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).
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.
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