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PREPARE YOUR PRACTICE
FOR THE CHANGES

  Torrey Kim, MA, CPC

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 Torrey Kim, MA, CPC
- Editor-in-C ief, Part B Insider
 en I·m not working on Part B Insider, I·m trying to
wrangle my t ree boys!
 Patient Protection and Affordable Care Act ²
r Signed Into Law Marc 23

Coding and billing staffers may feel like t e woman on t e rig t w en t ey t ink
about ow t e law mig t create systems confusion
 
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   at Is t e PPACA?
  How ill t e PPACA Impact Medicare?
   at Are t e Implementation Timelines?
   o is Responsible for Making C anges to
Your Systems?
   at Steps S ould You Take Now?
  Healt Care Reform Resources


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  T e Patient Protection and Affordable Care Act, also known as t e PPACA,

HR 3590, or simply t e ´ ealt care reform law,µ includes over 2,000
pages of ealt care-related provisions t at will take effect over t e neut
four years.

  Many of t e PPACA·s ot er provisions, suc as pre-euisting condition

coverage, ave received widespread media attention, but some practices
are still unclear of ow it impacts Medicare

  Today·s presentation will break down a few of t e most important factors

involving Medicare pay t at t e PPACA as in store
 
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  Every year ot er t an t e patient·s first year on Medicare, beneficiaries will
benefit from a ´ ealt risk assessment,µ not subject to t eir deductible or
coinsurance, w ic includes an euam of eig t, weig t, blood pressure, and
ot er routine measurements

  Based on t e results of t e ealt risk assessment, t e provider will:

ù Provide a screening sc edule for t e neut 5 to 10 years
ù Create a list of risk factors, counseling services, and referrals to ot er professionals
to provide interventions on suc issues as weig t loss, smoking cessation, nutrition, fall
prevention, and p ysical activity

  T e wellness visits will take effect as of Jan. 1, 2011

 
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  Effective Jan. 1, 2011, primary care practitioners ´s all be paid (on

a mont ly or quarterly basis) an amount equal to 10 percent of t e
payment amount for t e service,µ in addition to t eir normal fees
 
+$)`octors, nurse practitioners, clinical nurse specialists,
or p ysician assistants wit t e primary specialty designation of
family medicine, internal medicine, geriatric medicine, or pediatrics
qualify for t e bonus.
  |""T ese practitioners will ave to bill at least 60 percent of
t eir allowed c arges as ¶primary care services,· w ic are defined
by codes 99201-99215, 99304-99340, or 99341-99350.
 
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  In t e past, Part B providers ad 15 mont s or more to

submit t eir claims to Medicare, but t e new legislation
requires you to submit your claims ´one calendar year after
t e date of serviceµ for services provided on or after Jan.
1, 2010.

  ,T e legislation states t at ´t e Secretary may

specify euceptions to t e 1 calendar year period,µ but does
not yet indicate w at types of situations mig t qualify for
euceptions.
 
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  Major surgical procedures performed between Jan. 1, 2011 and `ec. 31,
2015 by a general surgeon in a ealt professional s ortage area will
qualify for a 10 percent bonus
  T e 10% payment will be disbursed ´on a mont ly or quarterly basisµ
  A general surgeon is defined as a doctor w o as designated specialty
code 02 (i    ) as t eir primary specialty
  ´Major surgical proceduresµ are t ose wit 10- or 90-day global periods
   -"Medicare will adjust your payment accordingly if you
provide services in a ZIP code t at falls wit in a pre-designated HPSA
county; owever, if you practice in a county not designated as an HPSA but
your town designated as one, you·ll ave to append modifier AQ
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  T e law eutends t e euceptions process for outpatient t erapy

caps, w ic means t at t ese t erapy providers may continue to
submit claims wit t e KX modifier (u 


  

 
 

 ) w en an euception is appropriate, for
services furnis ed between Jan. 1 and `ec. 31, 2010

  T e current outpatient t erapy cap is $1,860 for p ysical t erapy

and speec language pat ology services combined, and a
separate $1,860 limit for occupational t erapy services provided
in a calendar year.

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  Effective retroactive to Jan. 1, 2010, independent

labs can submit claims to Medicare for t e
tec nical component of p ysician pat ology
services furnis ed to ospital patients, w et er t e
patient was an inpatient or an outpatient
  Labs t at were previously denied for suc services
s ould contact t eir MACs ´for furt er instructions,µ
CMS advises.
 
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  T ree years ago, CMS reduced Part B payments for mental ealt
services during w at it called a ´Five Year Reviewµ period.
Congress gave mental ealt providers a 5 percent bonus payment
in 2008 to make up for t ese cuts, but t at eupired on `ec. 31,
2009. T e PPACA restores t e 5 percent bonus payment t roug
`ec. 31

  T e law makes t e 5 percent bonus retroactive to Jan. 1, 2010

 
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  T e following PQRI incentives/reductions are now applicable

t roug 2016 and beyond:

ù 2011: Incentive payment of a 1 percent bonus
ù 2012 t roug 2014: Incentive payment of a 0.5 percent bonus
ù 2015: Penalty of 1.5 percent
ù 2016 and beyond: Penalty of 2 percent

  T e PPACA calls for an informal appeals process to be in effect as

of Jan. 1, 2011 for providers ´to seek a review of t e
determination t at an eligible professional did not satisfactorily
submit data on quality measuresµ
 
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  If you receive an overpayment from Medicare, you must report and

return t e overpayment wit in 60 days after t e overpayment was

identified, or t e date any corresponding cost report is due
(w ic ever is later)
  You must notify t e secretary, state, intermediary, carrier, or
contractor in writing and inform t em of t e reason for t e
overpayment
ù ´Overpaymentµ refers to ´any funds t at a person receives or retains«to
w ic t e person, after applicable reconciliation, is not entitledµ
 
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  Effective Jan. 1, 2011, your claims must include an NPI (Sec. 6402)

  Any applicable manufacturer must submit a report on Marc 31,

2013 and on t e 90t day of eac calendar year t ereafter t at
includes information regarding ´transfers of valueµ t at t ey made
to covered recipients (including p ysicians). T ese include cas ,
items, services, consulting fees, gifts, entertainment, education,
travel, and ot er fees (Sec. 6002)
  T e PPACA eupands t e Recovery Audit Contractor (RAC) program

and rolls it out into Medicare Parts C and ` by t e end of 2010

(Sec. 6411)

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  0$T e ealt care reform bill included several pay boosts

t at were retroactive to Jan. 1.  en will t e fee sc edule
incorporate t ose retroactive c anges?

  #´T ere·s a compleu calculation of a variety of t ose

c anges t at we are going t roug to put t em toget er,µ said
CMS·s  *(during an April 13 CMS Open `oor Forum.
CMS must prepare before it incorporates t e pay boosts, w ic
could take ´a mont or two,µ s e said

  $Even after CMS releases t e new rates, ´e still ave our
Medicare contractors do eutensive tests on t ose to make sure t ey
are correct, so t at takes a little bit of time as well,µ said CMS·s
# # #on t e April 13 call.

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  (!If your practice c ronically submits claims

more t an one year after t e date of service, talk to
your billing department or outsource company about
ow to make claims processes more efficient

  #("))"Prepare to institute internal

systems t at will allow for annual wellness visits wit out
collecting deductibles or coinsurance, effective in 2011

  #"" #1*" If you don·t ave an NPI

yet, enroll via t e online NPPES system or using a paper
form
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  Be ready for questions from Medicare patients, w o

may eupect c anges to be in effect immediately
  Tig ten up your billing systems or talk to your billing
outsource companies to prepare for t e new 1-year
deadline for claims filing

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CMS staffers don·t even ave all of t e
answers yet, so you may not eit er.
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  You can read t e entire PPACA law (2,393 pages) at

www.opencongress.org/bill/111- 3590/s ow
  To determine w et er your area qualifies as a ealt
professional s ortage area, visit
www2.cms.gov/HPSAPSAP ysicianBonuses
  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 eb site at www.supercoder.com
  Email me any time at torreyk@in ealt care.com

T ank you!
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