2015 MEDICARE UPDATES

Transcription

1 Disclaimer 2015 MEDICARE UPDATES The information contained in these slides are current at the time of writing. However, CMS can change the information at any time. Please monitor the ISMA website and all of your list serves. I am not an employee of CMS or WPS and neither are responsible for the content of this material. ISMA has acquired permission to use the CPT codes. 2 Contact Information Jeri Biedenkopf, RN Toll free number: Direct fax: Wisconsin Physician Services Indiana Medicare Administrative Contractor - WPS Region J

2 Medicare Premium and Deductible Part B 2015 Standard premium is $ Deductible $147 Co-insurance remains at 20% Part A 2015 Deductible $1,260 Final Rules Final rules were released October 31, 2014 Released in Federal Register on November 13, Listed under Centers for Medicare and Medicaid Services tion?collectioncode=fr 5 6 Comment Period for Final Rules To be assured your comments are considered, they must be received no later than 5 p.m. on December 30, Information on ways to make comments can be found in the Federal Register. collectioncode=fr Conversion Factor (CF) 2014 Conversion factor January 1, 2015 through March 31, $ was $ For April 1, 2015 through December 31, $

3 SGR Intervention for the last several years has prevented a pay cut The problem: Each time a pay cut is postponed, it is factored into the future Medicare budget. If the SGR remains as it currently stands, annual pay cuts will increase to higher percentages that will continue to have to be overridden. SGR Congress being urged to eliminate the SGR formula. Without government intervention there will be a 21.2% decrease on the CF. Congress has applied 17 patches to the SGR Represents $170 billion in temporary fixes. 9 Indiana GPCIs 2015 A GPCI is the local difference in practice costs Indiana GPCI Work expense - $1.00 (mandatory $1.00 will expire March 31, 2015). The proposed GPCIs reflect the elimination of the 1.0 work GPCI floor from April 1, 2015 through December 31, Until congress votes we will not know if the work expense will change. Practice expense - $0.921 Malpractice expense - $0.617 Formula for Calculating Payment Work expense RVU x GPCI work RVU + Practice expense RVU x GPCI PE RVU + Malpractice RVU x GPC MP RVU Times the Conversion factor (CF) This formulates into a real dollar amount

4 Negative Impact on Specialties Specialties with a negative impact of more than 2% on the RVUs are: Dermatology Ophthalmology OIG Workplan Ambulance services Questionable billing, medical necessity, and level of transport Ambulance services Portfolio report on Medicare Part B payments Anesthesia services Payments for personally performed services Chiropractic services Part B payments for non-covered services Chiropractic services Questionable billing Chiropractic services Portfolio report on Medicare Part B payments OIG Workplan Ophthalmologists Inappropriate and questionable billing Physicians Place-of-service coding errors Physical therapists High use of outpatient physical therapy services Portable x-ray equipment Supplier compliance with transportation and setup fee requirements Sleep disorder clinics High use of sleep-testing procedures Diagnostic radiology Medical necessity of high-cost tests Imaging services Payments for practice expenses Selected independent clinical laboratory billing requirements (new) Global Surgical Codes The 10 day global service will be eliminated beginning day global service will be eliminated beginning

5 Anesthesia with Screening Colonoscopy As of January 1, 2015, beneficiary coinsurance and deductible do not apply to the anesthesia claim lines billed when furnished in conjunction with screening colonoscopy Anesthesia professionals who furnish a separately payable anesthesia service in conjunction with a colorectal cancer screening test should include the 33 modifier on the claim line with the anesthesia service. Anesthesia with Screening Colonoscopy In situations that begin as a colorectal cancer screening test, and another service such as colonoscopy with polyp removal is actually furnished, the anesthesia professional should report a PT modifier on the claim line rather than the 33 modifier. We will have to wait for official instructions from WPS via CMS in a MLN/CR Chronic Care Management (CCM) Effective January 1, 2015 CMS establishes separate payment beginning in 2015 for complex chronic care management services furnished to patients with multiple complex chronic conditions (must have two or more chronic conditions) Goal was to recognize critical non-face-to-face time and services of advanced primary care CPT code minutes or more of services per calendar month during the first quarter of 2015 the approximately reimbursement $ $43.00 this is not listed in fee schedule on WPS for 2015 at this time. Telehealth Currently approved Medicare telehealth services include the following: Initial inpatient consultations; Follow-up inpatient consultations; Office or other outpatient visits; Individual psychotherapy; Pharmacologic management; Psychiatric diagnostic interview examination; End-stage renal disease (ESRD) related services; Individual and group medical nutrition therapy (MNT); Neurobehavioral status exam; Individual and group health and behavior assessment and intervention (HBAI); 19 20

6 Telehealth cont. Subsequent hospital care; Subsequent nursing facility care; Individual and group kidney disease education (KDE); Individual and group diabetes self-management training (DSMT); Smoking cessation services; Alcohol and/or substance abuse and brief intervention services; Screening and behavioral counseling interventions in primary care to reduce alcohol misuse; Screening for depression in adults; Screening for sexually transmitted infections (STIs) and high intensity behavioral counseling (HIBC) to prevent STIs; CMS-1600-P 167 Intensive behavioral therapy for cardiovascular disease; and Behavioral counseling for obesity Telehealth Con t. The following services have been added to telehealth for Psychotherapy services CPT codes 90845, and Prolonged service office CPT codes and Annual wellness visit HCPCS codes G0438 and G Telehealth Con t. Allowed practitioners Physician Physician assistant (PA) Nurse practitioner (NP) Clinical nurse specialist (CNS) Nurse-midwife Clinical psychologist Clinical social worker Registered dietitian or nutrition professional CT Payment Reduction Effective for services furnished on or after January 1, 2016, there will be payment reductions for the technical component of CT imaging services performed on equipment not meeting certain equipment standards. This applies to codes , , , , , , , , and (and any succeeding codes)

7 CT Payment Reduction Specifically, the payment reduction would apply to services performed on machines that do not meet the NEMA Standard. The technical component payment reduction would be 5 percent for 2016 and 15 percent for years 2017 and beyond. This would apply to both the physician fee schedule and the hospital outpatient prospective payment system. PQRS 2015 must report at least 9 measures, cover at least 3 of the National Quality Domains and report each measure for at least 50 percent of the eligible professionals patients seen during the reporting period to which the measure applies. The negative 2% penalty for 2017 is based on 2015 There is no PQRS incentive payment for Overview of PQRS Assessment- Instruments/PQRS/Downloads/PQRS_OverviewFactSheet_20 13_08_06.pdf Help Desk EPs who have questions or need assistance with PQRS reporting should contact the QualityNet Help Desk. The help desk is available Monday Friday; 7:00 AM 7:00 PM CST: Phone: TTY: Qnetsupport@hcqis.org Bonus payments 1.0% for % for % for % for 2014 Last year for bonus PQRS Penalty 1.5% for % for 2016 and subsequent years 27 28

8 Value Based Modifier What is the Value Based Modifier It is a budget-neutral mechanism for rewarding physicians with high-quality, low-cost care in traditional Medicare Fee- For-Service based on a per claim basis. Penalizing physicians identified as low-value providers Implementation will begin in Could affect 900,000 physicians. The Value modifier is applied at the Taxpayer Identification Number (TIN) level and applies to all physician billing under that TIN Value Based Modifier Applied to: 2015 physicians in groups with 100 or more eligible professionals (Eps) based on 2013 performance physicians in groups with 10 or more EPs based on 2014 performance physician solo practitioners and physicians in groups with 2 or more EPs based on 2015 performance 2018 physicians and non-physician EPs who are solo practitioners or are in groups with 2 or more EPs Value Based Modifier Summary of VBM ValueModifierPolicies.pdf Value Based Modifier Information Quality Resource Use Reports (QRUR) Help Desk (select option 3); QualityNet Help Desk or qnetsuppor@hcqis.org 32

9 The Penalty Phase Year/Program erx PQRS Meaningful Use Value Modifier % % % % -1.0%* -1.0% % -2.0% -2.0% % %** (each year) -4.0% * Penalties will be greater for unsuccessful e-prescribers ** Penalty amount could increase up to 5% depending on meaningful use success rates Copyright Medical Group Management Association (MGMA ). All rights reserved. Incentive Payment Primary care incentive payment Effective April 1, 2012 through December 31, % payment made on a quarterly basis Codes: PCP furnishing a primary care service in a HPSA may receive both a HPSA and PCIP payment A surgeon in a HPSA is only eligible to receive the HPSA surgical incentive payment (HSIP) payment (receives only one payment not two) Reference: MM7561 SE Network-MLN/MLNMattersArticles/downloads/MM7561.pdf 34 Vaccine Payment Allowances until CPT 90655: pending CPT 90656: $ CPT 90657: $6.022 CPT 90662: $ Q2035 (Afluria): $ Q2036 (Flulaval): $8.579 Q2037 (Fluvirin): $ Q2038 (Fluzone): $ Q2039 (N.O.S.): locally priced 90672: $ : $ : $ G0008, G0009, G0010 $ $23.78 Based on CPT Website Delayed until October 1, 2015 OK, so sometimes google doesn t work

10 Modifier 59 Specific Modifiers for Distinct Procedural Services Changes - MLN Matters Number: MM Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/MM 8863.pdf Modifier 59 Specific Modifiers for Distinct Procedural X- modifiers XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter, XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure, XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner, and XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service Outpatient Therapy Caps On April 1, 2014, President Obama signed into law the Protecting Access to Medicare Act of This new law extends the exceptions process for outpatient therapy caps through March 31, Section 103 of this Act contains a number of Medicare provisions affecting the outpatient therapy caps and manual medical review (MR) threshold. Therapy caps for 2014 through March 31, 2015 are $1,940. There are two types of therapy caps One for Occupational Therapy One for Physical Therapy and Speech-language Pathology After expenses have exceeded the therapy caps the KX modifier is to be used to request an exception to the therapy caps Medicare Appeals 5 levels of appeal Redetermination (MAC) Reconsideration by a Qualified Independent Contractor (QIC) Administrative Law Judge (ALJ) - $150 ($10 increase) Departmental Appeal Board (DAB)/appeal council Judicial review in Federal District Court $1460 ($30 increase) 39 40

11 Open Payments Open Payments (Known as the Sunshine Act) is the federally run program that collects information about financial relationships between drug and device manufactures and certain healthcare providers and makes this information available. Sometimes, doctors and hospitals have financial relationships with health care manufacturing companies. Can include: Money for research activities Gifts Speaking fees Meals Travel Open Payments The Social Security Act requires CMS to collect information in order to report their financial relationships with physicians and hospitals. To gain a deeper understanding view CMS Fact sheet: Sept Published-Data.pdf 41 Enrollment 855 R CMS finalized a new 855R form. This is used to reassign an individual physician's Medicare billing privileges to an organization. The revised form will be available December 29, Medicare administrative contractors may accept both the current and revised versions of the form through May 31, 2015, once the new form is available. The online Medicare Provider Enrollment, Chain and Ownership System (PECOS) will be revised to include the new 855R. 43