SMB Newsletter February 2012

By Joni Lovvorn • February 3rd, 2012

2012 Newsletter Volume 1

Important changes effecting Medical Practices in TX

Texas Medicaid Dual Eligible Payment Cuts

The Texas Legislature directed HHSC to implement the change to reduce Medicaid costs.  The rules, scheduled to take effect n January 1, 2012, will eliminate payment of Medicare Part B coinsurance if the payment would result in Medicaid paying more than its allowable.  If Medicaid pays mopre than Medicare, then the state would pay the coinsurance or up to the Medicaid allowble, whichever is less.

Here are some examples.  They are for illustation purposes only.  Medicare payments vary by region of the state.

Example 1:  Established dual-eligible patient has not met any of the Medicare deductible and is seen during a routine office visit.  Physician bills Medicare “CPT code 99213”.  Maximum Medicare allowable is $66.90 (rest of Texas).  Medicare pays $0 because deductible has not been met.  Medicaid will pay $33.27, the Medicaid allowable for this code.

Example 2:  Established dual-eligible patient has met $100 of $140 Medicare 2012 deductible.  Patiet is seen in office for routine office visit.  Physician bills Medicare CPT code 99213.  Medicare pays $21.52, which is 80% of the allowable after deductible, ($66.90-$40).  Medicaid will pay $11.75 (33.27-21.52).

Example 3:  Established dual-eligible patient visits physician office for routine visit, Medicare deductible has been met.  Physician bills Medicare CPT code 99213.  Medicare allowable is $66.90.  Medicare pays $53.52, 80% of the allowable.  Physician bills Medicaid for the remaining 20%.  Medicaid allowable is $33.27, so no coinsurance will be paid.

Patients cannot be balance-billed

 TrailBlazer Loses Medicare Contract

This report-in part- was published by the Texas Medical Association Nov 15, 2011

The Centers for Medicare & Medicaid Services (CMS) says Highmark Medicare Services will replace TrailBlazer Healthcare Enterprises in paying Medicare Part A and Part B fee-for-service claims in Texas by late July 2012.  Highmark also will handle claims in Arkansas, Colorado, Louisiana, Mississippi, New Mexico and Oklahoma.  It now administers claims in Delaware, New Jersey, Pennsylvania, Maryland and the District of Columbia.

CMS says the change is part of its plan to reduce the number of Medicare administrator jurisdictions from 15 to 10 by 2016.

TrailBlazer said its contract runs through August 2012 and any transition to Highmark “will include extensive communications with providers and other impacted parties about transition requirements and activities.  Throughout such a transition, TrailBlazer will continue to provide cost-effective, efficient administrative services to the Medicare program and superior customer service to health care providers.”

Physician’s could see delays in payment if billing is not set up in their systems correctly to process through the new channels.  SMB will be working with Highmark and going through any training they will have available.

EMG Coding Changes

The American Academy of Neurology AAN published a guide to follow for the EMG coding changes that go into affect January 1, 2012.

Beginning January 1, 2012, new coding changes will affect physicians who perform electromyography (EMG) on the same patient on the same date of service as nerve conduction study (NCS).  The AAN has developed the following guidance to assist members with these changes.

When performing EMG and NCS on the same patient on the same date of service you will need to bill the EMG as an add-on code using one of the following new codes:

Use codes 95870 or 95885 when four or fewer muscles are tested in an extremity.  Use codes 96860-95864 or code 95886 when five or more muscles are tested in an extremity.

Use EMG codes (95860-95864 and 95867-95870) when no nerve conduction studies (codes 95900-95904) are performed on that day.  Use codes 95885, 95886 and 95887 for EMG services when nerve conduction studies (codes 95900-95904) are performed on the same day.  Report either code 95885 or 95886 once per extremity.  Codes 95885 and 95886 can be reported together up to a combined total of four units of service per patient when all four extremities are tested.  New code 95887 was written and valued to be used per site tested.  Sites recognized are unilateral face, cervical and lumbar paraspinal muscles without needle EMG examination of corresponding limb muscles, thoracic paraspinal muscles, laryns, hemidiaphragm, thoracic and abdomial muscles.  For example, if EMG is done in bilateral face muscles, the physcian should report two units of service of 95887.

For help with your EMG coding questions, register for the AAN’s Practice Management Webinar “CPT Coding for Nerodiagrnastic Procedures Made Easy” on Tuesday, March 13, 2012.

95885: Needle electromyography, each extremity with or without related paraspinal areas, done with nerve conduction, amplitude and latency/velocity study; limited (list separately in addition to code for primary procedure) per extremity

95886: Complete, five or more muscles studied, innervated by three nerves or four spinal levels (list separately in addition to code for primary procedure) per extremity

95887: Needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (List separately in addition to code for primary procedure)

Use 95887 in conjuction with 95900-95904

Do not report 95887 in conjuction with 95867-95870 or 95905

HIPAA 5010 Conversion In Effect 1/1/2012

 What is 5010?  The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated that the healthcare industry use standard formats for electronic claims and claims-related transactions.  Because the current version 4010 format cannot support new developments in health care and the upcoming ICD-10 code set changes, all electronic healthcare transactions must convert to the HIPAA-compliant version 5010 on January 1, 2012.

The Department of Health and Human Services (HHS) issued a final rule in 2009 replacing the current versions of the standards with version 5010.  Certain covered entities-including health plans, healthcare clearinghouses and healthcare providers-must adopt the new required standards for claims, remittance advice, eligibility and claim status inquiry.

What does this mean for your practice?

The HIPAA 5010 conversion requires substantial changes to the information that is submitted on claims.  If these changes are not made, processing of your claims could be delayed.

To prepare for the HIPAA 5010 conversion and avoid delays in reimbursement, the most important thing you can do is to contact your practice management software (PMS) vendor or billing service about the changes needed for your software.  They can help you identify needed updates and make a plan for implementing these changes to your system.



Electronic Prescribing aka eRx Penalties Begin 2012

Some of you may be seeing the effects of the 1% decrease in reimbursements from Medicare.  If you did not report in 2011 the number of eRx measures needed to escape the cuts you will start seeing the decrease on dates of service 1/1/12 and forward.  If you continue to not report your eRx measures you will see a 1.5% decrease in 2013 and a 2.0% decrease in 2014.  SMB can help you start reporting now to insure no further decrease in your payments from Medicare. 

ICD-10 Code Set to Replace ICD-9

√  The differences between ICD-9 and ICD-10 are significant and physicians and practice management staff need to start educating themselves now about this major change so they will be able to meet the October 1, 2013 compliance deadline.

√  ICD-10-CM codes are the ones designated for use in documenting diagnoses.  They are 3-7 characters in length and total 68,000, while ICD-9-CM diagnosis codes are 3-5 digits in length and number over 14,000.  The ICD-1o-PCS are the procedure codes and they are alphanumeric, 7 characters in length, and total approximately 87,000, while ICD-9-CM procedures codes are only 3-4 numbers in length and toal approximately 4,000 codes.

√  Moving to ICD-10 is expected to impact all physicians.  Due to the increased number of codes, the change in the number of characters per code, and increased code specificity, this transition will requiore significant planning, training, software/system upgrades/replacements, as well as other necessary investments.

√  Before the ICD-10 codes can be used however, physicians and others in the health care community must start using the new version of HIPAA transaction standards known as 5010 by January 1, 2012, as the current version, 4010, does not accommodate use of the ICD-10 codes.

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