Medicare FQHC Changes 2011
Change Request 7038
National Association of Community Health Centers (NACHC) 7200 Wisconsin Avenue, Suite 210
Bethesda, MD 20814 301-347-0400
301-347-0459 FAX www.nachc.com
Agenda
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Introduction
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FQHC Overview
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CR7038 Impact (MEDICARE ONLY!!)
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Preventive, AWV, & other 2011 Updates
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Production Alerts
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Enrollment Application Fee (855A)
FQHC… What makes a CHC unique
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Encounter Rate… Face-to-face with core provider
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Fixed Rate of Reimbursement vs. FFS
–So why is coding important?
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Appropriate capture of breadth & scope of service
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Commercial FFS maximization
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Managed Medicaid with Encounter Rate secondary
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Data collection for PPS change for Medicare in 2014 - data
is being collected as of 1/1/11
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Cost Based Oversimplified… $100,000 to see 1,000 visits
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PPS- Method of reimbursement in which payment is made
FQHC - Core Provider
•
Medicare
’
s definition of a visit or billable encounter is: A
face-to-face encounter in an outpatient setting between a patient and a
FQHC Core Practitioner.
– Medical Doctor (MD, DO) – Optometrist
– Podiatrist – Chiropractor
– Physician’s Assistant (PA)
– Certified Midwife (CNM) – Nurse Practitioner (NP) – Clinical Psychologist (CP)
– Licensed Clinical Social Worker (LCSW) – Certified Diabetic Educator
FQHC… Medicare Encounter Rate
• Unique Medicare Benefits
–Deductible… waived (EXCEPT Part B)
–Preventive Visits (e.g., 99387/99397) covered
• Expanded to include Annual Well Visit (AWV)
• Encounter Rate (Typically 80% of rate below) –Rural: $109.24; Urban: $126.22
–Co-pay based on FFS charges
• 99212 has charge of $45… co-pay is $9 NOT 20% of encounter rate
• Coinsurance waived on some preventive services
• Additional Encounter Rate Scenarios
FQHC…COINSURANCE WAIVER
“Effective for dates of service on or after January 1, 2011,
coinsurance and deductible are being waived for all Preventive
Services as enacted in section 4104 of the Affordable Care
Act”
Medicare will provide 100 percent payment (in other words, will
waive any coinsurance or copayment) for the:
–Initial Preventive Physical Examination (IPPE) –Annual Wellness Visit (AWV), and
–Those preventive services that are identified with a grade of A or B by the United States Preventive Services Task Force (USPSTF) for any indication or population and are appropriate for the individual
Annual Wellness Visit (AWV) Personalized
Prevention Plan Services (PPPS)… (1 of 4)
Effective 1/1/11, Medicare covers AWV
NOT interchangeable with Preventive E&M (i.e., 99381-99397) Co-pay and deductible waived in all POS (Not just FQHC)
Note: 993XX at FQHC… only deductible, not co-pay, waived MD, DO, PA, NP, CNS, health educator, RD, nutritionist, or
combination team may provide AWV services G0438 for First visit & G0439 for Subsequent
G0438 is allowed once per patient per lifetime
G0439 is allowed every 12 months after either 1. a IPPE (Welcome to Medicare) or, 2. Initial AWV
Note: Benefit is per patient not per provider
G0439 and G0438 are not allowed within 12 months of the patients initial enrollment into Medicare. Bill an IPPE (G0402).
Annual Wellness Visit (AWV) Personalized
Prevention Plan Services (PPPS)… (2 of 4)
• Initial: G0438 and Subsequent: G0439
• Required Services/Documentation (Subsequent parenthetical)
• Establishment (Update) of medical/family history
• Establishment (Update) of a list of current providers and
suppliers that are regularly involved in providing medical care • Measurement (Update) of height, weight, BMI (or waist
circumference), BP, and other data as deemed appropriate • Detection (Update) of cognitive impairment
• Review of the individual’s potential (risk factors) for depression, including current or past experiences with depression or other mood disorders
• Review of the individual’s functional ability and level of safety based on direct observation, or the use of appropriate screening questions or a screening questionnaire
Annual Wellness Visit (AWV) Personalized
Prevention Plan Services (PPPS)… (3 of 4)
• Initial: G0438 and Subsequent: G0439
• Required Services/Documentation (Subsequent parenthetical)
• Review of the individual’s potential (risk factors) for depression, including current or past experiences with depression
• Review of the individual’s functional ability and level of safety based on direct observation, or the use of appropriate screening questions or a screening questionnaire (Update)
• Establishment (Update) of a list of risk factors and conditions for which primary, secondary, or tertiary interventions are
recommended or/are underway
• Furnishing of personalized health advice to the individual and a referral, as appropriate... see actual document for specifics
Annual Wellness Visit (AWV) Personalized
Prevention Plan Services (PPPS)… (4 of 4)
• Initial: G0438 and Subsequent: G0439
• Required Services/Documentation (Subsequent parenthetical)
• Voluntary advance care planning (as defined in this section) upon agreement with the individual (Update)
• Any other element(s) determined appropriate by the Secretary of Health and Human Services through the National Coverage Determination (NCD) process (Update)
Source: MBPM Pub 100-02, Transmittal 134,
FQHC Covered Preventive
Services Billable to Part B
The technical component of the following specific preventive services (the professional component is an RHC/FQHC service if performed by a RHC/FQHC physician or non-physician practitioner)
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Screening pap smears and screening pelvic exams;
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Prostate cancer screening;
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Diabetes outpatient self-management training services;
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Colorectal cancer screening tests;
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Screening mammography;
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Bone mass measurements; and
•
Glaucoma screening.
FQHC Covered Preventive Services
(1 of 2)
The following preventive primary services may be covered and
billed to the intermediary when provided by FQHCs to Medicare
beneficiaries:
● Medical social services;
● Nutritional assessment and referral; ● Preventive health education;
● Children’s eye and ear examinations; ● Prenatal and post-partum care;
● Prenatal services;
● Well child care, including periodic screening;
● Immunizations, including tetanus-diphtheria booster and influenza vaccine;
● Voluntary family planning services; ● Taking patient history;
FQHC Covered Preventive Services
(2 of 2)
The following preventive primary services may be covered and
billed to the intermediary when provided by FQHCs to Medicare
beneficiaries: (continued)
● Blood pressure measurement; ● Weight measurement;
● Physical examination targeted to risk; ● Visual acuity screening;
● Hearing screening; ● Cholesterol screening;
● Stool testing for occult blood; ● Dipstick urinalysis;
● Risk assessment and initial counseling regarding risks; and ● For women only:
● Clinical breast exam;
● Referral for mammography; and
Medicare Reporting:
2011 Changes (1 of 5)
For dates of service on or after January 1, 2011, when billing services on a 77X type of bill, all services provided should be listed with the appropriate revenue code and HCPCS code for each line.
• For each billable visit, FQHCs must submit the appropriate revenue code and a valid HCPCS code for all claims.
• In addition, FQHCs must submit separate service lines with revenue codes and HCPCS codes to reflect any cost associated with all FQHC covered services provided by the FQHC but not reflected on the
service line submitted for the billable visit
•Pneumococcal, influenza and hepatitis B vaccine and their
administration should be reported separately with the appropriate HCPCS code and revenue codes.
The only types of services payable on TOBs 77x:
•Professional or primary services not subject to the
Medicare outpatient mental health treatment limitation are
bundled into line item(s) using revenue code 052x;
•An additional payment maybe received for professional
and primary services furnished on the same day at different
times. These services should be billed using revenue code
052x and modifier 59.
Medicare Reporting:
2011 Changes (2 of 5)
•Services subject to the Medicare outpatient mental health
treatment limitation are billed under revenue code 0900;
•Telehealth originating site facility fees are billed under revenue
code 0780 and HCPCS code Q3014;
•Diabetes Self Management Training (DSMT) billed under
revenue code 052x and HCPCS code G0108 and Medical
Nutrition Therapy (MNT) billed under revenue code 052x and
HCPCS code 97802, 97803, or G0270; and
•FQHC supplemental payments are billed under revenue code
0519, effective for dates of service on or after 01/01/2006.
Medicare Reporting:
2011 Changes (3 of 5)
•
0521
= Clinic visit by member to RHC/FQHC;
•
0522
= Home visit by RHC/FQHC practitioner;
•
0524
= Visit by RHC/FQHC practitioner to a member in a
covered Part A stay at the SNF;
•
0525
= Visit by RHC/FQHC practitioner to a member in a SNF
(not in a covered Part A stay) or NF or ICF MR or other residential facility;•
0527
= RHC/FQHC Visiting Nurse Service(s) to a member’s
home when in a home health shortage area; and
•
0528
= Visit by RHC/FQHC practitioner to other non
RHC/FQHC site (e.g., scene of accident)
•
0519
= Clinic, Other Clinic (only for the FQHC supplemental
payment)
Medicare Reporting:
2011 Changes (4 of 5)
• For dates of service on or after January 1, 2011, all except the
following revenue codes may be used when billing for services
provided in a FQHC: 002x-024x, 029x, 045x, 054x, 056x, 060x,
065x, 067x-072x, 080x-088x, 093x, or 096-310x.
NOTE: This information is being captured for data collection and
gathering purposes only.
Medicare Reporting:
2011 Changes (5 of 5)
2011 Coding Update (1 of 2)
• Q Codes for Flu Vaccine
Production Alerts
NGS and MAC Production Alerts
Lists resolved and unresolved processing issues for Medicare
claims
Recent Issues
•Preventive services coinsurance calculating incorrectly
•Misplaced decimal on number of units
•Invalid diagnosis code RTP
Application Fee for 855A
Effective Friday, March 25, 2011, Medicare Administrative Contractors (MACs) will begin collecting application fees with certain provider/supplier enrollment applications (both paper and online applications) as described below. The application fee is currently $505 for CY2011; however, this fee will vary from year-to-year based on adjustments made pursuant to the Consumer Price Index for Urban Areas (CPI-U).
Note that these application fees do not apply to physicians, non-physician practitioners, non-physician organizations, and non-non-physician organizations. All institutional providers of medical or other items or services or suppliers must pay the application fee. (‘‘Institutional provider’’ includes any provider or supplier that submits a paper Medicare enrollment application using the CMS-855A
ICD-10: Timelines for Change
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Jan 2009 Revised… Federal Register Update:
–5010: Jan 2012 –ICD-10: Oct 2013
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2010:
“
To Do
”
list for providers
–Transition team development & needs assessment
–Individual plan creation & Launch
•
Jan 2011 Testing of 5010 by CMS
Summary
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Read, understand and implement
changes
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Sign up for List serve
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Monitor Medicare for updates
FQHC Resources
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CMS FQHC / RHC Claims Processing Manual (IOM 100-4
Chpt.9)
https://www.cms.gov/manuals/downloads/clm104c09.pdf
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CMS FQHC / RHC Manual (IOM 100-2 Chpt.13)
http://www.cms.hhs.gov/manuals/Downloads/bp102c13.pdf
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FQHC Yearly Payment Limits
http://www.ugsmedicare.com/providers/audit_reimbursement/fqhcm axlim.asp
FQHC Resources
MLN Matters – CR 7038
http://www.cms.gov/MLNMattersArticles/downloads/MM7038
CMS Manual System – Change Request 7038 Transmittal
http://www.cms.gov/transmittals/downloads/R2034CP.pdf
NGS Medicare Revenue Coding Card
http://www.ngsmedicare.com/wps/wcm/connect/49317600443b96 9d8743e7e46ee7c6fe/294_0810_ub_04_other_codes.pdf?MOD =AJPERES&CACHEID=49317600443b969d8743e7e46ee7c6fe
FQHC Resources
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USPSTF – Grades of Preventive Services
http://www.palmettogba.com/Palmetto/Providers.Nsf/files/CR7012-Deductible_and_Coinsurance_for_Preventive_Services.pdf/$File/CR701 2-Deductible_and_Coinsurance_for_Preventive_Services.pdf
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2011 to FQHC Yearly Payment Limits
www.cms.gov/MLNMattersArticles/downloads/MM7101.pdf
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Implementation of Application Fees for Medicare Institutional
Provider/Supplier Enrollment
http://www.GPO.gov/fdsys/pkg/FR-2011-02-02/pdf/2011-1686.pdf.•
Production Alerts
http://www.ngsmedicare.com/wps/portal/ngsmedicare/!ut/p/c4/04_SB8K8x LLM9MSSzPy8xBz9CP0os3gDr2BnRzdTEwMDs1BHA09HD0ffIFdzY2dP E_2CbEdFAKVSEXA!/?attestation=AcceptRaymond T. Jorgensen is President and CEO of Priority Management Group, Inc. (PMG). Ray is responsible for oversight of consulting operations as well as coding, reimbursement, and payer related issues for the out-sourced billing component of PMG’s services (more than 850,000 annual encounters). He has personally trained thousands of providers from over 35 states on coding, billing, and reimbursement in addition to authoring two books and dozens of articles.
Ray’s health care experience and education is unique in that he was schooled by the payers. Having worked for Blue Cross and Blue Shield as well as United HealthCare Corporation, primarily in professional relations and contracting, Ray has an understanding and perspective on the payer’s objectives and process unlike other medical business consultants groomed from the provider side.
•BA from The College of the Holy Cross (Worcester, MA) •MS from Northeastern University (Boston, MA)
•CPC from the American Academy of Professional Coders (Salt Lake City, UT)
•CHBME from the Healthcare Billing & Management Association (Laguna Cliffs, CA)
Speakers:
PMG’s Vice President, Consulting and Compliance
Caroline has more than 25 years experience in the physician billing and coding industry. Her extensive experience includes serving as the Vice President, Coding and Compliance, Manager of coding and Billing Operations Manager for physician billing companies that serviced a wide range of specialties and practice types. She has broad experience with hospital-based physician and private practice where she was integral to coding and compliance education and training for clinical providers, practice and billing office staff members. She has performed and managed chart audits with objective of both compliance and optimizing reimbursement through correct coding and thorough documentation.
Caroline holds a Bachelor of Science degree in Health Service
Administration from Providence College. She is an AAPC certified coder and PMCC instructor.
Speakers:
Robert Skeffington a founding partner and Executive VP of Sales and Marketing for Priority Management Group, Inc. (PMG). Responsible for PMG‘s overall business development strategy, Robert also works with staff to assess the impact of Health Care Reform on PMG and its hundreds of clients. Robert works diligently to enhance relationships with the National Association of Community Health Centers, state and regional CHC organizations, and individual community health sites. In addition to his role in PMG Billing, Robert also leads marketing and sales efforts for PMG Consulting which provides CHC centric education, operational assistance, and training services around revenue cycle management, coding, and other health care finance related matters.
During his more than 17 years in health care Robert has worked with CHCs in the 48 contiguous states with an exclusive focus on revenue cycle management for the past 12 years with PMG. He is a speaker for NACHC and other regional CHC associations on a variety of health care revenue cycle related topics.
•BS from Salve Regina University (Newport, RI)
•CHBME from the Healthcare Billing & Management Association (Laguna Cliffs, CA)
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