Thursday, November 26, 2015



Read the latest medical news for the San Bernardino County area.

CMS changes enrollment requirements for Part D prescribers

Beginning on June 1, 2016, all physicians and other providers who prescribe Medicare Part D drugs must be enrolled in Medicare or have a valid record of opting out. Failure to do so will result in a denial of the pharmacy claim or the beneficiary’s request for reimbursement.

The Centers for Medicare and Medicaid Services (CMS) had originally intended to begin enforcing this regulation last June, but the agency delayed implementation to allow sufficient time for beneficiaries and Medicare Part D plans to prepare.

All physicians and other prescribers who are not currently in compliance are encouraged to complete their Medicare enrollment or submit an opt-out affidavit no later than January 1, 2016. This will ensure sufficient processing time so that their Part D patients will continue to have access to necessary medication without interruption.

If you are unsure if you are compliant with this requirement, please review the CMS prescriber enrollment file.

Enrollment applications can be submitted on paper or online via PECOS. To enroll offline using a paper enrollment form, complete the CMS-855O application and mail to Noridian, California's Medicare contractor. Providers should be aware, however, that this form only allows you to enroll in Medicare for the purpose of ordering and certifying services and items, and to prescribe Part D drugs. It will not allow you to bill or be paid for Medicare services. To apply as a Medicare provider with full billing privileges, you will need to complete the appropriate CMS-855 form(s).

For more information, see the CMS Part D Prescriber Enrollment webpage and MLN Matters number SE1434. CMS has also put together a Part D Provider Enrollment FAQ.

For more information on opting out, see the Noridian website.

CMS extends Physician Compare preview period

The Centers for Medicare and Medicaid Services (CMS) has extended the Physician Compare preview to November 16, 2015, to allow more time for physicians to preview their data for the 2014 quality measures that will be reported on the Physician Compare website later this year.

The Affordable Care Act required CMS to create a website that would allow consumers to search for and compare physicians and other health care professionals who provide Medicare services. That site—the "Physician Compare" website, initially launched in 2010—provides contact information, specialties and clinical training, hospital affiliations and group practice information.

In 2014, the website also began phasing in physician quality data from the Physician Quality Reporting System (PQRS), including the Group Practice Reporting Option, the Electronic Prescribing Incentive Program and the Electronic Health Record Meaningful Use Program.

Physicians can access the preview site now via the PQRS portal-Provider Quality Information Portal. To learn more about which measures will be publicly reported and how to preview your measures, visit the Physician Compare Initiative page.

If you have any questions about Physician Compare, public reporting or the 2014 quality measure preview period, please contact CMS at

CMS issues final 2016 Medicare payment rule; includes reimbursement for end-of-life discussions

On Friday, the Centers for Medicare and Medicaid Services (CMS) released the final 2016 Medicare physician fee schedule. One of the biggest changes in the CMS proposal is the assignment of codes to pay physicians for end-of-life consultations.

Key policies finalized in the 2016 payment rule include:

Advanced care planning: The final fee schedule includes two CPT codes to reimburse for advance care planning. Compensating health care professionals for time spent with patients discussing treatment wishes and goals of care is a critical step forward in honoring patient treatment preferences, particularly for those nearing the end of life.

Physician payments: The final rule includes a 0.5 percent overall increase in Medicare reimbursement in 2016 for all providers.

Merit-Based Incentive Payment System: In the final rule, CMS has made changes necessary to begin implementation of the new Merit-Based Incentive Payment System for physicians and other practitioners, which will fully take effect in 2019.

For more information, see the CMS fact sheets.

Click here to view the final rule.

Noridian Medicare announces web-based provider enrollment workshops

Noridian, the Medicare Administrative Contractor for California, announced that it will offer web-based workshops focusing on provider enrollment. These webinars are intended for the Part B provider using the online Provider Enrollment, Chain and Ownership System (PECOS) to change enrollment information, track revalidation or set up a sole proprietorship.

The Internet-based PECOS process can be used in lieu of the Medicare enrollment application (i.e., paper form CMS-855).

The advantages of PECOS are:

  • Faster than paper-based enrollment (45-day processing time in most cases, vs. 60 days for paper)
  • Tailored application process means you only supply information relevant to YOUR application
  • Gives physicians more control over their enrollment information, including reassignments
  • Easy to check and update your information for accuracy
  • Less staff time and administrative costs to complete and submit enrollment to Medicare
There is no registration or teleconference fee. The presentations will be conducted through a web-based training tool that requires an Internet connection and a telephone (toll-free number provided in confirmation email).

For more details and to register, visit

Noridian announces new audits

Noridian, California's Medicare administrative contractor, has announced it will be conducting service-specific targeted audits of procedure codes 99205 and 99233 when rendered by providers with specific specialties:

  • 99205 performed by cardiology (Centers for Medicare and Medicaid Services specialty designation 06) and pulmonary (29)
  • 99233 performed by internal medicine (11) and hematology/oncology (83)
Noridian conducts these targeted reviews based on data analysis. An analysis of these procedure codes, when performed by physicians in these specialties, indicated a higher utilization by California providers when compared to national claim payment ratios for the same services by the same specialties.

These reviews are conducted on a pre-payment basis, meaning Noridian will notify physicians selected for claim audits through the additional documentation request (ADR) process before payment is made. Upon receipt of a request for information, practices must submit all applicable documentation for each claim with a copy of the ADR as a cover sheet. Records should be mailed (hardcopy or CD) or faxed to Noridian within 45 days of receipt, or a claim denial will result.

More information on the ADR process can be found here. Documentation that may support the services billed includes:

  • Legible copy of the patient's medical record for listed date(s) of service
  • Legible physician signature
  • Consultation reports
  • Physician progress notes
  • Diagnostic test results/reports, including imaging reports if applicable
  • Any other documentation to support the CPT Code that was billed
For more assistance on signature and documentation requirements, refer to the Documentation Guidelines for Medicare Services on Noridian’s website.

Noridian will review the documentation submitted within 30 days of receipt. No letters will be sent on the outcome of each individual claim. The claim decisions will be reflected in the remittance advice and may be appealed through the normal appeal process, if unfavorable.

When the audit is complete, Noridian will analyze the results and determine if any subsequent actions are necessary. The results will be posted to Noridian’s JE Part B website.

Spending for federal health programs is expected to remain 'modest' over the next 10 years

Total health care spending growth for federal health programs such as Medicare and Medicaid is expected to average 5.8 percent in aggregate over 2014-2024, according to a report published by the Centers for Medicare & Medicaid Services (CMS) Office of the Actuary. The authors noted that this rate of growth is still substantially lower than the 9 percent average rate seen in the three decades before 2008.  

“Growth in overall health spending remains modest even as more Americans are covered, many for the first time. Per-capita spending and medical inflation are all at historically very modest levels,” said CMS Acting Administrator Andy Slavitt.

In 2014, health spending in the United States was projected to have reached $3.1 trillion, or $9,695 per person, and to have increased by 5.5 percent from the previous year.

With new expensive specialty drugs hitting the market, prescription drug spending increased 12.6 percent in 2014, the highest growth since 2002. While more people are getting coverage, annual growth in per-enrollee expenditures in 2014 for private health insurance (5.4 percent), Medicare (2.7 percent) and Medicaid (-0.8 percent) remained slow in historical terms.

Other findings from the report included:

  • Medical price inflation averaged 1.4 percent nationally – even with the implementation of the Affordable Care Act (ACA). Hospital and physician and clinical services, which make up the largest portions of medical prices, also increased slowly at 1.4 and 0.5 percent, respectively.

  • Premium growth in private health plans is projected to slow to 2.8 percent in 2015, reflecting the expectation of somewhat healthier marketplace enrollees and the increasing prevalence of high-deductible health plans offered by employers. The authors projected that per-capita premium growth would remain below 6 percent through the end of the projection period (2024).

  • Approximately 19.1 million additional people are expected to enroll in Medicare over the next 11 years as more members of the Baby Boomer generation reach the Medicare eligibility age.

  • In 2014, per capita Medicaid spending was projected to have decreased by 0.8 percent as the newly enrolled were expected to be somewhat healthier than those who were enrolled previously. Overall spending, however, is projected to have increased by 12 percent in 2014 as a result of a 12.9-percent increase in enrollment related to the ACA coverage expansion.
  • While the newly enrolled Medicaid adult population is projected to cost more than adults who were enrolled in the program in 2013, the authors expect that per-enrollee costs will fall below the costs of other adults after pent-up demand for medical care is satisfied.
  • The insured rate is expected to rise from 86 percent to 92.4 percent as the number of uninsured persons is projected to fall by 18 million over the next 11 years.

  • With increases in coverage, the share of health expenses that Americans pay out-of-pocket is projected to decline from 11.6 percent in 2013 to 10 percent in 2024.
Click here to read the report. Read the article published in Health Affairs here.

CMS releases proposed 2016 Medicare physician fee schedule

The Centers for Medicare and Medicaid Services (CMS) recently released the 2016 proposed Medicare physician payment rule. The rule reflects the 0.5 percent increase in payment as of July 1, 2015, and the additional 0.5 percent increase in payment on January 1, 2016, recently adopted by Congress. Overall, Medicare will pay physicians nearly $700 million more in 2016 than they will have paid in 2015.

Most notable in the payment rule is CMS’ proposal to pay for advance care planning and end-of-life counseling. The fee schedule would establish two new codes to cover early conversations between patients and their physician about care options. These codes were recommended by the American Medical Association (AMA) Relative Value Scale Update Committee (RUC). The codes include discussion before an illness progresses and during the course of treatment so patients can make decisions about appropriate treatment for their personal situation. One code would cover the first 30 minutes and the other would cover additional 30-minute blocks of time. AMA and the California Medical Association (CMA) have been pushing CMS to cover such services.

CMS is seeking comments on the 2019 implementation of the new Medicare payment systems recently adopted by Congress as part of the permanent repeal of the sustainable growth rate (SGR) formula. The agency also noted its strong support for promoting primary care services and is soliciting comments on potential coverage of collaborative care services and an expansion of the Comprehensive Primary Care initiative. The proposal also includes an expansion of payment for telehealth services mainly for in-home treatments for end-stage renal disease.

There are numerous changes to the relative values of services – many recommended by the AMA RUC. Most notably, payment for gastroenterology services will be reduced 5 percent, with colon and rectal surgery reduced by 1 percent. Organized medicine is fighting many of these changes.

Other notable provisions of the rule include:

  • Myriad changes to the Accountable Care Organization Shared-Savings program, the Physician Quality Reporting System (PQRS) and the value-based payment modifier, which will soon apply to all physicians who bill under a tax identification number.
  • CMS will no longer require physicians who opt out of the Medicare program to notify Medicare on an annual basis.
  • New appropriate use criteria for advanced diagnostic imaging mainly based on recommendations from the related specialty societies.
  • Some new exceptions to physician self-referral laws.
The overall payment impact by specialty can be found on page 711 of the rule. Please note that these payments do not account for adjustments made by PQRS, the value-based payment modifier or meaningful use.

CMS is also updating the Geographic Adjustment Factors for all localities nationwide. California will see increases of 0.1 to 0.3 percent. Please note that starting in 2017, California localities will move to Metropolitan Statistical Areas due to the CMA-sponsored geographic practice cost index legislation; there will be larger payment increases to the urban counties currently within the "Rest of California" locality.

AMA and CMA are carefully analyzing the multitude of changes to the physician payment system and will be submitting extensive comments.

Contact: Elizabeth McNeil, (800) 786-4262(800) 786-4262 FREE FREE or

CMS to begin provider reimbursement for end-of-life care

On July 8, the Centers for Medicare & Medicaid Services (CMS) released the first proposed update to the Medicare physician payment schedule since the repeal of the sustainable growth rate (SGR) formula through the Medicare Access and Children’s Health Insurance Plan (CHIP) Reauthorization Act of 2015. One of the biggest changes in the CMS proposal is the assignment of codes to pay providers for end-of-life consultations. In addition the department would make advance care planning “an optional element” of a beneficiary's annual wellness visit.

The American Medical Association (AMA) lauded CMS for the advance care planning proposal. “The proposed Medicare payment rule affirms the need to support conversations between patients and physicians to establish and communicate the patient’s wishes in responding to various medical situations,” said AMA president-elect Andres Gurman, M.D.

As far as general reimbursement of Medicare visits, the document includes a 0.5 percent overall increase in Medicare reimbursement in 2016 for all providers.

The release of the rule triggers a 60-day comment period by stakeholders and the public. CMS is accepting public comments on the proposed rule until September 8, 2015. A final rule will be published this fall.

Click here for a fact sheet on the proposed rule. The full rule will be published soon in the Federal Register.

The California Medical Association is reviewing the proposed rule and will provide additional details and comments in the future.

CMS announces changes to make Medicare ICD-10 transition less disruptive for physicians

The Centers for Medicare & Medicaid Services (CMS) announced that it will provide a one-year grace period during which it will allow for flexibility in the claims payment, auditing and quality reporting processes as the medical community gains experience using the new ICD-10 code set. The ICD-10 implementation date of October 1, 2015, has not changed.

The changes announced include:

Claim denials: Medicare review contractors will not deny claims based solely on the specificity of the ICD-10 diagnosis code as long as a valid code from the right family of codes is used. Moreover, physicians will not be subject to audits as a result of ICD-10 coding mistakes during the grace period.

Quality reporting: Physicians also will not be penalized under the quality reporting programs for errors related to the additional specificity of the ICD-10 diagnosis code, again as long as a code from the correct family of codes is used.

Advance payments: If Medicare contractors are unable to process claims within established time limits because of administrative problems, such as contractor system malfunction or implementation problems, advance payment may be available to keep resources flowing to physician practices.

ICD-10 communication center: CMS will set up a communication center to monitor the implementation of ICD-10 in an effort to quickly identify and resolve issues related to the transition. As part of the center, CMS will have an ICD-10 ombudsman to help receive and triage physician and provider issues.

These provisions are a culmination of organized medicine's efforts to convince CMS of the need for a transition period to avoid financial disruptions during this time of tremendous change. The California Medical Association (CMA) has been working closely with the American Medical Association (AMA) and other medical associations, urging CMS to help mitigate the impact of the transition. Most recently, CMA, AMA and other large state medical associations (New York, Texas and Florida), met with CMS and Congressional leadership, urging them to support a two-year grace period during which physicians would not have claims delayed, denied or subject to audits because of simple ICD-10 errors.

ICD-10 education and training available

Recognizing that health care providers need help with the transition, CMS, AMA and CMA are also working to make sure physicians and other providers are ready for the October 1 transition to the new ICD-10 code sets. CMS and AMA will be offering webinars, on-site training, educational articles and national provider calls to help physicians and other health care providers prepare for the transition. For more information, see CMS's ICD-10 provider page and AMA's ICD-10 web page.

CMA, in partnership with its local county medical societies and the California Medical Group Management Association, is offering two-day ICD-10 code set seminars around the state. The two-day boot camps include 16 hours of intensive general ICD-10 code set training, along with hands-on coding exercises. To view the available dates and locations, visit the CMA event calendar. For the latest ICD-10 news and updates, see CMA's ICD-10 resource page and visit AMA Wire.

Physicians should be aware the Medicare claims processing systems will not have the capability to accept ICD-9 codes for dates of services after September 30, 2015, nor will they be able to accept claims for both ICD-9 and ICD-10 codes.

Slight increase to Medicare reimbursement rates effective as of July 1

A 0.5 percent physician payment increase will go into effect for dates of service from July 1 through December 31, 2015. This mid-year increase is a result of the Medicare Access and CHIP Reauthorization Act. The Centers for Medicare & Medicaid Services released the updated RVU files reflecting the payment increase and new conversion factor, $35.9335 (previously $35.7547).

Noridian, the Medicare Administrative Contractor for California, has posted the new fee schedule that will be in effect from July 1 through December 31, 2015. There will be an additional 0.5 percent increase on January 1, 2016.


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