2011 3rd Party Update
In the 3rd Party Area…
What has happened in the last 12 months
What to expect in the next 12 months
1
2011 3rd Party Update
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HIPAA (EDI)
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Claim Format
ICD-10-CM
Privacy
EHR
PQRS
eRx
WPS
CMS
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Noridian
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CEDI
Medicaid
Coding
AOA
Potpourri
2
2011 3rd Party Update

HIPAA (EDI)


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
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

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Claim Format
ICD-10-CM
Privacy
EHR
PQRS
eRx
WPS
CMS

Noridian
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


CEDI
Medicaid
Coding
AOA
Potpourri
3
HIPAA EDI – Version 5010
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
The Health Insurance Portability and
Accountabiliy Act (HIPAA) electronic data
interchange (EDI) federal regulations require
that health data be transmitted in a
standardized form.
HIPAA is updating that transmission method
from HIPAA version 4010A1 to HIPAA version
5010 starting January 1, 2012.
4
HIPAA EDI – Version 5010

WHO: Any plan, clearinghouse or provider
who transmits any health information in
electronic form.
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Includes changes to CMS-1500 claim forms.
WHY: The current format is unable to support
ICD-10 and pay for performance (PQRS; eRx; EHR).
WHEN: Mandatory January 1, 2012.
5
HIPAA EDI – Version 5010
WHAT TO DO:
 Providers who use practice management and
other applicable software programs should
make sure that their software programs
feature the updated Versions 5010 and D.0
HIPAA transaction standards.
 It's likely that your practice management
software will need to be upgraded.
6
HIPAA EDI – Version 5010
WHAT TO DO:
 To meet the January 1, 2012 implementation
date, providers should begin testing Version
5010 with their trading partners NOW. You
must test before January 1, 2012.
 Talk to your software vendor, clearinghouse,
or billing service NOW, and work together to
make sure you'll have what you need to be
ready.
7
HIPAA EDI – Version 5010
WHAT TO DO:
 Contact your Medicare Administrative
Contractor MAC to inquire about their testing
protocols.


WPS Medicare http://www.wpsmedicare.com/j5macpartb/departments/edi_/
Noridian (CEDI) http://www.ngscedi.com/5010/5010.htm
8
HIPAA EDI – Version 5010
WHAT TO DO:
 Use 9-digit zip codes for billing provider
address
 Use 9-digit zip code for service facility
locations (POS)
 Lock box and post office boxes are not
acceptable billing provider addresses
http://nebraska.aoa.org/prebuilt/noa/2011-05%203RD%20Party%20Newsletter.pdf
9
HIPAA EDI – Version 5010
Paper Claims:
 CMS-1500 claim
forms will also
be altered
 Modification
proposals are
now being
considered
10
HIPAA EDI – Version 5010
Resources 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
11
2011 3rd Party Update

HIPAA (EDI)








Claim Format
ICD-10-CM
Privacy
EHR
PQRS
eRx
WPS
CMS

Noridian





CEDI
Medicaid
Coding
AOA
Potpourri
12
HIPAA – 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.
13
HIPAA – ICD-9 to ICD-10
https://www.cms.gov/ICD10/11b1_2011_ICD10CM_and_GEMs.asp
14
HIPAA – ICD-9 to ICD-10
http://www.revoptom.com/content/d/practice_management/c/14816/
15
HIPAA – ICD-9 to ICD-10
https://www.cms.gov/ICD10/Downloads/ICD-10QuickRefer.pdf
16
2011 3rd Party Update

HIPAA (EDI)








Claim Format
ICD-10-CM
Privacy
EHR
PQRS
eRx
WPS
CMS

Noridian





CEDI
Medicaid
Coding
AOA
Potpourri
17
HIPAA Privacy Updates
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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.
18
HIPAA Privacy Updates
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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.
19
HIPAA Privacy Updates


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.)
20
HIPAA Privacy Updates



Find “Uses and Disclosures for Treatment, Payment,
and Health Care Operations,” which is at
http://www.hhs.gov/ocr/privacy/hipaa/understandin
g/ coveredentities/usesanddisclosuresfortpo.html
Review the “Summary of the HIPAA Privacy Rule” at
http://www.hhs.gov/ocr/privacy/hipaa/understandin
g/summary/ index.html
FAQs bys by category may be found at
http://www.hhs.gov/hipaafaq/.
21
2011 3rd Party Update

HIPAA
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






Claim Format
ICD-10-CM
Privacy
EHR
PQRS
eRx
WPS
CMS

Noridian





CEDI
Medicaid
Coding
AOA
Potpourri
22
2011 Payments
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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.
23
Attestation Resources
CMS has resources to help you attest to having
met meaningful use requirements in order to
receive your EHR incentive payment.
 An Attestation page,
http://www.cms.gov/EHRIncentivePrograms/32_Attestation.asp,
where participants in the Medicare EHR
Incentive Program can find important
information on attestation.
24
Attestation Resources


The Meaningful Use Attestation Calculator,
http://www.cms.gov/apps/ehr/ which allows EPs and eligible
hospitals to check whether they have met
meaningful use guidelines before they attest in the
system. The calculator prints a copy of each EP's or
eligible hospital's specific measure summary.
The Attestation User Guide for Medicare
http://www.cms.gov/EHRIncentivePrograms/Downloads/EP_Attestation_User_Guide.pdf ,
which provide step-by-step guidance for EPs and
eligible hospitals participating in the Medicare EHR
Incentive Program on navigating the attestation
system.
25
Attestation Resources

Attestation Worksheet for
http://www.cms.gov/EHRIncentivePrograms/Downloads/EP_Attestation_User_Guide.pdf

,
which allow users to fill out their meaningful use
measure values, so they have a quick reference tool
to use while attesting.
Attestation is currently open for all participants in
the Medicare EHR Incentive Program via the
Medicare & Medicaid EHR Incentive Program
Registration and Attestation System
https://ehrincentives.cms.gov/hitech/login.action .
26
EHR Approved Software
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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
27
EHR 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.
28
2011 Attestation Q & A
Do you have questions about attestation?
Get answers to some of the most commonly asked questions about
attestation.

How will I attest for the Medicare and Medicaid Incentive Programs?

When can I attest?

What can I do now to prepare for attestation?
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Where can I find user guides and other resources?
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What will I need to login to the Attestation System?
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What is the EHR Certification Number?
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I am an Eligible Provider. Can I designate a third party to register and/or
attest on my behalf?
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When will I get paid?
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How will I get paid?

Will CMS conduct audits?
https://www.cms.gov/EHRIncentivePrograms/32_Attestation.asp
29
2011 3rd Party Update

HIPAA
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






Claim Format
ICD-10-CM
Privacy
EHR
PQRS
eRx
WPS
CMS

Noridian





CEDI
Medicaid
Coding
AOA
Potpourri
30
Medicare Reimbursement Adjustment
(penalty).

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2012 Medicare Payments docked 1%*
2013 Medicare Payments docked 1.5%
2014 Medicare Payments docked 2%
*It is still unknown whether or not the -1% 2012 payment adjustment
applies to ODs
31
Avoiding Adjustment

Must use approved eRx software as required by
Medicare

Must report at least 25 unique eRx events for
patients in the denominator of the measure before
12/31/11. (92000 or 99000 exam).

ODs use “Claims-based reporting” of the electronic
prescribing measure. Report a successful e-Rx with
G-code (G8553) for 2011
32
Avoiding the Medicare
e-Prescribing “Adjustment” (penalty)
You can get e-Rx credit for re-prescribing an Rx…but
you cannot get credit for giving a pharmacy
permission to refill an Rx.
You can get credit if you successfully e-Rx with your
approved e-Rx software, even if an intermediary
changes your e-Rx to a Fax.

33
Exemptions and Exceptions

To request an exemption to the eRx Incentive
Program and the payment adjustment, there are two
“hardship codes” that can be reported via claims
should one of the following situations apply, plus an
exemption for not having prescribing privileges.

There are also two exceptions
34
Exemptions

G8642 - The eligible professional practices in a
rural area without sufficient high speed
internet access and requests a hardship
exemption from the application of the
payment adjustment under section
1848(a)(5)(A) of the Social Security Act.
35
Exemptions

G8643 - The eligible professional practices in
an area without sufficient available
pharmacies for electronic prescribing and
requests a hardship exemption from the
application of the payment adjustment under
section 1848(a)(5)(A) of the Social Security Act
36
New Exemptions
The final rule provides additional significant
hardship exemption categories for 2011 for
the 2012 eRx payment adjustment:
(1) eligible professionals who register to
participate in the Medicare or Medicaid EHR
Incentive Program and adopt certified EHR
technology;
37
New Exemptions
(2) eligible professionals who are unable to
electronically prescribe due to local, state, or
federal law or regulation;
(3) eligible professionals who have limited
prescribing activity;
(4) eligible professionals who have insufficient
opportunities to report the e-prescribing
measure due to limitations of the measure’s
denominator.
38
Exceptions


Does not have prescribing privileges. Note: (S)he
must report (G8644) at least one time on an
eligible claim prior to December 31, 2011;
Does not have at least 100 cases containing an
encounter code in the measure denominator
(92000 and 99000 exam codes)
39
What to Do?


Go to the CMS e-prescribing web site
Click on “How to get Started” (left column)
http://www.cms.gov/ERxIncentive/03_How_To_Get_Started.asp#TopOfPage
40
2010 eRx Payments
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


LE will appear on the electronic remit.
CMS created a 4-digit code to indicate the type of
incentive and reporting year. For the 2010 eRx
incentive payments, the 4-digit code is RX10.
For example, eligible professionals will see LE to
indicate an incentive payment, along with RX10 to
identify that payment as the 2010 eRx incentive
payment.
The paper remittance advice will read, “This is an eRx
incentive payment.” The year will not be included in
the paper remittance.
41
2010 eRx Payments

Who to Contact for Questions? Provider Contact
Center. The Contact Center Directory is available at
http://www.cms.gov/MLNProducts/Downloads/CallCenterTollNumDirectory.zip


The QualityNet Help Desk is available Monday
through Friday from 7:00 a.m. – 7:00 p.m. CST at 1866-288-8912 or via qnetsupport@sdps.org. The help desk
can also assist with program and measure-specific
questions.
The following CMS resource is available to help
eligible professionals understand the 2010 eRx
Incentive Payments, view A Guide for Understanding the 2010
eRx Incentive Payment [PDF 57 KB], on the CMS website.
42
2011 3rd Party Update

HIPAA
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






Claim Format
ICD-10-CM
Privacy
EHR
PQRS
eRx
WPS
CMS

Noridian





CEDI
Medicaid
Coding
AOA
Potpourri
43
Nursing Home Coding
1. Make sure there is a justifiable medical reason for the
visit.
2. If using E&M coding, make sure your documentation
justifies your 99307, 99308, or 99309 claim.
3. Don’t let your documentation look “cookie-cutter”. If
all your documentation looks alike, it raises question
of authenticity.
4. 3. The AOA says an OD can use the 92xxx exam codes
when making nursing home visits, using the place of
service codes of 31 (skilled nursing facility) or, more
likely, 32 (nursing facility).
44
Final Code must be
Reasonable and Necessary
Considering
• Chief Complaint/ Reason for visit /
Presenting Problem
• History
• Clinical findings
• Decision Making Required
45
Must 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.
46
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
92018
92019
92260
92270
92287
92541
92542
92544
99221-99223
99231-99233
99281-99283
99350
99354
99355
99356
99357
47
CHANGES IN THE WPS OPTOMETRY LCD,
EFFECTIVE JANUARY 1, 2011

The following Codes have been added to Table II for
Optometrists with a therapeutic license;
65272
65275
65286
65600
67825
67850
68020
98020
68530
68810
68840
76529
82785
87070
87081
87205
87809
87809.
48
CHANGES IN THE WPS OPTOMETRY LCD,
EFFECTIVE JANUARY 1, 2011

The following CPT codes, found in Table II, no
longer require a -55 modifier;
67820
67938
68040
68761
68801
49
2011 3rd Party Update

HIPAA
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






Claim Format
ICD-10-CM
Privacy
EHR
PQRS
eRx
WPS
CMS

Noridian





CEDI
Medicaid
Coding
AOA
Potpourri
50
Consolidated Billing
Medicare’s Consolidated Billing is when you bill the
patient's SNF for materials, and some services, rather
than 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.
51
Consolidated Billing
Whenever you have a scheduled patient who is
residing in a SNF, prior to examination you
should always ask the SNF if the patient is
currently covered under Medicare A.
If so, you need to explain to the SNF about
consolidated billing, since most are unfamiliar
with the term or its consequences.
52
Consolidated Billing


All post-op DME billing that would normally go
to Noridian must now go to the SNF.
The technical component of most ancillary
testing must also go to the SNF.
53
Consolidated Billing
Technical component of the following codes must be
billed to the SNF

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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
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




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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.
54
Consolidated Billing


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.
55
Medicare Limiting Charge
Non-Participating Medicare Providers Cannot
Bill or Charge Usual and Customary Fees.
The rules are….
 You do not have to see Medicare patients.
 But, if you see ANY Medicare patients, federal
law requires you to follow Medicare
guidelines.
 Non-Par providers must file claims for their
Medicare Patients.
56
Medicare Limiting Charge



Non-Par providers must not bill more than the
Medicare limiting charge (last column on
Medicare Fee Schedule), under penalty of
federal law.
Non-par Providers Cannot Collect From
Medicare Patients & Medigap &/or Patient a
Total $ Amount More Than The Medicare
Limiting Charge
Excessive billing or failure to file claims will
incur severe fines.
57
Medicare Limiting Charge
58
Medicare Limiting Charge
A provider who violates the limiting charge is
subject to
 Assessments of up to $10,000 per violation
plus
 Triple the amount of the charges in violation,
and
 Possible exclusion from the Medicare
program.
59
Medicare Fees
You Cannot Charge Medicare Patients Extra
Fees such as
 A Finance Charge
 Interest
 Other Similar Types Of Charges.
60
New 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
61
2011 3rd Party Update

HIPAA








Claim Format
ICD-10-CM
Privacy
EHR
PQRS
eRx
WPS
CMS

Noridian





CEDI
Medicaid
Coding
AOA
Potpourri
62
Medicare DME Enrollment


DME Suppliers Must Now Pay $500+ To Enroll
Or To Re-Enroll
DME Suppliers Must Re-Enroll Every 3 Years.


CMS requires that all DMEPOS suppliers re-enroll
every three years with the NSC
Requires application fee of $505 in 2011 as
part of the enrollment process
http://www.cms.gov/MLNMattersArticles/downloads/MM7350.pdf
http://www.cms.gov/MedicareProviderSupEnroll/
63
DME 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
64
DME Electronic Claims:
Annual CEDI Recertification
CEDI Recertification Now Required Annually
 Beginning in 2011, CEDI is requiring all Trading
Partners to recertify their user access on an
annual basis.
 If you have your own submitter ID that
contains A08, B08, C08, or D08, you are a
"trading partner”. DO IT NOW.
http://www.ngscedi.com/forms/formsindex.htm
65
2011 3rd Party Update

HIPAA








Claim Format
ICD-10-CM
Privacy
EHR
PQRS
eRx
WPS
CMS

Noridian





CEDI
Medicaid
Coding
AOA
Potpourri
66
Medicaid Managed Care


At the behest of the Unicameral, Medicaid
managed care will go state wide in July (?) of
2012.
No one yet knows which insurers will be
approved as MCOs in the newly affected areas
of the state.
67
Medicaid 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.
68
Medicaid Managed Care





If the MCOs currently serving eastern Nebraska are
approved for out-state, and
If they handle the situation the same as they have in
the eastern 10 counties,
Then Nebraska ODs will need to be a Block Vision
provider to see routine care Medicaid patients, and
Will need to be a Share Advantage and a Coventry
Nebraska provider to see medical diagnosis patients.
However BCBS should also be a strong contender.
69
2011 3rd Party Update

HIPAA








Claim Format
ICD-10-CM
Privacy
EHR
PQRS
eRx
WPS
CMS

Noridian





CEDI
Medicaid
Coding
AOA
Potpourri
70
WPS: 92004 Dilation
WPS Q & A on 92004 Eye Exams
 CERT [Comprehensive Error Rate Testing]
states that 92004 must include initiation of
diagnostic and treatment services, and should
include dilation, unless documentation show
contraindication
71
Medicare Coverage


VEP And Tear Osmolarity Not Covered By
Medicare
Make sure you have a ABN signed if you plan
to perform either test on Medicare patients.
72
Medicare Coverage
Diabetic Examinations
 Despite HHS and CMS ostensibly advocating
preventative medicine, 250.0x by itself is no
longer reimbursable by Medicare.
73
74
Medicare Probe Results for CPT 99213
- Optometry

Of all the specialties checked by WPS and
displayed on their website, optometry was the
only profession that had



More 99214 claims than the national average
Less 99213 claims than the national average
Make sure your documentation shows
justification for the level billed
75
Billing Punctal Plugs to Medicare


The bottom line: ignore the 50 modifier and
all the fancy coding;
Just vary the number of units. 3 plugs, three
units. 4 plugs, 4 units.
76
Ordering/Referring Physicians Must Be
in Capital Letters
Medicare Providers who


order health care products for Medicare
beneficiaries or
refer Medicare beneficiaries for health care
services
must be identified entirely in capital letters on
Medicare claims
77
2011 3rd Party Update

HIPAA








Claim Format
ICD-10-CM
Privacy
EHR
PQRS
eRx
WPS
CMS

Noridian





CEDI
Medicaid
Coding
AOA
Potpourri
78
From the AOA: Forget The S Codes!


Optometrists play an ever increasing role as
members of the primary health care team and
Using S Codes poses many risks for access to
the full range of optometric services.
79
Pay for Performance, Not for
Procedures
From the AOA: National Strategy for Quality
Improvement in Health Care Business as usual, including basing payment
on procedures performed, is going by the
wayside.



Diagnosis related groups (Hospitals)
Acute Care Episode (cardiac, orthopedic A & B)
Episode of Care (Home Health)
80
2011 3rd Party Update

HIPAA








Claim Format
ICD-10-CM
Privacy
EHR
PQRS
eRx
WPS
CMS

Noridian





CEDI
Medicaid
Coding
AOA
Potpourri
81
FTC Red Flags Rule
Most Optometrists Exempt From Red Flags Rule
Applies only when
 1) Using credit reports in the ordinary course
of business
 2) Furnishing information to credit reporting
companies
 3) Loaning money
82
Review Insurance Agreements

October is a great time to launch your 'annual'
review of all the agreements you've signed
with HMOs, medical insurers, and vision plans.
83
The Medical Home
The Medical Home: Communicate with Your
Patient's PCP -- In order for an optometrist to be considered a
player in the upcoming medical home
scenario, the OD must communicate
significant findings to the patient's PCP on a
regular basis. 11p4
84