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July 2011 Client Newsletter

Medicare routine services

Routine services such as a TB test are not covered by Medicare. In such cases, an Advanced Beneficiary Notice (ABN) is NOT required and payment can be collected on the date of service.

Medicare eRx & EHR Vendor Codes

Just a reminder, the eRx & EHR vendor codes for Medicare is required to be billed on the same claim as the E&M code it goes with. It cannot be billed later per Medicare rules. A few more points:
You cannot collect both the eRx program incentive and the EHR incentive.
You can be penalized under the eRx program and still receive the EHR incentive.
The only way to avoid the eRx penalty is to report the G8553 code a sufficient number of times within the time frame specified. Participating in the EHR program does NOT exempt you from this requirement.

Useful related websites:
Meaningful Use Attestation Calculator:
CMS Attestation Page:

Spring 2011 HHS OIG Semi-annual Report to Congress

This report was recently released and contained examples of hospitals, physicians, therapists, etc. who were found to have committed various types of healthcare fraud. Following are a few examples from the report:
· Pennsylvania—John Kristofic, a physician, was excluded for a minimum of 20 years based on his health care fraud conviction. Over a 5‐year period, Kristofic submitted false and fraudulent claims to Medicare, TRICARE, the Federal Employee Health Benefit (FEHB) program, and private insurers for treatment and services which were not rendered because Kristofic was not in the office or the patients were being treated by other physicians on the dates claimed. Kristofic was sentenced to 1 year and 1 day of incarceration and ordered to pay $1 million in restitution.”
· Florida—Orthopedic surgeon Steven J. Lancaster agreed to pay $101,000 to resolve his civil monetary penalty liability for allegedly soliciting kickbacks from a medical device manufacturer. The Government contends that Lancaster offered to leverage his product usage and ability to influence purchasing decisions through his position as Chief of Orthopedics at Baptist Medical Center Beaches Hospital in exchange for a personal services contract worth a guaranteed $40,000.

CMB’s Compliance Plan actively works to help prevent such issues for our clients when we become aware of any possible concerns.

Medicare EHR Incentive payments

In order to qualify for the full payment incentives of $44,000 over a 5-year period an EP's initial year of reporting must be 90 days in either 2011 or but no later than October 1, 2012.

The 90-day requirement is applicable in 2013 and beyond for the initial year of reporting; however the payment incentives are reduced after 2012. If an EP's initial reporting year is 2013 the EP may report on a 90-day period but s/he will only qualify for a maximum of $39,000 in payment incentives. If the initial reporting year is 2014, the payment incentives are reduced to $24,000. And in 2015 there are no more payment incentives and the payment penalties kick in at -1%.


Beginning June 1, 2011 the Department of Defense (DoD) is removing Social Security Numbers from all ID cards and replacing them with a new DoD Identification number and a DoD Benefits number.
We have been informed by our clearinghouse that these newly assigned numbers, however, will not work for Claim submission or Eligibility so continue to use the insured’s Social Security Numbers as the Member ID. If you are presented with one of these new cards, request the Insured’s Social Security Number for Claim Submission and Eligibility.

Centers for Medicare & Medicaid Services (CMS) BAnking change

On 6/17/11 CMS announced it “has converted its banking contracts with JP Morgan and U.S. Bank to Federal Acquisition Regulation (FAR) contracts. These banks serve all the Medicare contractors. Accordingly, CMS has instructed the banks to close all bank accounts and letters of credit associated with the old configuration and contracts.

Normally, Medicare checks are valid for a 12-month period after the payment date on the check and then they are automatically stale-dated, at which point they become void. CMS needed to close some of the old bank accounts prior to the end of the 12-month period due to contractual requirements. Some checks drawn on these old bank accounts may be presented for payment within the next two to three months, but will be returned and annotated “account closed.” If providers encounter this situation, they may contact the Provider Contact Center and have the checks reissued under a new appropriate account number. If the provider receives a fee for the check being returned as unpaid please bring that to the attention of the Provider Contact Center and they will address that issue as well for the provider.”

July 1, 2011

Medicare Preventive Services

There is some confusion about billing the 3 Wellness visit codes. Neither code has a co-pay or deductible so is particularly helpful during the first 3 months of the year when all Medicare patients must meet their annual deductible.

Medicare has recently prepared 2 guides (a copy of each has been enclosed) to assist with:
· What is required for each code, and
· When they can be billed.

The Initial Preventive Physical Examination (IPPE)
“In addition to the new AWV, Medicare also provides coverage for the Initial Preventive Physical Examination (IPPE), commonly known as the "Welcome to Medicare" Visit (WMV). Medicare has provided coverage for this exam since 2005; it is provided as a one-time service to newly-enrolled beneficiaries. The IPPE is an introduction to Medicare and covered benefits, with a focus on health promotion and disease detection. The IPPE must be performed within the first 12 months after the beneficiary’s effective date of their Medicare Part B coverage. It contains a number of components that focus on prevention, including a complete medical/social/family history, a focused physical examination (i.e. body mass index, blood pressure, visual acuity), an assessment of functional ability, and counseling.”

The Annual Wellness Visit (AWV) – New for 2011
“Under the Affordable Care Act, Medicare beneficiaries may now receive coverage for an Annual Wellness Visit (AWV), which is a yearly office visit that focuses on preventive health. During the AWV, healthcare providers will review a patient’s history and risk factors for diseases, ensure that the patient’s medication list is up to date, and provide personalized health advice and counseling. The first AWV also allows the provider to establish a written personalized prevention plan. This new benefit will provide an ongoing focus on prevention that can be adapted as a beneficiary’s health needs change over time.”

Effective for dates of service on or after January 1, 2011, Medicare will pay for an AWV (G0438 or G0439) for a beneficiary who is no longer within 12 months after the effective date of his or her first Medicare Part B coverage and who has not received either an IPPE (G0402) or an AWV providing PPPS within the past 12 months.
Medicare pays for only one first AWV (G0438) per beneficiary per lifetime, and pays for one subsequent AWV (G0439) per year thereafter.

When you bill the IPPE (G0402) and perform an EKG, you can also bill a G0403 if you also do the interpretation and report. If you only do the tracing with someone else doing the interpretation and report, use G0404. If you are doing the interpretation and report for another provider, then you can bill G0405. Let Rich know if you need these codes added to your charge form.

A patient comes to you during the first 12 months of their Medicare coverage (traditional Medicare, not Medicare Advantage) for a preventive visit. During the first 12 months you must use G0402 for the visit. If an EKG is also performed as noted above, you can bill G0403.
A patient comes to you beyond their 12 months of initial Medicare coverage for an Annual Wellness visit and who received an IPPE (G0402) visit during that time. As long as 12 months have passed since the IPPE, then you can bill the G0438.
A patient comes to you beyond their 12 months of initial Medicare coverage for an Annual Wellness visit and who did not receive an IPPE (G0402) visit during that time. The G0402 cannot be billed but as long as 12 months have passed since the IPPE, you can bill the G0438.
The subsequent Annual Wellness Visit code, G0439, can be billed 12 months after the G0438 was last billed. If you have a new patient be sure to ask whether he/she received previous IPPE or AWV services before attempting to bill

For all of the examples above, you can also treat a patient for non-preventive issues on the same date and bill the appropriate E&M code. “Medicare payment can be made for a significant, separately identifiable medically necessary E/M service (Current Procedural Terminology [CPT] codes 99201-99215) billed at the same visit as the AWV when billed with modifier -25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member.”

Be sure that your office notes clearly show both services as separate and distinct from the other and meet all the requirements for each code billed. On the charge form, be sure to indicate which diagnoses are linked to each code.

One last suggestion. We have had a number of patients who have called to ask about the Wellness charges. Medicare, as do most other insurers, has historically focused on illness and injury rather than prevention and wellness. It will help patients understand both the additional service you provided, as well as their billing, if you take a moment to explain the value of the wellness service to their health and longevity.

If you develop a severe case of insomnia and enjoy reading as “therapy,” here is the link to download the entire 298 pages of the Medicare Guide to Preventive Services:
2011 Client Newsletter Archive