Fraud: CMS Places Doc Moratoria in Six States

By Brad Ericson
Aug 15th, 2016
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The Centers for Medicare & Medicaid Service (CMS) established a a temporary provider enrollment moratoria July 29, to help fight fraud.

This move was paired with a new, related demonstration project to allow for certain exceptions to the moratoria and heightened screening requirements for new providers.  CMS also announced it is immediately lifting the current temporary moratoria on all Medicare Part B, Medicaid, and Children’s Health Insurance Program (CHIP) emergency ground ambulance suppliers.

CMS announced it is extending for six months and expanding statewide the temporary provider enrollment moratoria on new Medicare Part B non-emergency ground ambulance suppliers in New Jersey, Pennsylvania, and Texas and home health agencies in Florida, Texas, Illinois, and Michigan. Additionally, the statewide expansion also applies to Medicaid and CHIP. CMS also announced the Provider Enrollment Moratoria Access Waiver Demonstration (PEWD), which gives CMS the ability to allow for provider and supplier enrollment exceptions in the moratoria areas if access to care issues are identified and for the development and improvement of methods of investigating and prosecuting fraud in Medicare, Medicaid, and CHIP.

The statewide expansion of the temporary moratoria coupled with the PEWD will allow CMS to continue to target fraud within these services, while granting individual enrollment waivers. These changes will address access to care issues and allow providers and suppliers who are subject to the moratoria to enroll in Medicare, Medicaid, and CHIP after passing heightened screening requirements.

Hospice: Quality Rules, Pay for 2017 Released

By Brad Ericson
Aug 15th, 2016
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Final changes to the hospice quality reporting program, along with new wage index, payment rates, and cap amounts for 2017 have been announced by the Centers for Medicare & Medicaid Services (CMS). The rule looks to the future, as well, describing a new data collection instrument.

This is important with two new quality measures—Hospice Visits when Death is Imminent and Hospice and Palliative Care Composite Process Measure—being added to the rest that are required of providers of end-of-life care. CMS plans to publicly display quality measures and other hospice data beginning calendar year 2017.

Quality is the End Goal

This final rule provides a description of the Hospice CAHPS® Survey, a component of the Hospice Quality Reporting Program (QRP),  including the model of survey implementation, the survey respondents, eligibility criteria for the
sample, and the languages in which the survey is offered, among other details. The final rule also outlines participation requirements for the fiscal year 2019 and fiscal year 2020 annual payment updates (APU).

  • For fiscal year 2019 APU, hospices must collect survey data on an ongoing basis from January through December of calendar year 2017.
  • For the fiscal year  2020 APU, hospices must collect survey data on an ongoing basis from January through December of calendar year 2018. The final rule also includes survey data submission deadlines for the FY 2018, FY 2019, and FY 2020 APU periods.

Public display of the survey results will not occur until CMS has collected at least four quarters of data. CMS anticipates public display of the data will occur during calendar year 2017. CMS began collecting data in June.

Payment Based on Quality

Hospices would see a 2.1 percent ($350 million) increase in their payments for fiscal year 2017, according to the new rule. This reflects an estimated 2.7 percent inpatient hospital market basket update, reduced by a 0.3 percentage point productivity adjustment and a 0.3 percentage point adjustment required by law.

As discussed in the  2016 Hospice Wage Index and Payment Rate Update final rule (80 FR 47183), CMS  implemented changes required by the Improving Medicare Post-Acute Care Transformation Act of 2014 (Pub. L. 113-185) (IMPACT Act). For accounting years that end after Sept. 30, 2016 and before Oct. 1, 2025, the hospice cap is updated by the hospice payment update percentage rather than using the consumer price index for urban consumers (CPI–U). As required by section 1814(i)(2)(B)(ii) of the Act, the hospice cap amount for the 2017 cap year will be $28,404.99, which is equal to the 2016 cap amount ($27,820.75) updated by the 2017 hospice payment update percentage of 2.1 percent.

The 2017 cap year will start on October 1, 2016 and end on September 30, 2017.As a reminder, in the FY 2016 Hospice Wage Index and Payment Rate Update final rule (80 FR 47142).  Table 26 in the FY 2016 Hospice Wage Index and Payment Rate Update final rule (80 FR 47185) outlines the time frames for counting beneficiaries and payments during the 2017 transition year.

Mastectomy or Excision? Consider the Margins

By John Verhovshek
Aug 15th, 2016
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When deciding between 19120 Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions and 19301 Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy, search the documentation to determine whether a margin of health tissue was removed, along with the breast mass.

If the surgeon removes only the mass, with little or no margin, look first to 19120. Report one unit of 19120, per incision (not per mass removed). CPT® Assistant (March 2005) instructs:

…code 19120 should be reported for each of the separate excised areas since it includes one or more lesions through the same incision. However, if excisions are performed on different areas of the breast through separate incision sites, code 19120 should be reported for each incised area. Modifier 59 [Distinct Procedural Service] should be appended to the second procedure code.

For more extensive resection performed for gynecomastia [benign enlargement of breast tissue], report 19300 [Mastectomy for gynecomastia]” (CPT® Assistant, March 2014). Claim 19300 for male patients, only, “as gynecomastia is a male condition” (CPT® Assistant, Feb. 2007).

When the surgeon removes a breast lesion with a margin of healthy tissue, look to 19301. CPT Assistant (Feb. 2007) instructs:

Partial mastectomy procedures describe open excisions of breast tissue and include specific attention to adequate surgical margins surrounding the breast mass or lesion. In a partial mastectomy, a larger amount of breast tissue and some skin are removed with the tumor. This also includes removal of the lining over chest muscles below the tumor. This surgery is usually performed for stage 1 and 2 tumors. This code is reported also for the performance of a lumpectomy where the tumor and a small amount of surrounding tissue are removed.

In these cases, the mass is suspected or known to be malignant, and the margin of health tissue is removed to ensure that the entire malignancy has been excised.

Coding for Suture Removal

By John Verhovshek
Aug 15th, 2016
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Both CPT® and CMS consider suture removal to be part of a minor surgical procedure’s global package. If the same physician who placed the sutures removes them during the original procedure’s global period, you cannot report the removal separately. If a different physician removes the sutures, the removal becomes part of any E/M service reported. Possible exceptions include:

  • If the patient must be placed under general anesthesia to remove the sutures, you may report 15850 Removal of sutures under anesthesia (other than local), same surgeon or 15851 Removal of sutures under anesthesia (other than local), other surgeon. Circumstances under which generally anesthesia would be medically necessary or appropriate for suture removal are rare.
  • If your payer allows, report S0630 Removal of sutures by a physician other than the physician who originally closed the wound, as long as a different physician than the one who placed the sutures removes them. Check with your insurer before submitting this code.

Billing for a School Physical

By Karla Hurraw
Aug 10th, 2016
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Schools may require a “sports physical” for students prior to participation in sports or other programs. Typically, a healthcare provider must perform a physical exam and fill out the required form. There are two common choices to document and bill for these exams.

  1. Charge a Flat Fee

Some offices choose to set a flat fee to fill out the school physical form and collect it from the patient, without billing insurance. The patient agrees to pay the lower fee for the reduced exam required, and agrees not to file insurance.

  1. Make the Physical Part of a Well Visit

The other common option is to incorporate the school physical into a well-child check. The form can be filed into the chart to document the exam, and the rest of the well-child check can be documented in the visit note; or, a full well-child check can be documented, with the form filled out, in addition. Because a full well-child check is performed, it can be billed to insurance.

Some offices have a strict policy and only offer one option, while others offer both and let the patient choose which works best for his or her situation. Either way, make sure the patient understands your policy and billing procedures.

Similar policies could be applied to other types of physicals, such as pre-employment physicals, commercial drivers license (CDL) physicals, etc. Note, however, that with the increasing regulations and certifications required (in some states) to perform a CDL physical, more providers are choosing to not offer a CDL physical as part of a wellness visit. The CDL physical requires an extensive exam, time, and decision-making, and does not allow enough time to address the preventive aspects of a wellness visit. Providers feel that performing a CDL physical as part of a wellness visit is a disservice to the patient because the provider is not able to adequately perform the comprehensive wellness visit, in addition to the CDL physical.

There is a CPT® code for filling out forms (99080), but it is not a covered benefit with most plans. Although you could report 99080 instead of billing the patient directly, the bill most likely will be the patient’s responsibility, after the insurance processes.

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Karla Hurraw, CPC, CCS-P, holds a degree in Medical Office Administration and is the Lead Professional Coder for DeKalb Health Medical Group at DeKalb Health in Auburn, Ind. She is a member of the Fort Wayne, Ind., local chapter.