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January 2015 Client Newsletter


We are pleased to announce that CPB was accepted by Novitas to participate in ICD-10 end-to-end testing at the end of January.  This allows us to fully test ICD-10 claims for not only acceptance into the ICD-10 processing system, but also to confirm payment (the most important part!).  Only 100 practices and billing services were accepted into the testing in Novitas’entire five (5) state region. 


Due to many changes in the ACA insurance plans effective January 1stsome plans are no longer being offered so the patient will have a different plan, or even have no coverage.  BE SURE TO VERIFY PATIENT ELIGIBILITY with the insurer before treating the patient.  Changes include not only deductibles and co-pay amounts, but as mentioned above, the patient may also not have re-enrolled so has no coverage at all.  Do not rely on the insurance card presented by patients. 

Thought the link below from HFMA might be a significant interest to all of our office-based clients.  Deductibles are serious challenges – the more a pt. owes the less likely s/he is to pay it.  That makes collecting it each visit (smaller amounts) critical to cash flow. 

“The out-of-pocket maximum—the most enrollees can pay for in-network care, including deductibles and cost-sharing—rose in 2015 from $6,350 to $6,600 for individual plans and from $12,700 to $13,200 for family plans. Beyond that limit, insurers cover the full cost of in-network care. The law set no limits for out-of network care.”

Clearly, if your office does not have firm, clear policies to collect deductibles and co-pays on the date of service, you risk seeing a loss of revenue. 

If you are interested in tightening your office financial policies, feel free to contact me.  We do not charge for that guidance.

ACA Plans Lift Out-of-Pocket Caps


Co-pays are rarely required for Well Visits or procedures.  They are usually only required for Office visits.  Collecting co-pays when not needed increases the number of refunds (OIG requires them to be refunded within 60 days) and can create serious Compliance issues.  For an interesting article, click here:



Medicare continues to emphasize primary care by making payment for chronic care management (CCM) services – non-face-to-face services to Medicare beneficiaries who have multiple, significant, chronic conditions (two or more) – beginning in 2015. Chronic care management services include regular development and revision of a plan of care, communication with other treating health professionals, and medication management.  We do not expect this to be billable on the same day as any other E&M code is billed. 

CMS has established a payment rate of $40.39 for the CCM code 99490 that can be billed up to once per month per qualified patient.  CMS is finalizing its proposal to allow greater flexibility in the supervision of clinical staff providing CCM services. The proposed application of the “incident to” supervision rules were widely supported by the commenters.

CMS proposed standards for electronic health records (EHR) – specifically, a 2014-certified EHR. In response to public comments indicating that very few practices have adopted a 2014-certified EHR at this time, CMS will require the version of the certified EHR that is in use on December 31 of the prior calendar year for the EHR Incentive Programs to bill for CCM services.


• The patient must give written consent to bill this service
• A written dynamic care plan
• The practice must be using a certified EHR
• 24/7 patient access to the practice

Advanced Planning are new codes (99497-99498) – but are not covered by Medicare.


The additional Medicaid payments made by the state/federal governments for 2013 & 2014 have not been renewed so far in New Jersey so we do not expect that money in 2015.  The federal government paid all costs for 2013 & 2014 New Jersey so far as not agreed to make those payments going forward. 


As most, if not all, of our physician providers know, modifier 59 is required to be paid for many valid, separate and distinct services.  However, per CMS Transmittal #1422 (dated 8/15/14) CMS states “It is also associated with considerable abuse and high levels of manual audit activity, leading to reviews, appeals and even civil fraud and abuse cases.”  The effective date is January 1, 2015. 

As a result, CMS has defined four new HCPCS modifiers to selectively identify subsets of Distinct Procedural Services (-59 modifier) as follows:

  • 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
  • XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service

“These modifiers, collectively referred to as -X{EPSU} modifiers, define specific subsets of the -59 modifier. CMS will not stop recognizing the -59 modifier but notes that CPT instructions state that the -59 modifier should not be used when a more descriptive modifier is available. CMS will continue to recognize the -59 modifier in many instances but may selectively require a more specific - X{EPSU} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI PTP code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other -X{EPSU} modifiers.”

CPB staff have been trained on the use of the 4 modifiers and we expect most of our PCP clients will continue to properly use only -59 (injections, vaccines, etc.).  However, it is possible that you may be asked to confirm which “X” modifier is correct if we or an insurer rejects -59. 


If you haven’t submitted your PQRS codes yet for 2014, failure to do so will result in a 2% decrease in Medicare payments in 2016.  You can still meet the requirements by Registry for encounters in 2014.  You will need to decide which Measures codes you qualify for and which you want to report on.  The short version of reporting requirements…20 patient encounters will need to be submitted of which 11 must be Medicare. To avoid the cuts, report 3 measures.  To get the incentive, report 9 measures.  If you still have not met the requirements, please contact Rich ASAP.


The Medicare Annual Deductible for 2015 remains at $147.  Just a reminder, due to deductibles for many insurances starting on January 1 each year, there is usually a cash flow slow-down until March or April.  Be sure to check patient insurance eligibility when the appointment is made to remind patients to bring their co-pays & deductibles.  We also strongly urge clients to collect part of the deductible on the day of service if a substantial amount of it has not been met.

2015 Client Newsletter Archive