdf

6262






6363

Medicare DME EnrollmentMedicare DME Enrollment

DME Suppliers Must Now Pay $500+ To DME Suppliers Must Now Pay $500+ To Enroll Or To Re-Enroll Enroll Or To Re-Enroll

DME Suppliers Must Re-Enroll Every 3 YearsDME Suppliers Must Re-Enroll Every 3 Years. . CMS requires that all DMEPOS suppliers re-enroll CMS requires that all DMEPOS suppliers re-enroll

every three years with the NSC every three years with the NSC Requires application fee of $505 in 2011 as Requires application fee of $505 in 2011 as

part of the enrollment process part of the enrollment process http://www.cms.gov/MLNMattersArticles/downloads/MM7350.pdf

http://www.cms.gov/MedicareProviderSupEnroll/

6464

DME Supplier StandardsDME Supplier Standards•Medicare standards a supplier of DME must meet•The supplier must certify it meets the standards. •The supplier standards can be found in 424 CFR Section 424.57

http://nebraska.aoa.org/documents/ne/2010-12-3RD-PARTY-NEWLSETTER.pdf

6565

DME Electronic Claims:DME Electronic Claims:

Annual CEDI Recertification Annual CEDI RecertificationCEDI Recertification Now Required AnnuallyCEDI Recertification Now Required Annually Beginning in 2011, CEDI is requiring all Trading Beginning in 2011, CEDI is requiring all Trading

Partners to recertify their user access on an Partners to recertify their user access on an annual basis. annual basis.

If you have your own submitter ID that If you have your own submitter ID that contains A08, B08, C08, or D08, you are a contains A08, B08, C08, or D08, you are a "trading partner”. DO IT NOW."trading partner”. DO IT NOW.

http://www.ngscedi.com/forms/formsindex.htm

6666






6767

Medicaid Managed CareMedicaid Managed Care

At the behest of the Unicameral, Medicaid At the behest of the Unicameral, Medicaid managed care will go state wide in July (?) of managed care will go state wide in July (?) of 2012.2012.

No one yet knows which insurers will be No one yet knows which insurers will be approved as MCOs in the newly affected areas approved as MCOs in the newly affected areas of the state. of the state.

6868

Medicaid Managed CareMedicaid Managed Care

MCOs authorize, arrange, provide, and pay for the delivery of health care services to enrolled clients.

Cover all Medicaid recipients except Those also covered by Medicare, Residents of nursing or intermediate care facilities Certain other narrow exclusions.

6969

Medicaid Managed CareMedicaid Managed Care If the MCOs currently serving eastern Nebraska are If the MCOs currently serving eastern Nebraska are

approved for out-state, and approved for out-state, and If they handle the situation the same as they have in If they handle the situation the same as they have in

the eastern 10 counties, the eastern 10 counties, Then Nebraska ODs will need to be a Block Vision Then Nebraska ODs will need to be a Block Vision

provider to see routine care Medicaid patients, and provider to see routine care Medicaid patients, and Will need to be a Will need to be a Share AdvantageShare Advantage and a and a Coventry Coventry

NebraskaNebraska provider to see medical diagnosis patients. provider to see medical diagnosis patients. However However BCBSBCBS should also be a strong contender. should also be a strong contender.

7070






7171

WPS: 92004 DilationWPS: 92004 Dilation

WPS Q & A on 92004 Eye ExamsWPS Q & A on 92004 Eye Exams CERT [Comprehensive Error Rate Testing] CERT [Comprehensive Error Rate Testing]

states that 92004 must include initiation of states that 92004 must include initiation of diagnostic and treatment services, and should diagnostic and treatment services, and should include dilation, unless documentation show include dilation, unless documentation show contraindicationcontraindication

7272

Medicare CoverageMedicare Coverage

VEP And Tear Osmolarity Not Covered By Medicare

Make sure you have a ABN signed if you plan Make sure you have a ABN signed if you plan to perform either test on Medicare patients.to perform either test on Medicare patients.

7373

Medicare CoverageMedicare Coverage

Diabetic Examinations Despite HHS and CMS ostensibly advocating

preventative medicine, 250.0x by itself is no longer reimbursable by Medicare.

7575

Medicare Probe Results for CPT 99213 Medicare Probe Results for CPT 99213 - Optometr- Optometryy

Of all the specialties checked by WPS and Of all the specialties checked by WPS and displayed on their website, optometry was the displayed on their website, optometry was the only profession that had only profession that had More 99214 More 99214 claims than the national average claims than the national average Less 99213 Less 99213 claims than the national average claims than the national average

Make sure your documentation shows Make sure your documentation shows justification for the level billedjustification for the level billed

7676

Billing Punctal Plugs to Medicare

The bottom line: ignore the 50 modifier and The bottom line: ignore the 50 modifier and all the fancy coding; all the fancy coding;

Just vary the number of units. 3 plugs, three Just vary the number of units. 3 plugs, three units. 4 plugs, 4 units. units. 4 plugs, 4 units.

7777

Ordering/Referring Physicians Must Be in Capital Letters

Medicare Providers who Medicare Providers who orderorder health care products for Medicare health care products for Medicare

beneficiaries or beneficiaries or referrefer Medicare beneficiaries for health care Medicare beneficiaries for health care

services services

must be identified entirely in capital letters on must be identified entirely in capital letters on Medicare claimsMedicare claims

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7979

From the AOA: Forget The S Codes!From the AOA: Forget The S Codes!

Optometrists play an ever increasing role as Optometrists play an ever increasing role as members of the primary health care team and members of the primary health care team and

Using S Codes poses many risks for access to Using S Codes poses many risks for access to the full range of optometric services.the full range of optometric services.

8080

Pay for Performance, Not for Pay for Performance, Not for ProceduresProcedures

From the AOA: National Strategy for Quality From the AOA: National Strategy for Quality Improvement in Health Care-Improvement in Health Care-

Business as usual, including basing payment Business as usual, including basing payment on procedures performed, is going by the on procedures performed, is going by the wayside. wayside. Diagnosis related groups (Hospitals)Diagnosis related groups (Hospitals) Acute Care Episode (cardiac, orthopedic A & B)Acute Care Episode (cardiac, orthopedic A & B) Episode of Care (Home Health)Episode of Care (Home Health)

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8282

FTC Red Flags RuleFTC Red Flags Rule

Most Optometrists Exempt From Red Flags Most Optometrists Exempt From Red Flags Rule Rule

Applies only when 1) Using credit reports in the ordinary course

of business 2) Furnishing information to credit reporting

companies 3) Loaning money

8383

Review Insurance AgreementsReview Insurance Agreements

October is a great time to launch your 'annual' October is a great time to launch your 'annual' review of all the agreements you've signed review of all the agreements you've signed with HMOs, medical insurers, and vision plans. with HMOs, medical insurers, and vision plans.

8484

The Medical HomeThe Medical Home

The Medical Home: Communicate with Your The Medical Home: Communicate with Your Patient's PCPPatient's PCP --- ---

In order for an optometrist to be considered a In order for an optometrist to be considered a player in the upcoming medical home player in the upcoming medical home scenario, the OD must communicate scenario, the OD must communicate significant findings to the patient's PCP on a significant findings to the patient's PCP on a regular basis. 11p4regular basis. 11p4

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