Electronic Health Record (EHR) Information
Southern Medical Association is pleased to provide the following opportunity to our members. We encourage you to apply for the Project as its benefits are numerous for your practice and community. If you are selected to participate, please let us know so that we can provide assistance and support as needed. (posted 3/08)
CMS Invites Practices to Join 5-Year EHR Demonstration Project
Deadline to Apply: May 13, 2008 - 5pm
A new national Medicare demonstration program is aiming to show health care professionals the on-the-ground advantages of connecting to the information age.
Medicare is looking for 12 communities across the country that can bring together a broad cross-section of community leadership, leverage resources, and recruit small and medium-sized physicians’ practices willing to provide the evidence that electronic health records (EHRs) can improve the quality of patient care.
As many as 1200 small and medium-sized primary care practices nationwide could be eligible for incentive payments of up to $58,000 per physician—up to $290,000 per practice—over the five-year life of the demonstration. Incentives would be based on a practice’s level of EHR use, and for reporting and performance on 26 clinical quality measures.
But the rewards of joining are much more than financial. An entire community can benefit from the use of EHRs, which can help avoid drug interactions, redundant lab and diagnostic tests, which in turn mean greater accuracy for practices and potentially lower costs. Medicare plans to announce the winning communities in June, 2008.
There is no question that EHRs will be a key part of the healthcare landscape in the future. Medicare’s objective, with this demonstration, is to launch the construction of an interconnected electronic information system quickly and seamlessly. The challenge before us is not whether to move forward to improve health care quality through the secure exchange of medical information, but when.
To learn more about the new EHR demonstration project, visit: http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/
2008_Electronic_Health_Records_Demonstration.pdf.
Email EHR_Demo@cms.hhs.gov or EHR_Demo_communityselections@cms.hhs.gov for more information about community selection.
EHR Article by Kerry N. Weems, Acting Administrator of the federal Centers for Medicare and Medicaid Services.
National Provider Identifier (NPI)
Reminder - Effective March 1, 2008, when required for Medicare claim submission, all 837P and CMS-1500 claims must have an NPI or NPI/legacy pair in the required primary provider fields. Failure to include an NPI will cause the claim to reject. (posted 3/08)
Visit the CMS NPI web page at http://www.cms.hhs.gov/NationalProvIdentStand/02_WhatsNew.asp for more details.
TEST NPI-only NOW: If you have been submitting claims with both an NPI and a Medicare legacy number and those claims have been paid, you need to test your ability to get paid using only your NPI by submitting one or two claims today with just the NPI (i.e., no Medicare legacy number). If the Medicare NPI Crosswalk cannot match your NPI to your Medicare legacy number, the claim with an NPI-only will reject. You can and should do this test now! If the claim is processed and you are paid, continue to increase the volume of claims sent with only your NPI. If the claims rejects, go into your NPPES record and validate that the information you are sending on the claim is the same information in NPPES. If it is different, make the updates in NPPES and resend a small batch of claims 3-4 days later. If your claims are still rejecting, you may need to update your Medicare enrollment information to correct this problem. Call your Medicare carrier, FI, or A/B MAC enrollment staff or the National Supplier Clearinghouse for advice right away. Have a copy of your NPPES record available. The enrollment telephone numbers are likely to be quite busy, so don't wait.
National Plan and Provider Enumeration System (NPPES) FOIA-Disclosable Data to be Available on September 4, 2007 (posted 9/07)
NPPES health care provider data that are disclosable under the Freedom of Information Act (FOIA) will be disclosed to the public by the Centers for Medicare & Medicaid Services (CMS). In accordance with the e-FOIA Amendments, CMS will be disclosing these data via the Internet. Data will be available in two forms:
CMS has extended the period of time in which enumerated health care providers can view their FOIA-disclosable NPPES data and make any edits they feel are necessary prior to our initial disclosure of the data. CMS will be making FOIA-disclosable NPPES health care provider data available beginning Tuesday, September 4, 2007. The NPI Registry will become operational on September 4 and the downloadable file will be ready approximately one week later.
CMS has posted several documents to help providers understand what the downloadable file will look like, including a “Read Me” file, Header File, and Code Value document for the downloadable file on the CMS NPI web page at http://www.cms.hhs.gov/NationalProvIdentStand/
06a_DataDissemination.asp
Starting September 3, 2007, Medicare Carriers and DME MACs Will Begin Transitioning their Systems to Start Rejecting Claims when the NPI and Legacy Provider Identifier cannot be found on the Medicare Crosswalk (posted 9/07)
Since May 29, 2007, Medicare Fiscal Intermediaries, as well as Part B CIGNA Idaho and Tennessee, have been validating NPIs and Legacy Provider Identifier pairs submitted on claims against the Medicare NPI Crosswalk. Between the period of September 3, 2007 and October 29, 2007, all other Part B carriers and DME MACS will begin to turn on edits to validate the NPI/Legacy pairs submitted on claims. If the pair is not found on the Medicare NPI crosswalk, the claim will reject. Contractors have been instructed to inform providers at a minimum of 7 days prior to turning on the edits to validate the NPI/Legacy pairs against the Crosswalk.
If you are receiving informational edits today, we strongly urge you to validate that the NPPES has ALL of the NPI and legacy numbers you intend to use on claims and for billing purposes. If NPPES is correct, and you continue to receive information edits, you should ask your contractor to validate the provider information in their system. If the contractor information is not correct, you may be instructed to submit an enrollment form or CMS-855. Please include ALL of your NPI/Legacy numbers in NPPES AND all of your NPIs that are to be used in place of your legacy on the CMS-855. If the information is different in the two systems, there is a very good chance your claim will reject. NPPES data may be verified at https://nppes.cms.hhs.gov on the web.
Medicare Efforts to Minimize Rejections and Suspensions (posted 9/07)
CMS CR5649, Transmittal number 1262 dated June 8, 2007, instructed Medicare Contractors to identify providers with the highest volume of rejections (or potential rejections/informational edits) due to invalid NPI information. They were also instructed to identify providers who are not submitting their NPI. Contractors have begun calling providers that fit these categories. If you are contacted, you may be asked to validate your NPPES information or confirm that the information in the Contractor’s Provider file is correct. If you are not submitting your NPI at this time, your Contractor will ask: why you are not submitting it, the date you plan to submit it, and will ask you to send a small batch of claims using your NPI only, if possible.
Additionally, all Medicare providers could receive phone calls and/or letters from their contractors in the event that a claim suspends due to problems with mapping a provider’s NPI to a legacy provider identifier. This could happen in the instance where one NPI is tied to several legacy identifiers. If it is determined that the claim suspended due to incorrect data in the Contractors provider file or NPPES, the provider will be requested to either update their information in NPPES and/or submit an updated CMS-855 form.
If the provider does not respond within 14 calendar days to this communication, the Contractor will return the claim as unprocessable. Conversely, if the provider does respond, it may furnish the Legacy number over the phone; however, the Contractor will ensure that it is in compliance with the Medicare Program Integrity Manual (Publication 100-08), chapter 10, section 17.2 regarding the release of information.
Reporting a Group Practice NPI on Claims (posted 9/07)
Medicare has identified instances where the Multi-Carrier System (MCS) is correcting billing or pay-to provider data on Part B claims submitted by group practices. As of May 18, 2007, the MCS Part B claims processing systems no longer corrects claims submitted by group practices that are reporting the individual rendering Provider Identification Number (PIN) or individual rendering NPI in either the billing or pay-to provider identifier fields. Groups should enter either their group NPI or group NPI and legacy PIN number pair in either of these fields.
Medicare has also reported instances of incorrect billing occurring with DME MAC’s. Providers must ensure that if they enumerate as individuals in the National Supplier Clearinghouse (NSC), they must enumerate as individuals in NPPES. If they enumerate as organizations in NSC, they should do the same in NPPES.
Update to 835 Remittance Advice Changes in MLN SE0725 (posted 9/07)
In MLN SE0725 Medicare described the 835 changes that would occur for the 835 Remittance Advice and that those changes would occur July 2, 2007 for DME MACS only. The article also went on to note that Medicare would notify providers when the Part A Institutional and Part B Professional 835 would be changing. Medicare 835 Electronic Remittance Advices will reflect the noted changes on Remittances for Part A and Part B, starting April 7, 2008.
Transcript for August 2nd Roundtable Now Available (posted 9/07)
The transcript for the August 2nd, Medicare FFS Q&A Session: Common Billing Errors, Roundtable is now available at http://www.cms.hhs.gov/NationalProvIdentStand/
Downloads/aug_2_npi_transcript.pdf on the CMS NPI page.
Reminder: Recent MLN Matters Articles (posted 9/07)
Several recent Special Edition MLN Matters articles contain important billing information for Medicare providers and suppliers, including:
General Medicare Claims Processing Reminder (posted 9/07)
Unrelated to the NPI, Fee-for-Service Medicare claims can be rejected by contractors for a variety of reasons including:
If a provider has questions about a claim rejected by an FI/carrier or MAC, the provider should contact the contractor directly. It is never appropriate to direct the beneficiary, who received the service billed on the claim, to the 1-800-Medicare toll free line to resolve a claim rejection.
Incorrect Implementation Schedule Published (posted 9/07)
It has come to CMS' attention that a trade publication recently published a schedule of implementation dates, by contractor, for claim rejections based on the inability to locate an NPI/legacy identifier pair on the Medicare NPI Crosswalk. The dates listed in the publication are incorrect. Providers will be advised by their Medicare contractor as to the particular timeframe for their transition. Any other published schedules are unofficial and may have inaccurate dates. Medicare providers are urged to only rely on information from their Medicare contractors.
Providers may find a recent MLN Matters article helpful in determining how to use the NPI on Part A and Part B claims. You can view the article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0725.pdf on the CMS website.
As always, more information and education on the NPI can be found through the CMS NPI page www.cms.hhs.gov/NationalProvIdentStand on the CMS website. Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1-800-465-3203. Having trouble viewing any of the URLs in this message? If so, try to cut and paste any URL in this message into your web browser to view the intended information.
Physicians' Quality Reporting Initiative (PQRI)
2007 Physician Quality Reporting Initiative (PQRI) Update (posted 9/07)
It’s been one month since reporting quality data codes for the 2007 Physician Quality Reporting Initiative (PQRI) on claims for dates of service starting July 1 through December 31, 2007 began. Eligible professionals participating in the 2007 PQRI indicate that the PQRI Tool Kit and Data Collection worksheets are an asset to successful reporting. Provider organizations report successful reporting by their members. Information about the 2008 PQRI was released in the Notice of Proposed Rulemaking for the 2008 Medicare Physician Fee Schedule.
To ensure successful reporting, the Centers for Medicare & Medicaid Services (CMS) would like to bring to your attention the following items:
Use of Modifiers with PQRI Quality Data Codes (posted 9/07)
The PQRI quality data codes should only be reported with CPT II modifier(s) (1P, 2P, 3P or 8P), if applicable. If any other modifier, i.e. CPT I modifier or HCPCS Level II modifier, is placed on the same line as a PQRI code, it may cause the claim to be rejected or denied as an invalid procedure/modifier combination.
Reminder: PQRI Letter to Medicare Beneficiaries (posted 9/07)
CMS has posted a letter to Medicare beneficiaries with important information about the PQRI at, http://www.cms.hhs.gov/PQRI, on the CMS website. The letter is from Medicare to the patient explaining what the program is, and the implications for the patient. Physicians may choose to provide a copy to their patients in support of their PQRI participation.
Question of the Week (posted 9/07)
Question
The 1.5% bonus is subject to a cap. How and when will CMS calculate the cap for an individual eligible professional?
Answer
The bonus cap calculation is defined as follows: (the individual's instances of reporting quality data) multiplied by (300%) multiplied by (the national average per measure payment). The third factor, the "national average per measure payment amount" can only be calculated after the reporting period ends because it is equal to (the total amount of allowed charges under the Physician Fee Schedule for all covered professional services furnished during the reporting period on claims for which quality measures were reported by all participants in the program) divided by (the total number of instances where data were reported by all participants in the program for all measures during the reporting period.)
Because the "national average per measure payment amount" is not yet available, the following is a hypothetical example:
Example
How to View the Measures and Specifications (posted 9/07)
To view the entire list of 2007 PQRI quality measures and the associated measure specifications, visit the PQRI website at, http://www.cms.hhs.gov/PQRI, and click on the “Measures/Codes” section of the page.
How to View the List of Eligible Professionals (posted 9/07)
To see the complete list of eligible professionals who may choose to participate in the 2007 PQRI, visit the PQRI website at, http://www.cms.hhs.gov/PQRI, and click on the “Eligible Professionals” section of the page.
PQRI Resources (posted 9/07)
New information is continually added to the most reliable source of information for the 2007 PQRI, the CMS website, http://www.cms.hhs.gov/PQRI. Here you will find new and revised Frequently Asked Questions, updates on issues related to both the 2007 and 2008 PQRI, new educational products, and access to the latest information you need to successfully participate in the 2007 PQRI.
General Information
Rejected Claims (posted 9/07)
Fee-for-Service Medicare claims can be rejected by contractors for a variety of reasons including: incorrect billing information, terminated provider, the beneficiary is not eligible for Medicare or the claim was sent to the wrong contractor. If a provider has questions about a claim rejected by a Medicare Fiscal Intermediary, Carrier or Administrative Contractor, the provider should contact the contractor directly. It is never appropriate to direct the beneficiary who received the service billed on the claim to the 1-800-Medicare toll free line to resolve a claim rejection.
Part B Drug Information
Medicare Part B Drug Competitive Acquisition Program (CAP): 2008 Physician Election (posted 9/07)
The 2008 Physician Election Period for the Medicare Part B Drug Competitive Acquisition Program (CAP) will begin on October 1, 2007 and concludes on November 15, 2007. The CAP is a voluntary program that offers physicians the option to acquire many injectable and infused drugs they use in their practice from an approved CAP vendor, thus reducing the time they spend buying and billing for drugs. The 2008 CAP program will run from January 1 to December 31, 2008.
Once a physician has elected to participate in CAP, they must obtain all drugs on the CAP drug list from the CAP drug vendor. Physicians can still continue to purchase and bill Medicare under the Average Sale Price (ASP) system for those drugs that are not provided by the physician's CAP vendor.
Additional information about the CAP is available at the following website: http://www.cms.hhs.gov/CompetitiveAcquisforBios/01_overview.asp
The physician election form can be found at the following webpage in the Downloads section. Additional information for physicians can also be found at this site: http://www.cms.hhs.gov/CompetitiveAcquisforBios/02_infophys.asp
The list of drugs supplied by the CAP vendor, including NDCs, is in the Downloads section at: http://www.cms.hhs.gov/CompetitiveAcquisforBios/15_Approved_Vendor.asp
Please note that completed and signed physician election forms should be returned by mail to your local carrier. Forms must be postmarked on or before November 15, 2007. DO NOT return forms to CMS offices. (posted 9/07)
More detailed information will be available in an upcoming Medicare Learning Network (MLN) Matters Article.
Miscellaneous
* NEW * Present On Admission Indicator (posted 10/07)
As part of his commitment to make health care more affordable and accessible, President Bush directed the U.S. Department of Health and Human Services to make cost and quality data available to all Americans. As a first step in this initiative, on June 1, 2006, Medicare posted information about the payments it made to hospitals in fiscal year 2005 for common elective procedures and other hospital admissions. Similar postings of Medicare payment data followed during the year for Ambulatory Surgery Centers (ASCs), Hospital Outpatient Departments, and Physician Services.
On June 20, 2007 and August 29, 2007, Medicare updated last year's inpatient hospital and ASC data, respectively. On Thursday, September 27, 2007, we posted an update to last year's physician services data, including anesthesia services. In addition, we added a table reflecting physician payment data for many Medicare covered preventive services. The information is being displayed in the same format as last year, updated with calendar year (CY) 2006 data. The posting update may be found at http://www.cms.hhs.gov/HealthCareConInit/
Present On Admission Indicator (posted 9/07)
Effective October 1, 2007, Medicare will begin to accept a Present On Admission (POA) Indicator for every diagnosis on inpatient acute care hospital claims; however, providers must submit the POA on hospital claims beginning with discharges on or after January 1, 2008. Critical access hospitals, Maryland waiver hospitals, long term care hospitals, cancer hospitals, psychiatric hospitals, inpatient rehabilitation facilities, and children’s inpatient facilities are exempt from this requirement.
For more information on this POA requirement, please see MLN Matters Article #MM5499 which can be downloaded at the following url:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5499.pdf
Cms Issues Final Rule Prohibiting Physician Self-Referral (posted 9/07)
CMS today issued final regulations prohibiting physicians from referring Medicare patients for certain items, services and tests provided by businesses in which they or their immediate family members have a financial interest. This regulation is the third phase of the final regulations implementing the physician self-referral prohibition commonly referred to as the Stark law.
“These rules protect beneficiaries from receiving services they may not need and the Medicare program from paying potentially unnecessary costs,” said Herb Kuhn, CMS acting deputy administrator.
This third phase of rulemaking (Phase III) responds to public comments on the Phase II interim final rule published March 26, 2004 in the Federal Register. The rule does not establish any new exceptions to the self-referral prohibition, but rather makes certain refinements that could permit or, in some cases, require restructuring of some existing arrangements, CMS officials explained.
The final rule, which was put on display Monday, will be published in the September 5, 2007 Federal Register. To view the rule, go to: http://www.cms.hhs.gov/PhysicianSelfReferral/04a_regphase3.asp. For more information, visit the following link on the CMS website: http://www.cms.hhs.gov/PhysicianSelfReferral/ . To view the entire press release, please click here: http://www.cms.hhs.gov/apps/media/press_releases.asp
“The Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Health Care Professionals” (posted 9/07)
The 2nd Edition of “The Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Health Care Professionals” is now available in downloadable format from the Centers for Medicare & Medicaid Services, Medicare Learning Network (MLN). This comprehensive guide provides fee-for-services health care providers and suppliers with coverage, coding, billing and reimbursement information for preventive services and screenings covered by Medicare. This guide gives clinicians and their staff the information they need to help them in recommending Medicare-covered preventive services and screenings that are right for their Medicare patients and provides information needed to effectively bill Medicare for services furnished. To view online, go to http://www.cms.hhs.gov/MLNProducts/downloads/mps_guide_web-061305.pdf on the CMS website.
