NOA
rd
3
Party Update
2012
1
Resource For This Presentation

NOA 3rd Party Web Page found at
HTTP://
NEBRASKA.AOA.ORG/
PREBUILT/
NOA/
INDEX.HTM
http://nebraska.aoa.org/prebuilt/NOA/index.htm
2
3
4
5
NOA 3rd Party Educational Videos
http://nebraska.aoa.org/prebuilt/NOA/index_Page353.htm6
7
2012
rd
3
Party Update
HIPAA (Privacy, EDI, Security)
 CMS Incentive Programs (EHR, eRx, PQRS)
 CMS Quality Care – Pay For Performance
 Medicaid
 Coding
 Office Procedures
 BCBS

8
HIPAA Privacy Audits
For the first time, HIPAA Privacy audits are
coming.
 It is important that your staff annually
review your HIPAA Privacy Manual and
update personnel and other required
information.
 You should also review your HIPAA privacy
policies during staff meetings at least
twice a year.

9
HIPAA Privacy Audits

For the first time, HIPAA Privacy audits are
coming.
http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html
10
HIPAA Privacy Audits
http://nebraska.aoa.org/prebuilt/noa/HIPAA%20NOA%20Manual.PDF
11
HIPAA Privacy Audits
The OCR director reinforced that it is a
consumer’s legal right to obtain a copy of
their health information.
 Visit the OCR website to obtain a copy of
the memo and for videos, pamphlets,
frequently asked questions, etc.

http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html
12
HIPAA EDI
ICD-10
ICD-10 codes provide more specific data
to improve patient care & information
exchange
 ICD-10 used by rest of world for years.
 HHS has postponed the date by which
health care entities must comply with ICD10 until October 2014
 ICD-10 HHS education can be found at

http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD10/
13
HIPAA

HIPAA Security Reminder
– Action Required
 Manual
http://www.aoa.org/documents/AOA_HIPAA_Security_Regulation_Manual.pdf
14
2012
rd
3
Party Update
HIPAA (Privacy, EDI)
 CMS Incentive Programs (EHR, eRx, PQRS,

MOC)
CMS Quality Care – Pay For Performance
 Medicaid
 Coding
 Office Procedures
 BCBS

15
All CMS Incentives 2011-2019
http://nebraska.aoa.org/prebuilt/noa/2012-06-3RD-Party-Newsletter.pdf
16
EHR
CMS recommends that all eligible professionals
register as early as possible for EHR Incentive
Programs.
 If you do not resolve registration problems in
time, you will not be able to attest and could
potentially miss out on a payment year.

https://ehrincentives.cms.gov/hitech/login.action
17
EHR


2012 is the last year you can earn the maximum
incentive.
October 3rd is the Last Day for EPs to Begin their 90-Day
Reporting Period for 2012
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/CMS_eHR_Tip_Sheet.pdf
18
EHR

CMS has posted a series of new videos about
the Medicare EHR Incentive Programs to the
CMS YouTube channel
http://www.youtube.com/user/CMSHHSgov.

Make sure to visit the EHR Incentive Programs
website for the latest news and updates on the
EHR Incentive Programs.
http://www.cms.gov/EHRIncentivePrograms/
19
EHR

The CMS EHR Incentive Program listserv provides
timely information on program requirements and
changes in the EHR Incentive Programs at
https://www.cms.gov/EHRIncentivePrograms/65_CMS_EHR_Listserv.asp#opOfPage
20
EHR - Documentation
Do you take notes from a previous visit and
“clone” them into the current visit?
 If so, WPS reports that you may be the target of
the Office of the Inspector General (OIG).

21
EHR - Documentation
A “cloned” entry (e.g., HPI) can lead to an
erroneously high coding level, when a more
abbreviated HPI would have been appropriate for
the follow-up visit.
 Regardless, WPS computers are looking for
duplicate verbiage

– between one patient’s multiple visits
– between visits of multiple patients.
22
Meaningful Use Stage 2: Timeline



You start Stage 2 of Meaningful Use no sooner than 2014.
However, you must complete 2 years of Stage 1 before
starting Stage 2.
In 2014, everone (stage 1 or 2) demonstrates for 90 days.
23
Meaningful Use Stage 2: Objectives
CMS created Stage 1 vs. Stage 2 Comparison Tables to
help providers navigate the next Stage of meaningful
use.
 Providers will be able to see which measures are new,
which ones are changing, and which ones are being
removed.
 Example below…

Stage 1 Objective
Stage 1 Measure
Stage 2 Objective
Stage 2 Measure
Implement drug-drug and
drug-allergy interaction
checks
The EP has enabled this functionality
for the entire EHR reporting period
No longer a separate objective for Stage
2
This measure is incorporated into the Stage
2 Clinical Decision Support measure
Generate and transmit
permissible prescriptions
electronically (eRx)
More than 40% of all permissible
prescriptions written by the EP are
transmitted electronically using
certified EHR technology
Generate and transmit permissible
prescriptions electronically (eRx)
More than 50% of all permissible
prescriptions written by the EP are
compared to at least one drug formulary and
transmitted electronically using Certified
EHR Technology
24
Meaningful Use Stage 2: CQMs



Beginning in 2014, the reporting of clinical quality
measures (CQMs) will change for all providers, those
participating in Stage 1 or Stage 2.
All providers must report on CQMs to demonstrate
meaningful use.
All providers in their second year and beyond of
demonstrating meaningful use must electronically report
CQM data to CMS.
Provider
Before 2014
2014 and Beyond
EPs
Complete 6 out of 44 CQMs
3 core or 3 alternate core
3 menu
Selected CQMs must cover at least 3 of
the National Quality Strategy (NQS)
domains
Complete 9 out of 64 CQMs
Choose at least 1 measure in 3 NQS
domains
Recommended core CQMs include:
9 CQMs for the adult population
9 CQMs for the pediatric population
25
Prioritize NQS domains
http://www.cms.gov/EHRIncentivePrograms/Downloads/MU_Stage1_ReqSummary.pdf
26
http://www.cms.gov/EHRIncentivePrograms/Downloads/MU_Stage1_ReqSummary.pdf
27
http://www.cms.gov/EHRIncentivePrograms/Downloads/MU_Stage1_ReqSummary.pdf
28
Meaningful Use Stage 2
Not yet endorsed CQMs



GLC screening for adults
Closing the referral loop (letter to referrer)
Monitor for adverse drug event in chronic Rx med user
29
eRx
Optometrists can earn Medicare payment
bonuses for prescribing pharmaceuticals
electronically;
 However, they are NOT subject to Medicare
payment reductions for failure to e-prescribe
according to CMS.
 Watch Remittance Advice for erroneous negative
adjustments containing:

– LE
– Reason Code 237
– Remark Code N545
30
AOA: PQRS
Reporting Essentials:
1. Utilize on Medicare patients
2. Report with Quality Data Codes (QDCs) that
include CPT II and G codes
3. May report with paper-based CMS 1500 claims
4. May report with electronic 837-P claims
31
AOA: PQRS
5. Must report QDC codes on the same claim as a
CPT I code (charge as $0.01)
6. No penalty for more frequent reporting
7. AOA recommends submitting QDC for all
reportable cases
32
PQRS
Need to report on 3 PQRS measures 50% of the
time.
 No need to report on more than three – only
raises chances of failure to meet the 50%
threshold.
 Dr. Quack’s PQRS Traffic Sheet should help ease
your reporting.

33
http://nebraska.aoa.org/prebuilt/NOA/2011-12_3RD_Party_Newsletter.pdf
34
2012
rd
3
Party Update
HIPAA (Privacy, EDI)
 CMS Incentive Programs (EHR, eRx, PQRS)
 CMS Quality Care – Pay For Performance
 Medicaid
 Coding
 Office Procedures
 BCBS

35
QRUR:
Quality and Resource Use Reports
Medicare is moving to tie doctors’ pay to quality
and cost of care
 Value-based QRUR for MDs will begin in 2015,
probably based on performance in 2013.
 It will take effect for optometry in 2017, perhaps
based on performance in 2015.

36
QRUR:
Quality and Resource Use Reports
The formula Medicare ultimately designs to
judge and pay doctors could become a valuable
asset for private insurers
 It may be a tool that will be somewhat
bulletproof; physicians been part of the process
of development

37
CMS “Physician Compare”
Information currently on the website
includes:
 Provider names, addresses, phone
numbers, specialties, clinical training, and
genders;
 Whether provider write or speak
languages other than English;
http://www.medicare.gov/find-a-doctor/provider-search.aspx
38
CMS “Physician Compare”
Hospital affiliation
 Whether provider accepts the Medicareapproved amount as payment in full.
 Providers who participate in quality of patient
care programs…
– PQRS
– E-Rx

http://www.medicare.gov/find-a-doctor/provider-search.aspx
39
2012
rd
3
Party Update
HIPAA (Privacy, EDI)
 CMS Incentive Programs (EHR, eRx, PQRS)
 CMS Quality Care – Pay For Performance
 Medicaid
 Coding
 Office Procedures
 BCBS

40
Medicaid
There is now Coverage of Unborn Children of
Pregnant Women Not Otherwise Eligible for
Medicaid
 It is important to understand that this coverage
is for the unborn child, not the mother.
 Coverage of the mother is limited to only those
diagnoses that might have an effect on the
pregnancy or the unborn child.

41
Medicaid

Only 180 Days to File a Medicaid Claim Starting
in January 2013.

This is instead of the current 12 month time
limit.
42
Medicaid Medical Home

Nebraska Medicaid is doing a pilot project on the
Medicaid Medical Home concept a clinic in
Kearney, and in Lexington.
http://dhhs.ne.gov/medicaid/Pages/med_pilot_progress.aspx

Although the NE Medicaid medical home
physicians will not act as a true “gatekeeper”
(cannot limit access to providers), s/he will have
significant influence if a referral is needed for
eye care.
43
Medicaid Medical Home

Thus, ODs must establish and maintain close
relationships with PCPs to assure access to
patients under the medical home concept.

Providing updates to the PCP via
correspondence, copies of consultations, reports
and test print-outs, plus necessary phone
conversations, are ways to develop such
relationships.
44
Medicaid Patients Rate Doctors

A New Provider Rating and Review System
(PRRS) Website has been launched, which
allows consumers to monitor and evaluate the
quality of provider services.

Although the ratings may not directly affect
optometry at this time, they will likely include all
types of providers in the future.

The link to the Nebraska Medicaid Provider
Rating and Review System is available at
https://prrs.ne.gov/ Scroll to the bottom of the page.
45
Medicaid now using…
National Correct Coding Initiative

The National Correct Coding Initiative (NCCI)
(also known as CCI) was implemented by CMS
to control improper coding.

NCCI code pair edits are automated prepayment
edits used when certain codes are submitted
together for Part B-covered services.

You can find the NCCI edits for physicians, codes
90000-99999, in zip files at
https://www.cms.gov/NationalCorrectCodInitEd/NCCIEP/list.asp?intNu
mPerPage=all&submit=Go
46
Medicaid now using…
National Correct Coding Initiative
NCCI edit examples:

Prevents payment for 92083 (fields) with 99211
(level 1 established E&M encounter)

Prevents payment for 92004 with 92002
(mutually exclusive exam codes)

Prevents payment for 92082 with 92083
(mutually exclusive fields codes)
47
National Correct Coding Initiative
Resources

“How to Use the Searchable Medicare Physician
Fee Schedule MLN Booklet”
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/How-to-MPFS-Booklet-ICN901344.pdf

“How to Use the Medicare Coverage Database”
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/MedicareCvrgeDatabase_ICN901346.pdf

“How to Use the National Correct Coding
Initiative (NCCI) Tools“
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf
48
Medicaid: Medically Unlikely Edits

In addition to code pair edits, the NCCI includes
a set of edits known as Medically Unlikely Edits
(MUEs).

An MUE is a maximum number of Units of
Service (UOS) allowable under most
circumstances for a single HCPCS/CPT code
billed by a provider on a date of service for a
single beneficiary.
49
Medically Unlikely Edits

Examples of MUE maximum number of
units:
92081
92082
92083
92100
92132
92133
92134
1
1
1
1
1
1
1
If NCCI or MUE would
deny a code on a claim,
the provider cannot
utilize an Advance
Beneficiary Notice
(ABN) to seek payment
from a Medicare patient.
50
2012
rd
3
Party Update
HIPAA (Privacy, EDI)
 CMS Incentive Programs (EHR, eRx, PQRS)
 CMS Quality Care – Pay For Performance
 Medicaid
 Coding
 Office Procedures
 BCBS

51
Coding: Medicare Coverage

Medicare Now Covers Visual Evoked Potential
code 95930. It was published on the WPS
Optometry LCD on March 1st, 2012, and will be
effective retroactively to April 1st, 2011.

Medicare Now Covers Tear Osmolarity Testing,
CPT 83861, Effective 5/1/12.
52
Coding: CPT on Therapeutic CLs

CPT has created two new special
ophthalmological codes for services for reporting
the use of therapeutic contact lenses:
– 92071 – fitting of contact lens for treatment
of ocular surface disease
– 92072 – fitting of contact lens for
management of keratoconus, initial fitting.

53
Coding: CPT on Therapeutic CLs

These new codes replace the 92070, "Fitting of
contact lens for the treatment of disease,
including supply of lens"

Both 92071 and 92072 are considered 'per lens‘
by CPT reported with RT or LT modifier to
indicate which eye (WPS ‘bilateral’)

Neither code includes the supply of the contact
lens.
54
Coding: CPT on Therapeutic CLs
Reimbursement for the CLs has been problematic…..

3rd Parties do not pay for 99070 (supply of
materials)

Some 3rd parties are paying for V-codes

Medicare B does not pay for CL V-codes

Medicare DME does not pay for CLs except for
aphakia.

Other 3rd Parties are as confused as Medicare.
55
Coding: Medicare & Keratoconus CLs

The WPS Communiqué, our Medicare carrier’s quarterly
newsletter, announced that CPT 92072, the fitting of
contact lenses for keratoconus, is now considered
inherently bilateral.

Therefore, reimbursement is for both eyes being fitted,
and the use of a 50 modifier, or an RTLT modifier, is
inappropriate.

If only one eye is fitted, then modifier 52 is called for,
and the fitting fee should be adjusted down accordingly.

(A 52 modifier is appropriate whenever a bilateral
procedure is performed on only one eye. Fee should be
adjusted accordingly.)
56
Coding: Glaucoma Severity
Glaucoma codes 365.10-365.65 must be reported
with new codes 365.70-365.74 to provide
information regarding the stage of the disease.

365.70 Unspecified

365.71 Mild Stage*

365.72 Moderate Stage*

365.73 Severe Stage*

365.74 Indeterminate
*specific definitions in CPT-2012
57
WPS: New Low Vision LCD

From 2012 Winter Communique
http://www.wpsmedicare.com/j5macpartb/publications/communique
/archived/_files/2012-winter-cq.pdf

Low Vision Services LCD
http://www.wpsmedicare.com/j5macpartb/policy/active/local/l32007
_ophth026.shtml

Low Vision Services Billing and Coding
instructions http://www.cms.gov/medicare-coverage-
database/lcd_attachments/32007_1/120811_00153_L32007_OPHTH
026_CBG_010112.pdf
58
NOC Code Requirements
(not otherwise classified)

The HIPAA Version 5010 implementation guide
describes Non-Specific Procedure Codes as
codes that may include, in their descriptor, terms
such as:
Not Otherwise Classified (NOC);
Unlisted;
Unspecified;
Unclassified;
Other;
Miscellaneous;
Prescription Drug Generic; or
Prescription Drug, Brand
Name”.
More……….
59
NOC Code Requirements

If a procedure code containing any of these
descriptor terms is billed, a corresponding
description of that procedure is required;

Otherwise, the claim is not HIPAA compliant,
and thus cannot be reimbursed.
60
Electronic Claim Narratives
When narratives are submitted on electronic claims
to provide additional information related to the
service line,
 they should be entered at the line level, the
2400 loop in the NTE segment (not the 2400
loop, SV101-7 segment.)
 There is a limit of 80 characters.
 Claims that require a narrative will be denied as
a return/reject if the narrative is not listed in this
segment.
61
2012
rd
3
Party Update
HIPAA (Privacy, EDI)
 CMS Incentive Programs (EHR, eRx, PQRS)
 CMS Quality Care – Pay For Performance
 Medicaid
 Coding
 Office Procedures
 BCBS

62
Documentation

WPS Medicare audits have noticed the provider
failed to document a face-to-face encounter with
the patient.

A face-to-face encounter with the patient must
occur and be documented in the medical record
in order to bill an E/M service.

Upon medical review, Medicare will reduce or
deny these services if there is no documentation
for a face-to-face service.
63
From the AOA: Cash Discount?

You must charge all patients your usual and
customary fees, including private pay patients.

The FTC indicates that it analyzes how much
overhead is really being saved. If savings are
unrealistic, the discount is phony.

The FTC has generally indicated that it views
any routine discount in excess of 25% not a
genuine discount, but a reflection of the true
price.
64
From the AOA: Cash Discount?

The Federal Trade Commission engages in
elaborate and highly sophisticated analysis to
assess such situations.

It should be noted that waivers of insurance copayments or out-of-plan charges is almost
always viewed as fraud.
65
ABN must be dated 3/2011
The latest version of the ABN (with the release
date of 3/2011 printed in the lower left hand
corner) is now available for immediate use and
can be accessed via the link below.
 All ABNs with the release date of 3/2008 that
are issued on or after January 1, 2012 will be
considered invalid.

http://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html
66
Do Not Email PHI

You should never include any protected health
care information (PHI), such as a beneficiary
Medicare number, in an e-mail sent to WPS
Medicare.

You can submit this information safely through
CSNAP's secure messaging feature.

You can sign up for C-SNAP at
https://www.medicareinfo.com/apps/cms/home.do.
67
PECOS Upgrade
Provider Enrollment, Chain, and Ownership System
Providers and staff using internet-based PECOS
will now see the following improvements:

Electronic Signature – You now have the ability

Access to More Information – Now you can see

Multiple Views of Your Information – Switch

Learn more about PECOS at
to digitally sign and certify the application.
if a request for revalidation has been sent by
your MAC.
between Topic View and Fast Track View
https://PECOS.CMS.hhs.gov
68
Medicare GLC Screenings

Medicare provides coverage of an annual
glaucoma screening GO-117 for beneficiaries in
at least one of the following high-risk groups:
–
–
–
–
Individuals with diabetes mellitus
Individuals with a family history of glaucoma
African-Americans age 50 and older
Hispanic-Americans age 65 and older
The diagnosis code is V80.1
 Payment in Nebraska: $47.65 for G0117

69
Medicare GLC Screenings
The patient’s appointment should have been
made for a glaucoma screening. A glaucoma
screening cannot be billed in addition to another
examination code.
 Medicare’s coverage of glaucoma screening
includes

– a dilated eye examination
– an intraocular pressure (IOP) measurement and
– a direct ophthalmoscopy examination or a slit-lamp
biomicroscopic examination.
70
Medicare Billing Certificate

CMS has launched new Medicare Billing
Certificate Programs for Part B providers.

To participate in the program, visit
http://www.CMS.gov/MLNproducts and select the "WebBased Training Modules" link under the heading
"Related Links Inside CMS."

This education includes required web-based
training courses and readings and a list of
helpful resources.

Upon successful completion of this Program you
will receive a CMS certificate in Medicare billing.
71
AOA: Medicare Audits
Additional Medicare medical pre-payment
reviews may be coming to our area soon.
 A prepayment reviewed claim will not be
processed until the physician responds to
the request to send records to the carrier.
 The 13 services announced are:

CPT
CPT
CPT
CPT
code
code
code
code
92235
92004
92014
92012
CPT
CPT
CPT
CPT
CPT
code
code
code
code
code
92083
92250
92002
92226
92225
CPT
CPT
CPT
CPT
code
code
code
code
92020
92285
76514
92015
72
AOA: OIG Compliance Program

The Office of the Inspector General’s Voluntary
Program for Medical Records Compliance can be
very helpful in lessening concerns about audits
by Medicare or other insurers.
Source: AOA News
http://viewer.zmags.com/publication/ed02913d#/ed02913d/34
73
Requests for Record Review

For practice utilizes an electronic health record,
verify all portions of the medical record are
visible prior to printing and submitting the
components to Medicare, e.g.,
– physician orders,
– physician signature,
– test results, etc.

This can avoid the need for additional requests
or claim denials for the missing documentation.
74
Medicare Re-enrollment
Through 03/23/15, WPS and Noridian will send
out notices on a regular basis to begin the
revalidation process for each provider and
supplier.
 There are recent upgrades to PECOS; Once
signed up, it makes your interactions with
Medicare much simpler. http://www.cms.gov/Medicare/Provider
Enrollment-and-Certification/MedicareProviderSupEnroll/InternetbasedPECOS.html

A copy of your IRS form CP 575 may be required
by the Medicare contractor to verify the provider
or supplier’s legal business name and EIN.
75
Manditory Education Resources

You are legally responsible for knowing
the information disseminated in the WPS
E-news listserv.
https://corpws.wpsic.com/apps/commercial/unauth/medicareListservUserWelco
meLoadAction.do

You are legally responsible for knowing
the information disseminated in the
Noridian E-news listserv.
https://naslists.noridian.com/list/subscribe.html?mContainer=2&mOwn
er=G30392x2n39372t36
76
2012
rd
3
Party Update
HIPAA (Privacy, EDI)
 CMS Incentive Programs (EHR, eRx, PQRS)
 CMS Quality Care – Pay For Performance
 Medicaid
 Coding
 Office Procedures
 BCBS

77
BCBS

Nebraska BCBS providers recently received
correspondence from BCBS and Davis
Vision announcing that, beginning in 2013,
routine vision services through Davis
Vision will be made available to Blue Cross
and Blue Shield of Nebraska.
78
BCBS
It is our understanding that
 Becoming a Davis provider is encouraged but
not required by BCBS
 Davis Vision has its own ophthalmic laboratories
for use by its providers, and
 Davis supplies a large display of Davis Vision
frames.
 As stated repeatedly in the past, Dr. Quack
recommends completely understanding any
provider agreement prior to enrolling with a 3rd
party
79
Coding: BCBS 50 Modifier
As a reminder, BCBSNE requires two line charges
when reporting bilateral surgery.
 The first side should be submitted unmodified
and with a charge for the first side.
 The second side should be submitted with
modifier -50 and a charge for the second line.
80
Resource For This Presentation

NOA 3rd Party Web Page found at
HTTP://
NEBRASKA.AOA.ORG/
PREBUILT/
NOA/
INDEX.HTM
http://nebraska.aoa.org/prebuilt/NOA/index.htm
81
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NOA 3rd Party Update 2012