Link to Slides at: www.scribd.com/doc/30938016/PPCA-Impact-on-Medicare-Pay The Health care reform law: how it affects your medicare payprepare your practice for the changes Torrey Kim, MA, CPC Editor-in-Chief Part B Insider firstname.lastname@example.org
Torrey Kim, MA, CPCEditor-in-Chief, Part B Insider When I’m not working on Part B Insider, I’m trying to wrangle my three boys!
Patient Protection and Affordable Care Act – Signed Into Law March 23 Coding and billing staffers may feel like the woman on the right when they think about how the law might create systems confusion
Agenda • What Is the PPACA? • How Will the PPACA Impact Medicare? • What Are the Implementation Timelines? • Who is Responsible for Making Changes to Your Systems? • What Steps Should You Take Now? • Health Care Reform Resources
What is the PPACA? • The Patient Protection and Affordable Care Act, also known as the PPACA, HR 3590, or simply the “health care reform law,” includes over 2,000 pages of health care-related provisions that will take effect over the next four years. • Many of the PPACA’s other provisions, such as pre-existing condition coverage, have received widespread media attention, but some practices are still unclear of how it impacts Medicare • Today’s presentation will break down a few of the most important factors involving Medicare pay that the PPACA has in store
How Will The PPACA Impact Medicare? Annual Wellness Visits (Sec. 4103) • Every year other than the patient’s first year on Medicare, beneficiaries will benefit from a “health risk assessment,” not subject to their deductible or coinsurance, which includes an exam of height, weight, blood pressure, and other routine measurements • Based on the results of the health risk assessment, the provider will: • Provide a screening schedule for the next 5 to 10 years • Create a list of risk factors, counseling services, and referrals to other professionals to provide interventions on such issues as weight loss, smoking cessation, nutrition, fall prevention, and physical activity • The wellness visits will take effect as of Jan. 1, 2011
How Will The PPACA Impact Medicare? 10% Bonus for Primary Care (Sec. 5501) • Effective Jan. 1, 2011, primary care practitioners “shall be paid (on a monthly or quarterly basis) an amount equal to 10 percent of the payment amount for the service,” in addition to their normal fees • Who qualifies? Doctors, nurse practitioners, clinical nurse specialists, or physician assistants with the primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatrics qualify for the bonus. • The catch: These practitioners will have to bill at least 60 percent of their allowed charges as ‘primary care services,’ which are defined by codes 99201-99215, 99304-99340, or 99341-99350.
How Will The PPACA Impact Medicare? You Have One Year to Submit Claims (Sec. 6404) • In the past, Part B providers had 15 months or more to submit their claims to Medicare, but the new legislation requires you to submit your claims “one calendar year after the date of service” for services provided on or after Jan. 1, 2010. • Caveat: The legislation states that “the Secretary may specify exceptions to the 1 calendar year period,” but does not yet indicate what types of situations might qualify for exceptions.
How Will The PPACA Impact Medicare? Health Professional Shortage Area (HPSA) Bonuses (Sec. 5501) • Major surgical procedures performed between Jan. 1, 2011 and Dec. 31, 2015 by a general surgeon in a health professional shortage area will qualify for a 10 percent bonus • The 10% payment will be disbursed “on a monthly or quarterly basis” • A general surgeon is defined as a doctor who has designated specialty code 02 (General surgery) as their primary specialty • “Major surgical procedures” are those with 10- or 90-day global periods • HPSA basics: Medicare will adjust your payment accordingly if you provide services in a ZIP code that falls within a pre-designated HPSA county; however, if you practice in a county not designated as an HPSA but your town is designated as one, you’ll have to append modifier AQ (Services provided in an HPSA) to your claims
How Will The PPACA Impact Medicare? Outpatient Therapy Cap Exceptions Extension (Sec. 3103) • The law extends the exceptions process for outpatient therapy caps, which means that these therapy providers may continue to submit claims with the KX modifier (Specific required documentation on file) when an exception is appropriate, for services furnished between Jan. 1 and Dec. 31, 2010 • The current outpatient therapy cap is $1,860 for physical therapy and speech language pathology services combined, and a separate $1,860 limit for occupational therapy services provided in a calendar year.
How Will The PPACA Impact Medicare? Labs Can Bill TC for Hospital Patients (Sec. 3104) • Effective retroactive to Jan. 1, 2010, independent labs can submit claims to Medicare for the technical component of physician pathology services furnished to hospital patients, whether the patient was an inpatient or an outpatient • Labs that were previously denied for such services should contact their MACs “for further instructions,” CMS advises.
How Will The PPACA Impact Medicare? Extension of 5% Mental Health Bonus (Sec. 3107) • Three years ago, CMS reduced Part B payments for mental health services during what it called a “Five Year Review” period. Congress gave mental health providers a 5 percent bonus payment in 2008 to make up for these cuts, but that expired on Dec. 31, 2009. The PPACA restores the 5 percent bonus payment through Dec. 31 • The law makes the 5 percent bonus retroactive to Jan. 1, 2010
How Will The PPACA Impact Medicare? PQRI Program Extended (Sec. 3002) • The following PQRI incentives/reductions are now applicable through 2016 and beyond: • 2011: Incentive payment of a 1 percent bonus • 2012 through 2014: Incentive payment of a 0.5 percent bonus • 2015: Penalty of 1.5 percent • 2016 and beyond: Penalty of 2 percent • The PPACA calls for an informal appeals process to be in effect as of Jan. 1, 2011 for providers “to seek a review of the determination that an eligible professional did not satisfactorily submit data on quality measures”
How Will The PPACA Impact Medicare? Timeliness of Refunding Overpayments (Sec. 6402) • If you receive an overpayment from Medicare, you must report and return the overpayment within 60 days after the overpayment was identified, or the date any corresponding cost report is due (whichever is later) • You must notify the secretary, state, intermediary, carrier, or contractor in writing and inform them of the reason for the overpayment • “Overpayment” refers to “any funds that a person receives or retains…to which the person, after applicable reconciliation, is not entitled”
How Will The PPACA Impact Medicare? Other Ways the Legislation Will Affect Medicare: • Effective Jan. 1, 2011, your claims must include an NPI (Sec. 6402) • Any applicable manufacturer must submit a report on March 31, 2013 and on the 90th day of each calendar year thereafter that includes information regarding “transfers of value” that they made to covered recipients (including physicians). These include cash, items, services, consulting fees, gifts, entertainment, education, travel, and other fees (Sec. 6002) • The PPACA expands the Recovery Audit Contractor (RAC) program and rolls it out into Medicare Parts C and D by the end of 2010 (Sec. 6411)
What Are the Implementation Timelines? • Question: The healthcare reform bill included several pay boosts that were retroactive to Jan. 1. When will the fee schedule incorporate those retroactive changes? • Answer: “There’s a complex calculation of a variety of those changes that we are going through to put them together,” said CMS’s Amy Bassano during an April 13 CMS Open Door Forum. CMS must prepare before it incorporates the pay boosts, which could take “a month or two,” she said • Plus: Even after CMS releases the new rates, “We still have our Medicare contractors do extensive tests on those to make sure they are correct, so that takes a little bit of time as well,” said CMS’s Stewart Streimer on the April 13 call.
Who Is Responsible for Making Changes to Your Systems? • Billing Dept: If your practice chronically submits claims more than one year after the date of service, talk to your billing department or outsource company about how to make claims processes more efficient • Front and Back Office: Prepare to institute internal systems that will allow for annual wellness visits without collecting deductibles or coinsurance, effective in 2011 • Practice Manager/Physicians:If you don’t have an NPI yet, enroll via the online NPPES system or using a paper form
Steps to Take Now • Be ready for questions from Medicare patients, who may expect changes to be in effect immediately • Tighten up your billing systems or talk to your billing outsource companies to prepare for the new 1-year deadline for claims filing KEEP IN MIND: CMS staffers don’t even have all of the answers yet, so you may not either.
Health Care Reform Resources • You can read the entire PPACA law (2,393 pages) at www.opencongress.org/bill/111-hh3590/show • To determine whether your area qualifies as a health professional shortage area, visit www2.cms.gov/HPSAPSAPhysicianBonuses • To obtain an NPI, visit www.cms.gov/NationalProvidentStand/03_apply.asp • Updates are continuing in Part B Insider and via our webinars, visit our Web site at www.supercoder.com • Email me any time at email@example.com Thank you!
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