Consultation codes
With the deletion of consultation codes (99241-99245 and 99251-99255) from the Medicare fee schedule, many questions have arisen. National Government Services (NGS) has hosted seven teleconference calls on this topic. To have your questions answered, watch for a question and answer page on the NGS Web site. 

Also, print a copy of MLN Matters Article MM6740 here.

This article will answer many of your questions regarding consultations, including questions about the AI modifier, which should be used on a claim by the principal physician of record. However, note AI is the alpha I, not the numeric number one. 

Rules for evaluation and management services have not changed and, as always, medical necessity is the driving force. On Jan. 19, the AMA Advocacy update indicated the physician organization had urged the Centers for Medicare & Medicaid Services (CMS) to delay implementation of its new consultation policy; however, CMS moved forward to implement the Medicare physician fee schedule.

The AMA is requesting CMS officials clarify the consultation policy and educate physicians. CMS assured the AMA it would release some additional materials in the near future.  

Continue to monitor the CMS and NGS Web sites. NGS also will send out listservs on this matter. If you are not signed up for the listserv, do so promptly here; click on listserv under “News and Publications.”

Fee schedule
The fee schedule will remain as listed on the NGS Web site until March 1, 2010. Without congressional intervention, MGS then will post a new schedule that will include the 21.2 percent reduction of the conversion factor.  

Please note the fee schedule does include the 2010 RVU update and a technical correction to the malpractice RVUs, resulting in a conversion factor of 36.0846. This update also includes the increase on the inpatient and outpatient codes.

DME and DMEPOS claims
Note this update regarding expansion of the Current Scope of Editing for Ordering/Referring Providers for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) and suppliers’ claims processed by Durable Medical Equipment Medicare Administrative Contractors (DME MACs).

According to MedLearn Matters MM6421, the following rule takes effect for claims dated April 5 and after:  If the ordering/referring provider is not on the claim, the claim will not be paid. If the ordering/referring provider is on the claim, Medicare will verify that the ordering/referring provider is in PECOS and eligible to order and refer. If the ordering/referring provider is not in PECOS or is in PECOS but is not of the specialty to order or refer, the claim will be rejected, not paid.

Expansion editing by MACs
For claims dated April 5, 2010, and after, MedLearn Matters MM6417 indicates: If the billed item or service requires an ordering/referring provider and the ordering/referring provider is not on the claim, the claim will not be paid but rejected. If the ordering/referring provider is on the claim, Medicare will verify that the ordering/referring provider is in PECOS and eligible to order and refer.

If the ordering/referring provider is not in PECOS, the carrier or Part B Medicare administrative contractors (MACs) will search their claims systems for the ordering/referring provider. If the ordering/referring provider is not in PECOS or the claims system, the claim will be rejected and not paid. If the ordering/referring provider is in PECOS or the claims system – but is not of the specialty to order or refer – the claim will not be paid but rejected.

E-prescribing
When reporting for e-prescribing you will now use only code G8553.

An individual eligible professional who generates at least one e-prescription associated with a patient visit on 25 or more unique events during the reporting period will be eligible for incentive payment. Submit both a denominator CPT code and a numerator G-code.

Two visits, two doctors, one day
Here is how NGS pays for two visits on the same day to two different physicians, both in the same specialty, but different subspecialties:

Example one: The Medicare Carrier System (MCS) has the ability to look only at the primary specialty. If the primary specialty is cardiology and the subspecialty is electrophysiology, the MCS cannot pick up this difference during initial claim processing. Systemically, it appears two physicians of the same specialty performed the same service on the same day.

The claim can be appealed and NGS would typically reimburse during the appeal in this example if NGS finds that the second visit meets medical necessity.

Example two: Another example presents a completely different outcome with the primary specialty being oncology, and the subspecialties being hematology/oncology and gynecology/oncology. When two visits were billed for the same patient on the same day by this group, NGS allowed only one during the initial processing because the system viewed only the primary specialty.

When the claim was appealed, NGS affirmed the appeal at the first two levels because no medical necessity existed for the visit.

Update on spend-down
HP announced that as of Jan. 1, 2010, providers would see enhanced information for members enrolled under the spend-down provision. This enhanced information will be available to providers who verify member eligibility using the eligibility verification systems (EVS), including Web interChange, Omni, Automated Voice Response (AVR) and the HIPAA 271 transaction.

Bulletin BT200527 announced important changes resulting from automated spend-down processing. Physician practices can use the enhanced spend-down information for financial planning with members for payment of the spend-down. When a provider verifies eligibility for a member with a spend-down, EVS will display the dollar amount of the remaining spend-down obligation for the month.

Physicians may not collect the member’s spend-down obligation at the time of service, but may bill the patient for the amount credited after the claim adjudicates.

Consistent with current spend-down policy, a member’s obligation to pay the spend-down begins upon receipt of the Monthly Spend-down Summary Notice, sent on the second business day of the following month.

Pharmacy consolidation
The pharmacy consolidation project took effect for dates of service beginning Dec. 31, 2009. Prior to Dec. 31, 2009, the risked-based managed care organizations were responsible for providing pharmacy services to Indiana Medicaid members in their respective plan.

Pharmacy services and some drug-related supplies processed by Anthem, MDwise or Managed Health Services (MHS) are now processed by the fee-for service contractor, HP.

The consolidation includes:

• All pharmacy-dispensed drugs
• Certain procedure-coded drugs when dispensed by a pharmacy
• Certain medical supply codes (supplies necessary to use and/or administer a drug such as diabetic test strips, blood glucose meters and spacers, when dispensed by a Durable Medical Equipment Provider or pharmacy)

Effective Dec. 31, 2009, the Affiliated Computer Services (ACS) Clinical Call Center and the HP Pharmacy Services Point of Sale Help Desk expanded their hours. For ACS, times are Monday through Friday 8 a.m. to 8 p.m. Expanded hours for HP Pharmacy Services Help Desk are Monday through Friday 8 a.m. to 8 p.m. and Saturdays 10 a.m. to 6 p.m. For prior authorization, continue to contact ACS.

New Right Choices Program
For 2010 the Restricted Card Program name changed to the Right Choices Program (RCP). Additional changes for 2010 include:

• The RCP philosophy shifts from punitive to interventional with intensive member education and case management. 
• Traditional Medicaid RCP members start receiving this service, which should translate into more effective management by the primary medical provider. 
• Hoosier Healthwise and Care Select RCP members will receive more extensive education and case management than the baseline delivery. 
• RCP members no longer have their term length in the program predetermined at enrollment. Instead, specific behavior modification and utilization management parameters are evaluated, beginning at two years and in subsequent years to graduate from the program.

The RCP is administered by the health plans within Hoosier Healthwise, Care Select and Healthy Indiana Plan (HIP), as well as ADVANTAGE for Traditional Medicaid, using uniform criteria and policies established by the state.

Referrals are required for professional services rendered by prescribers who provide “self-referral” services (behavioral health, dental, family planning, podiatry, vision and emergency services). Providers will receive a notification letter when they are selected to participate on the member’s team of experts. Information regarding the member’s authorized providers will be available via Web interChange, Omni and AVR.

Reimbursement update
The Indiana Health Coverage Programs (IHCP) has established reimbursement percentages for manually priced codes within certain procedure code ranges. BT200940, dated Nov. 17, 2009, provides specific code ranges that did not have pricing available from the Centers for Medicare & Medicaid Services (CMS) at the time the procedure codes were created.

The percent of reimbursement established for the manually priced codes that reside within each CPT code range is aligned with the average percentage of billed charges reimbursed for codes with established rates within the same code range. Find pricing for codes that do have pricing on file on the IHCP Web site under the fee schedule link.

PA and other enhancements
The Office of Medicaid Policy and Planning (OMPP) has enhanced the prior authorization (PA) decision letters and the Indiana Medicaid Notice of Appeal Rights for Care Select and Traditional Medicaid members. (Does not apply to pharmacy PA.) Now you will notice the language in the letters is more reader friendly and the message is clearer.
Enhancements include:

• The PA decision letter has a prior authorization toll-free telephone number and a table with definitions for service terms used throughout the PA decision letters. 
• The Notice of Appeal Rights accompanying the PA decision letter is tailored to the member and provider in frequently asked questions (FAQs) format.
• Members have access to an appeals form for PA decisions available here.   
• The Notice of Appeal Rights is now available in Spanish here or by contacting HP Member Services at (317) 713-9627 or 1-800-457-4584, Option 2 for Spanish. Even when a PA is granted, providers are always encouraged to verify the member’s eligibility before rendering services. Continue to check PA status via Web interChange.

Mental health and other changes
The Sterilization Consent form currently on the IHCP Web site expired Nov. 30, 2009. CMS has approved this until a banner page is published for the provider community.

Effective Jan. 1, 2010, for dates of service on or after that date, the IHCP is reimbursing for mental health services, including Psychiatric Residential Treatment Facility and Medicaid Rehabilitation Option under the Children’s Health Insurance Plan (CHIP) or Package C. This change comes as a result of Senate Enrolled Act 102.

Prior authorization (PA) is required for any codes currently requiring PA for fee-for-service members, and you may submit claims for services rendered on or after Jan. 1, 2010.

Information and outreach
Chris Kern, Provider Relations manager, MDwise, Inc, announced that Outreach Services of Indiana, a partner with Indiana’s Family and Social Services Administration (FSSA) and the Division of Disability and Rehabilitation Services, offers free guidance and information to those who care for people with intellectual and developmental disabilities. These consultative and technical services assist consumers, families and providers in accessing best practices in disciplines including primary care, dental, rehabilitation, durable/home medical equipment, therapy, nursing and more to enhance and supplement existing community resources available to this population.

These services are necessary so special needs individuals whose residences are often in the community can access quality health care in a manner that improves their lives and is consistent with other consumers.

Consultation and technical services are available in a variety of formats including in-person training and train-the-trainer events, Web-based fact sheets and information guides, or via telephone. Examples of training topics include Introduction to Intellectual and Developmental Disabilities, Behavior Support Plan Preparation, and Managing Medical Appointments.

All providers are invited to learn more about the consultative and technical services offered by Outreach Services of Indiana. Providers can also contact Outreach via phone at 1-866-429-5290 or by e-mail.