Wednesday, January 26, 2011

Other Medicare Changes under the Affordable Care Act (ACA)

In addition to the Annual Wellness Visit (AWV) with Personalized Prevention Plan Services (PPPS), the ACA makes several additional changes in Fee-for-Service (FFS) Medicare.  These changes were published in the Nov. 29, 2010 Federal Register: Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2011. 

Maximum Period For Submission Of Medicare Claims Reduced To Not More Than 12 Months The Affordable Care Act reduced the maximum time period for submission of Medicare fee-for-service claims to one calendar year after the date of service.  This change, which applies to services furnished after Jan. 1, 2010, reflects a reduction to the prior maximum timely filing deadline of 15 to 27 months.  The Affordable Care Act also mandated that providers and suppliers file claims for services furnished prior to Jan. 1, 2010 no later than December 31, 2010.  The final rule revises the timely filing regulations to reflect these new requirements.  It also establishes three new exceptions to the timely filing requirements for retroactive entitlement situations, dual-eligible beneficiary situations, and retroactive disenrollment from Medicare Advantage plans or PACE provider organizations.  NOTE: CMS has notified MA plans that they will be held to the same timely filing requirements for MA plan encounter data submitted to CMS for risk adjustment purposes.

Incentive Payments To Primary Care Practitioners For Primary Care Services:   The ACA provides incentive payments equal to 10 percent of a primary care practitioner's allowed charges for primary care services under Part B.  Under this policy,  primary care practitioners are:  (1) specialists whose primary  specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; as well as nurse practitioners, clinical nurse specialists, and physician assistants. In order to qualify, at least 60% of the provider's FFS Medicare allowed charges  for a prior period must be primary care services.  The law defines primary care services as limited to new and established patient office or other outpatient visits (CPT codes 99201 through 99215); nursing facility care visits, and domiciliary, rest home, or home care plan oversight services (CPT codes 99304 through 99340); and patient home visits (CPT codes 99341 through 99350).  

Physician Assistants Now Permitted To Order Post-Hospital Extended Care Services:  The Affordable Care Act newly authorizes physician assistants to perform the level of care certification that is one of the requirements for coverage under Medicare’s skilled nursing facility (SNF) benefit. 

Payment For Bone Density Tests The Affordable Care Act increases the payment for two dual-energy x-ray absorptiometry (DXA) CPT codes for measuring bone density for 2011. 

Payment Increase for Certified Nurse-Midwife Services:  The ACA increases the Medicare payment for certified nurse-midwife services from 65 percent of the physician fee schedule amount for the same service furnished by a physician to 100 percent of the physician fee schedule amount for the same service furnished by a physician.

Multiple Procedure Payment Reduction Policy for Therapy Services:  Although not part of the Affordable Care Act, to more appropriately recognize the efficiencies when combinations of therapy services are furnished together, CMS has adopted a  multiple procedure payment reduction policy for therapy services that will reduce by 25 percent the payment for the practice expense component of the second and subsequent therapy services furnished by a single provider to a beneficiary on a single date of service.  This policy will apply to all outpatient therapy services paid under Part B, including those furnished in office and facility settings.  This policy is similar to the multiple surgery reduction that has long been a part of Medicare payment rules.

Do you find these posts on FFS Medicare helpful? What other coding related topics would you find helpful?  Leave us a comment and let us know.

Friday, January 21, 2011

The Myth of Coding the "Rule Out" Diagnosis

We get a lot of questions in our "Ask A Coder" inbox,   There is no doubt that far and away, the most frequent question we get is some variation of "can I code all "rule-out" diagnoses for an inpatient"?

I've been coding a lot of years (about 25).  As a disclaimer, I have never been employed by a hospital as a coder --BUT--in my role at SCAN and other health plans, I've coded hundreds (maybe thousands) of inpatient charts. I can honestly tell you, the number of times I've coded a rule-out diagnosis can be counted on the fingers of both of my hands.  I'm sure that hospital coders have done so many more times than I have, but I'd bet they would tell you that this is not a common occurrence. 

Why isn't it?  Let's take a look at the Official Coding Guidelines themselves.  I've highlighted particularly important passages of the guideline.

H. Uncertain Diagnosis If the diagnosis documented at the time of discharge   is qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled out", or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.    This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.  

First, note that the condition is still probable, uncertain--i.e., not yet ruled out, then if the documentation indicates  at the time of discharge it is still a possible condition, then it is possible it can be coded.Second, you must have the entire hospital chart--why? Because you can't know if the treatment during the hospitalization was directed at that condition without it.

As to the related question of whether or not this can be used for the physician's record...the answer is NO.   Coding Clinic and the Official Guidelines indicate that physicians use the Outpatient coding guidelines, no matter what the place of service.

I hope this clarifies when coding a "rule-out" condition is acceptable.

What coding questions do you have?  Send them to us at  We'll do our best to answer within 72 hours. We de-identify questions of general interest and post them on under Ask A Coder.

Friday, January 7, 2011

CMS Announces Preparing for ICD-10 Implementation Call

Yesterday, CMS announced the next conference call in their series on ICD-10:  Preparing for ICD-10 Implementation in 2011.  The call will take place on Wednesday, January 12, 2011.  According to CMS, subject matter experts will review  information on the transition to ICD-10 and discuss implementation planning and preparation strategies for the current year   As with all of the industry calls, a question and answer period follows the presentation.

You must register no later than 1:00pm Eastern Time on January 11, 2011: Register For ICD-10 Implementation Call

Presentation materials for the January 12 call will be available Here in the downloads section no later than 24 hours before the call.  You can also find information on the site regarding CEUs. Both AHIMA and AAPC members will earn 1 CEU for participation in the call.

According to the announcement, the agenda will be:

·         Planning for transition to ICD-10 –A call to action
·         Implementation for services provided on and after October 1, 2013—No grace periods or delays
·         Date of service implementation requirements
·         Tools for converting codes – 2011 General Equivalence Mappings (GEMs)
·         Partial freeze of ICD-9-CM and ICD-10 code updates, except for new technologies and diseases
·         Use of unspecified codes in both ICD-9-CM and ICD-10
·         Updating payment and coverage policies for ICD-10
·         Differences between ICD-9-CM and ICD-10
·         Internal planning groups and organizational strategies
·         Awareness, educational strategies and assessing training needs
·         Implementation plan development and impact assessment
·         Determining vendor readiness
·         Coding gap analysis—What needs to be done for your coding staff
·         Assessing quality of medical record documentation
·         Developing an ICD-10 budget
·         Consequences of poor preparation

Just a reminder--If you are unable to participate in the call, all of the CMS ICD-10 conference materials (slides, call MP3s, call transcripts) are posted on HCC University in the Tools section as soon as they become available.