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April 2013 Client Newsletter


Now that sequestration has taken effect, unless Congress & the President can get their collective acts together, Medicare payments will be cut by 2% for dates of service April 1 and after.  So, what does that mean financially? 

The reduction applies to the amount Medicare will actually pay to the provider - AFTER - the appropriate deductible or copayment has been calculated. So, if the allowable is $100.00, the co-payment is 20% or $20.  Medicare's payment was - pre-sequestration supposed to be $80.00 (80% of the allowable).

NOW, post-sequestration, the $80.00 will be reduced by 2% ($1.60). So instead of the Medicare payment being $80.00, it will be $78.40. Unfortunately, providers are not authorized to collect the sequester related reduction from the patient.  The patient will still owe the full $20.00 (20%) co-insurance amount.  If the pt has no 2' insurance, it can be collected during the office visit. 

If anyone needs to know the monthly average amount of Medicare payments or has any questions, contact Rich.  Lots of partisan politics going on for the benefit of some BIG congressional egos.


Be sure to watch for a letter from Medicare requiring you to revalidate your information with them. You have a very limited time period to do this. Failure to do so results in de-activation of your provider # - and a stoppage of all payments - until the revalidation has been completed.


As you may know, Medicare providers who do not achieve 90 days of Meaningful Use by 12/31/2013 will lose $15,000 in Medicare EHR Incentive Funds. This means you need to START using your EHR no later than 10/1/2013. Allowing 6-8 weeks to implement and train, you need to purchase by July. Plus, it is expected many others will delay getting started also, thereby creating a backlog. CPB can offer some suggested vendors.

Transitional care management codes 99495 & 99496

So far, only Medicare & Horizon will pay. Aetna does not. Horizon & Medicare are allowing the same amount: 99495 = $176.73 & 99496 = $249.06.
Only one physician may bill Medicare for the TCM for any one patient's discharge from the hospital, and the physician must wait until 30 days after the discharge to bill for the service. The first physician who submits a claim will be paid. 

Can we bill any services during the 30-day post discharge period? Yes. Second and subsequent E/M services after the initial bundled E/M service may be reported. Other diagnostic or therapeutic services may be billed.

Anything else we can't report with these codes? Yes. Some of the codes that may not be billed with the TCM codes during the time period covered by the TCM codes (29 days post discharge), are:

- Care Plan Oversight (99339, 99340, 99474-99380)

- Prolonged services without patient contact (99358, 99359) (with patient contact is allowed)

- Anticoagulant management (99363, 99364)

- End stage renal disease services (90951-90970)


Effective May 1, 2013, the long delay in requiring only currently validated providers to be able to refer will end. On that date, if your referring provider is not in PECOS or in the carrier's system, you will not be paid for any services (Radiology, Lab, etc.) or equipment, that were referred to you.

Medicare & ICD-10

Good news, sort of. On January 18, 2013 CMS instructed its contractors to start the process to update CPT code National Coverage Determinations to ICD-10 codes (now ICD-9). Medicare uses that list to determine medical necessity for many CPT & HCPCS payments.


Just a reminder that Medicare is requiring providers to participate in the PQRS program to avoid a loss of Medicare payments. If you need assistance with that, please let me know ASAP as the measures require more participation than in past years.

Medicare AnnuAl wellness visits required documentation

If you need to know what Medicare requires to be documented for each of the 3 AWV codes, you can use this link:
2013 Client Newsletter Archive