Coding Strategy

Here are the pros and cons to help guide your decision.

Question: Our practice is considering accepting patients with PFFS plans. We’re heard that some patients are starting to have them, but we’re not sure whether we’re going to accept them or not. Are PFFS plans beneficial for us?

Answer: PFFS are Private Fee-for-Service plans, which are non-network plans. These plans let members receive care from any doctor or hospital that accepts the plan’s payment terms and conditions.

If your practice decides to accept these terms, you would become a “deemed” provider. Plan members can receive covered services from any deemed provider in the U.S. However, member patients must confirm that the provider is deemed every time a service is provided.

PFFS plans are different from Medicare Advantage plans because they do not require a doctor or hospital to contract with a health plan to provide services. This means that doctors or hospitals that do not agree to the PFFS plans’ terms and conditions may choose not to provide health care services to a plan member, except in emergencies.

Coming soon: Starting in 2011, PFFS plans will have to measure and report on their providers’ quality of care. But the catch is that they’ll also have to form provider networks with contracts.

In counties where there are two or more non-PFFS plans, PFFS plans will no longer be able to simply “deem” providers into the plan without a contract. Under current law, PFFS plans don’t have to prove they can meet access standards if they allow any willing qualified Medicare provider to participate, and they pay as traditional Medicare would pay.

One argument is that the network requirement would provide better access to care because there would be contracts between the providers of services and the plan. On the other hand, private FFS plans may limit the number of providers who participate, actually resulting in poorer access to care.

@ Medical Office Billing & Collections Alert (Editor: Joshua Thines).

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MACs won’t process June claims until today, in hopes that Congress will act.

The Senate’s delays could mean serious payment crunches for your practice.

Last month, the freeze that has been keeping the Medicare conversion factor at 2009 levels expired, meaning that Part B practices were due to face a 21-percent cut effective for dates of service June 1 and thereafter. Because Congress had not yet intervened to stop those cuts, CMS initially instructed MACs to hold claims for the first 10 business days of June while lawmakers could deliberate whether to eliminate the looming cuts.

When the Senate reconvened on June 7, many analysts expected its members to vote on H.R. 4213, “The American Jobs and Closing Tax Loopholes Act of 2010,” which was expected to increase your payments through the end of this year, according to the text listed on the House Ways and Means Committee Web site. However, the bill has not passed, leading CMS to extend the MACs’ claims hold through June 17.

According to a June 14 CMS notification, the agency directed its contractors “to continue holding June 1 and later claims through Thursday, June 17, lifting the hold on Friday, June 18.”

CMS acknowledged in its June 14 notification that the lengthened claims hold period “may present cash flow problems for some Medicare providers. However, we expect that the delay, if any, beyond the normal processing period will be only a few days.”

The impact of the 17-day claims hold will vary, depending on the practice and how many Medicare patients it sees, says Quinten A. Buechner, MS, MDiv, CPC, ACSFP/GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis.

Those practices with large Medicare populations could face a cash flow crisis, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J., and senior coder and auditor for The Coding Network.

“The claims hold effectively cuts off their Medicare pay for that period,” Cobuzzi says. “This has been happening almost monthly this year (with a few exceptions that gave us multiple month extensions).”

Avoid Holding Claims on Your Own

Some practices do not count on Medicare to do the claims hold correctly, so they are holding the claims themselves, Cobuzzi says. “In May, the MACs released payments before the fix was in, at the 21-percent reduction, and then those claims had to receive corrections,” she notes. “The practices that are holding their own claims figure that kind of mistake will not happen to them. But their delay will be even longer because they are not submitting to Medicare until the fix is voted on and then they have to wait the time period for Medicare processing.”

@ Part B Insider (Editor: Torrey Kim, CPC).

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Study frequency guidelines before you bill for counseling services.

Question: A 60-year-old established Medicare patient with a confirmed diagnosis of vanishing lung (emphysema) reports to the family physician (FP) for a medication check and blood work; the patient is a moderate smoker. During the medication check and blood work, which took about 5 minutes, the patient tells the practice’s non-physician practitioner (NPP) “I think I’m ready to quit smoking; can you help?” The NPP spends the next 7 minutes providing smoking cessation counseling for the patient. Can I report a cessation code and an E/M?

Answer: Provided the patient meets Medicare’s requirements for cessation counseling, you can report the following:

• 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes or less are spent performing or supervising these services.) for the E/M

• 492.0 (Emphysema; emphysematous bleb) appended to

• 99211 to represent the patient’s emphysema

• 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) for the smoking cessation counseling

• 305.1 (Tobacco use disorder) appended to 99406 to represent the patient’s tobacco dependency.

Know the rules: According to Medicare, its patients are entitled to smoking and tobacco use cessation counseling provided the patient is either:

• a tobacco user who has an illness caused or complicated by tobacco use or

• taking a therapeutic agent whose metabolism or dosing is affected by tobacco use as based on Food and Drug Administration-approved information.

Additionally, note these two frequency guidelines for spot-on 99406 and 99407 (… intensive, greater than 10 minutes) claims:

• Medicare will cover up to two counseling attempts per year for the first 12-month period of counseling (Each attempt can include up to four counseling sessions).

• Medicare will cover up to eight more sessions during a second or subsequent 12-month period of counseling after 11 full months have passed since the first Medicare covered cessation counseling session was performed. For example, if the first of eight covered sessions was performed in April 2009, a second series of eight sessions may begin in April 2010.

@ Family Practice Coding Alert (Editor: Chris Boucher, CPC).

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Treatment plans are a must, experts say.

You’ve treated your chiropractic patient, you’ve selected the correct codes, and you’ve submitted your claim. All set, right? Not quite. Check out this common mistake that chiropractors make.

“Many chiropractors do not create written chiropractic treatment plans for every new patient,” says Marty Kotlar, DC, CHCC, CBCS, president of Target Coding, a chiropractic coding and billing consulting firm. Use this checklist to ensure you send Medicare the information CMS most wants to see included “with every new patient plan of care,” Kotlar says:

__ The history
__ Present illness
__ Family history
__ The past health history
__ The physical examination
__ The diagnosis
__ The plan — This should include:

• Therapeutic modalities to effect cure or relief (patient education and exercise training)
• The level of care that is recommended (the duration and frequency of visits)
• Specific goals that are to be achieved with treatment
• The objective measures that will be used to evaluate the effectiveness of treatment
• Date of initial treatment.

__ Signature/initials to authenticate the records.

@ Part B Insider (Editor: Torrey Kim, CPC).

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CMS instructs MACs to hold claims for ten business days while Congress mulls bill.

Impending cuts to your Medicare pay have been a familiar story this year, but hopefully you won’t face a 21-percent payment drop while you’re trying to enjoy your summer.

Last month, Congress voted to extend freezing the conversion factor at 2009 levels so Part B practices wouldn’t have to face a 21 percent cut to the conversion factor, which was supposed to go into effect on April 1. Once the president signed the extension into law, it meant that practices didn’t have to worry about the Medicare cuts until June 1, in hopes that the government would find a more permanent solution to the pay cut crisis before the conversion factor freeze expires on May 31.

New Bill Could Put Off Cuts

The House Ways and Means Committee published the text of H.R. 4213, “The American Jobs and Closing Tax Loopholes Act of 2010,” on its website on May 20. The bill would increase your payments through the end of this year, according to the text listed on the Committee’s Web site, which states, “In lieu of the update to the single conversion factor … that would otherwise apply for 2010 for the period beginning on June 1, 2010, and ending on December 31, 2010, the update to the single conversion factor shall be 1.3 percent.” The bill also includes provisions that would ensure that additional cuts don’t take place through 2013.

The American College of Physicians posted support for the bill on its website, but the AMA expressed disappointment. “An intervention to delay a looming Medicare physician payment cut will provide temporary stability for seniors and their physicians, but the AMA is deeply disappointed that Congress will once again fail to permanently correct the Medicare physician payment formula that Republican and Democrat members of Congress, President Obama, and policy experts have said should be repealed,” said AMA President J. James Rohack in a May 20 statement.

“Lawmakers must realize that the underlying policy problem will return larger than ever in 2014,” Rohack added.

Whether Congress takes up the bill before the May 31 deadline remains to be seen, but CMS assures practices that it will act quickly if such a law passes.

“Congress, we know, is working hard in terms of trying to develop a fix for June 1,” said CMS’s Stewart Streimer during a May 25 CMS Open Door Forum. “We’re hoping for a Congressional action sometime this week, but we of course don’t know for sure.

Regardless, we will be prepared as best we can to pay claims June 1, but at this point in time there’s not much I can tell you until we see what the legislative landscape holds for us.”

CMS Instructs MACs to Hold Claims

Until Congress sorts out the payment issue, CMS has instructed its contractors to hold claims for the first ten business days of June. “This hold will only affect Medicare Physician Fee Schedule claims with dates of service June 1, 2010 and later,” a May 27 CMS email alert noted.

To read the full text of H.R. 4213, click here.

@ Part B Insider. Editor: Torrey Kim, CPC

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