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Medicare/Medicaid Coaltion Report
Medicare/Medicaid Coaltion Report
May 13, 2011 meeting
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Medicare Medicaid

Primary Care Incentive Payment
The Centers for Medicare & Medicaid Services (CMS) advised it is appropriate for a nurse practitioner, clinical nurse specialist or physician assistant to receive the 10 percent Primary Care Incentive Payment (PCIP). This bonus for non-physician practitioners does not take into consideration the specialty area in which the non-physician may be practicing.

Primary care services must account for at least 60 percent of allowed charges to qualify for the 10 percent PCIP. See MLN article MM7060 here.

“Incident to” job aid
Here are some key requirements and components to consider.

  1. Employed by the same entity – The person supervising and person performing the service must be employed by the same entity as the employee, leased employee or independent contractor.
  2. Only performed in office setting – “Incident to” service can be performed only in the office setting to qualify for Part B Medicare billing purposes. Enter POS 11 on the CMS 1500 form in item 24B or the electronic equivalent. Clinic refers to a physician owned and operated clinic, not a hospital or other facility-based clinic. The term clinic is sometimes used when several physicians of different specialties work together in a large office.
  3. The service must be integral although incidental – The physician must perform the initial service to establish the diagnosis and plan of treatment, which means the patient must be an established patient with an established diagnosis. To clarify, the follow-up services rendered must be connected to the course of treatment the physician planned at the initial visit. One of the keys to understanding “incident to” is relating services currently delivered to a previous service and tying the current care to that previous service. Incident to billing does not apply to a new patient or a new problem for an established patient.
  4. Active participation – It is expected a physician will perform subsequent services frequently enough to reflect active participation throughout the course of treatment for a specific problem. For example, a patient with chronic sinusitis will probably not need to be seen by the physician as often as a patient with congestive heart failure.
  5. Direct supervision – Incident to requires direct supervision, meaning a physician must be present in the office suite and immediately available and able to provide assistance or direction throughout the time a service is performed. The supervising physician does not need to be in the same room but must be in the office or clinic.
  6. Documentation – Documentation must also support the fact that the supervisor was present and available. The documentation submitted to support billing “incident to” services must clearly link the services of the NPP/auxiliary staff to the services of the supervising physician. Evidence may include:
    • Co-signature or legible identify and credentials (i.e., MD, DO, NP, PA, etc.) of both the practitioner who provided the service and the supervising physician on documentation entries
    • Documentation from other dates of service, such as an initial visit, establishing the link between the two providers

Make sure the name and professional designation of the person rendering the service is legible in the documentation for each service.

Signature guidelines
Find an excellent document for signature guidelines for medical review purposes on the CMS website.

See page 6 in this MM6698 article for a table detailing signature requirements.

Comprehensive Error Rate Testing
The national error rate for Comprehensive Error Rate Testing (CERT) for November 2010 was 10.5 percent; however, the president has directed the Medicare fee-for-service error rate be cut to 6.2 percent by 2012.

The National Government Services (NGS) internal data reflects:

  • Insufficient documentation - 16.76 percent
  • Most common error in the medical record - missing required legible signature
  • Services incorrectly coded - 5.23 percent

The most common errors on services incorrectly coded were evaluation and management codes because the medical record did not meet or exceed the key components required for the level of service submitted.

CERT audits are done on a random selection of claims that are reviewed. Any claim denied can be appealed. When you receive a CERT denial for any records omitted from the original request, you can fax them to the CERT documentation contractor at (240) 568-6222. Use the bar code letter as a cover sheet.

For questions regarding CERT, use the following contact numbers: Fax (800) 338-6101 and email Wellpoint.

Subsequent hospital visit
Use this example to assist with billing for subsequent hospital visit.

Dr. A admits patient to a hospital and asks Dr. B to evaluate the patient. Dr. B performs a major surgical procedure that then becomes the primary reason for the hospital stay. The major surgical procedure includes the hospital discharge day management.

If there is medical necessity for Dr. A to see the patient on the day of discharge, Dr. A would bill a subsequent hospital visit.


Katherine Wentworth, J.D., chief operating officer, and Laura Franklin, director of operations, attended the meeting. Wentworth addressed claims issues occurring since Jan.1, 2011. She advised that because of MDwise's business model, the process for changes in eligibility was more complicated than anticipated.

Wentworth said, “There was a brief issue where the history section of our Web portal (showing past enrollment segments) was not pulling data accurately, but this has now been corrected and validated, so our web portal should be a one-stop shop for all MDwise member enrollment queries.”

To check eligibility, go to the MDwise portal.

MDwise claims payers will conduct a mass reprocess of claims that were denied between Jan. 1 and March 31, 2011, due to eligibility issues. You need not resubmit paper claims denied during this period unless the claim was submitted to the wrong delivery system initially. If you submitted claims between the above dates that were rejected by a MDwise payer, please resubmit the claims to ensure processing.

If a provider determines through reviewing the myMDwise Provider Portal that prior authorization (PA) was obtained from the wrong MDwise delivery system, the provider should submit the PA number received as proof of good faith attempt to obtain PA.

Review the Provider Bulletin from MDwise.

To review an FAQs document from MDwise, see here.

Wentworth advised April claims should not be impacted by this issue; however, if you still have claims eligibility issues, contact your provider representative. If you need additional help, contact the ISMA's Gloria Kirkham.

Office of Medicaid Policy and Planning
Robin Kirby, Office of Medicaid Policy and Planning (OMPP) policy analyst, provided information on PERM or Payment Error Rate Measurement. CMS developed the PERM program to measure the accuracy of Medicaid and SCHIP enrollment, as well as payments for services rendered to recipients.

For the PERM audit during FFY 2011, the sample will be 500 fee-for-service claims, 125 claims per quarter. Also, 250 managed care claims will be examined for the year, totaling 62 or 63 per quarter. For more information, see IHCP bulletin BT201048 on the IHCP website.

Kim Forrest, OMPP Surveillance and Utilization Review, and Jina Hughes, OMPP Program Integrity manager, advised they will provide clarification on some ACA requirements (in various sections) from CMS beginning with the Sept. 16 coalition meeting.

Mona Green, Provider Relations consultant, announced Clear Claim Connection, a Web-based solution that enables HP and the OMPP to share claim auditing rules with providers. This includes National Correct Coding Initiative (NCCI) editing.

Providers will have access to Clear Claim Connection (C3) through a new menu option on Web interChange. The tool can be used to perform claim analysis prior to submitting a claim for processing. Web interChange users must have access to Claim Submission to use Clear Claim Connection Reductions. To view this website go here.

Green announced reductions and program changes, including a 5 percent rate cut (non-facility only) to laboratory and radiology. This does not apply to services in hospitals.

Eye care and eyewear are reduced by 5 percent. The rate reduction applies to services provided by optometrists and opticians, not to services provided by ophthalmologists.

The Family and Social Services Administration (FSSA) decreased rates paid to nursing facilities by 5 percent. The reduction is in the per diem cost before patient cost-sharing.

The 5 percent reduction for inpatient and outpatient hospital services has been extended until June 30, 2013.

Prescription drugs are limited to seven or nine fills per month; only four brands are allowed.

All members will be limited to a maximum of 10 prescriptions per month for the first three months. After three months, the maximum drops to seven prescriptions per month – with exceptions for certain conditions – with a maximum of nine per month.

FSSA will use existing pharmacy prior authorization (PA) rules to manage mental health drugs for members. Changes in legislation would subject mental health prescriptions to PA and allow the state to place drugs on a non-preferred list and collect supplemental rebates. This applies to all age groups; criteria and rules may differ. Affiliated Computer Services (ACS) will process all PAs. See this Bulletin.

Nancy Robinson, Regional Network manager, covered web enhancements to the MHS website. MHS included information on utilizing the website for eligibility verification, which can serve to complement Web interchange.

The MHS site will reflect primary medical provider (PMP) information as soon as selection is made. Other insurance information and Care Gap alerts for MHS members are also on the site. You can submit both professional and institutional claims and access Code Review, a claim audit tool similar to the one HP is rolling out. The tool assists with CCI edits and rationale behind denials.

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