ICD-10 grace period ends October 1 Physicians are reminded that the Centers for Medicare and Medicaid Services' (CMS) one-year grace period for ICD-10-coded claims is coming to an end on October 1, 2016. As of that date, providers will be required to use the correct degree of specificity in their coded claims. When ICD-10 went live last year, CMS said it would not deny or audit claims as long as providers used codes in the correct "family" related to the treatment. According to CMS, the ICD-10 grace period ensured that contractors performing medical reviews would not deny or audit claims solely for the specificity of the ICD-10 code as long as there was no evidence of fraud. As of October 1, 2016, Medicare contractors will begin denying claims not coded to the correct degree of specificity as required under ICD-10. Physicians should also be aware that there are more than 7,400 changes across the entire ICD-10 code set for this next year, including 2,305 new ICD-10-CM (diagnosis) codes and 3,836 new ICD-10-PCS (procedure) codes. These figures are dramatically higher than previous years, and physicians should review all sections of the guidelines to fully understand all of the rules and instructions needed to properly code their claims. Though the ICD-10 grace period will end on October 1, CMS said providers will still be allowed to use "unspecified" codes when they are warranted and there is no other option. Probably the most important step clinicians can take to prepare for these ICD-10 updates is to document patient diagnoses with precision. In addition, be sure to review the Local Coverage Determination (LCD) and National Coverage Determination (NCD) medical necessity policies for coding changes. The new ICD-10 codes become effective on October 1, 2016. September 12, 2016 Medi-Cal, Medicare Coding and Documentation, ICD-10, Billing/Coding 0 0 Comment Read More »
Aetna issues physician terminations over frequency of E/M visits The California Medical Association (CMA) has received several reports from physicians in the San Francisco Bay Area that they’ve received contract termination notices from Aetna due to their above-average use of high-level Evaluation and Management (E/M) codes. The termination letters, issued by Aetna in mid-January, advised physicians that upon review of claims for a one year period, their usage of high level E/M codes was “significantly outside the norm” of comparative physicians within their market. CMA has learned that approximately 40 physicians within the Northern California Aetna PPO network were issued the notice of termination. Contrary to the one-year timeframe for review stipulated in the termination notice, Aetna has advised that the review actually included approximately 30 months of prior claims data. Physicians whose billing pattern of high-level E/M codes exceeded two standard deviations above the mean for their assigned marketplace were issued a notice of termination per Aetna. As a result, CMA sent a letter to Aetna outlining a number of serious concerns regarding this initiative, including the following: Patients’ access to care may be unnecessarily jeopardized if physicians are not offered a meaningful opportunity to appeal or address the underlying issue prior to physician termination from the network. The inappropriateness of terminating physicians who billed outside the norm with respect to higher level E/M codes, without any prior-notice or opportunity to correct or explain the medical necessity of the care at issue, or to appeal the termination. The termination of physicians based solely on their billing levels without first engaging them to discuss factors that may have led to higher than average billing, such as physicians treating a sicker patient base (e.g., HIV patients or seniors with underlying conditions), thereby wrongly punishing providers who treat these most vulnerable patients. While physicians have been advised by Aetna of the right to request both a reconsideration of the Aetna E/M findings as well the ability to submit a separate appeal of their termination from the Aetna network, both processes failed to advise physicians of what information Aetna would consider relevant for review of this issue. However, feedback to CMA from physicians who were successful in the appeal of their termination highlighted valid reasons why their billing patterns differed from the norm, including being an urgent care practice or serving a high-risk population. This underscores the need for physicians and their staff to carefully read all payor correspondence; ensure contractual notices of any kind are immediately routed to the physician for review and response; and call CMA with any questions. Physicians impacted by the Aetna termination are encouraged to contact CMA at (916) 551-2865 or mlane@cmanet.org for additional assistance. July 6, 2015 General Billing/Coding, Coding and Documentation, Practice Resources, Aetna 0 0 Comment Read More »
How to file effective second bill reviews for workers' compensation This is the second in a two-part series focusing on coding, compliance and documentation issues relating specifically to Workers’ Compensation billing. This month’s tip comes from Catherine Montgomery, the founder and CEO of DaisyBill, which offers software solutions for workers’ compensation medical billing. Previously discussed was the importance of filing second bill reviews (SBR) for workers’ compensation medical bills, even if the underpayment is small. In the increasingly unforgiving workers’ comp billing environment , it is incumbent upon providers to make sure that billing staff or third-party billers correctly submit SBRs. Providers should assess and potentially overhaul their SBR procedures. Incorrect or untimely SBRs will result in denied bills, even if your SBR is late by even one day or is non-compliant in even one field. It is critical that billing staff or third-party billers understand that if the only dispute involves the payment amount and if a provider fails to submit a compliant SBR within 90 days, the claims administrator has no obligation to pay. This is true even if the error in payment originated with the claims administrator. Also, if an SBR is not successful, filing an independent bill review (IBR) is a provider’s next step – but only if an SBR was previously submitted. The practice is ultimately responsible, so it is critical that practices regularly ask for and review: Copies of the SBRs being submitted on your behalf, and Reports of SBR activity Number of days sent after explanation of review (EOR) Percentage of SBRs sent Dollar amount of additional payment collected from SBRs Carefully examine the SBRs to make sure they adhere to the following mandated timeframes, forms and information requirements. At the end of the day, if your bill is denied due to errors of your staff, it is you that does not get paid for the treatment provided to injured workers. SBR Timeframes SBR submission must occur within 90 days of the receipt of an EOR or within 90 days of the Workers Compensation Appeals Board resolving any threshold issues that prevented adjudication of the bill. The claims administrator must issue a final EOR within 14 days from receipt of your SBR. SBR Forms An SBR can be submitted either on paper or electronically. If on paper, a provider can use either an appropriately modified replica of the original bill or an SBR-1 form, with the exception that medical-legal bills can only be appealed on an SBR-1 form. If submitted on a copy of the original bill, the original bill must be modified as follows: CMS 1500 – Modify with “BGW3” in box 10D UB04 – Modify with “BGW3” in boxes 18-28 ADA Dental Claim Form 2006 – “Request for Second Review” in field 1 NCPDP – “Request for Second Review” written on form Required SBR Information Whether submitted electronically or on paper, either on a modified copy of the original bill or on an SBR-1 Form, the SBR must contain: Date of original EOR Claim number or other unique ID number from the EOR Item in dispute Dollar amount in dispute Additional payment requested Reason for SBR (i.e. short paid, not paid per contract, not a bundled code, etc.) Additional information provided in response to an EOR or other additional supporting information. August 8, 2014 General Practice Resources, Workers Compensation, Coding and Documentation 0 0 Comment Read More »
