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J a n u a r y 2 0 1 2

Important Updates/Changes for 2012

The Temporary Payroll Tax Cut Continuation Act of 2011 (TPTCCA) is the new law preventing a scheduled payment cut for physicians and other

practitioners who treat Medicare patients from taking effect immediately. The negative update for the 2012 Medicare Physician Fee Schedule is now scheduled to take effect on March 1, 2012.

CMS is currently developing the 2012 Medicare Physician Fee Schedule (MPFS) to implement the zero percent update.

As previously advised, Medicare claims administration contractors will be holding new January 2012 claims for up to 10 business days in order to effectively test and implement the new 2012 MPFS.

These claims are expected to be released into processing no later than January 18, 2012.

Claims with dates of service prior to January 1, 2012, are unaffected.

NEW!! ABN Mandatory Use Date: January 1, 2012 All ABNs with the

release date of March 2008 that are used after January 1, 2012, will be considered invalid. Here is the newest version of the ABN and the instructions on appropriate use.

CMS has indicated they will not levy any enforcement actions for the first 3 months of 2012 while HIPAA covered entities continue to

work towards compliance. The HIPAA 5010 compliance date was January 1, 2012. Medicare is planning to take the following steps:

Submitters/receivers that have tested and been approved for 5010/D.0 will be notified that they have 30 days to cutover to the 5010/D.0 versions.

Submitters/receivers that have not yet tested were notified in December 2011 that they must submit their transition plan and timeline to their MAC in 30 days.

MACs will notify the submitters/receivers; submitters/receivers have the responsibility to notify the providers they service.

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Payment Adjustments for Unsuccessful Electronic Prescribers Providers that were considered unsuccessful e-prescribers during January 1, 2011, to June 30, 2011, and didn’t submit a hardship exemption request on or before November 8, 2011, may be subject to a 1% payment reduction on their Medicare physician fee schedule payments starting on January 1, 2012. Remark code N545 will show on the remittance for claims affected by the adjustment.

CMS has indicated in the MLN Matters Special Edition article SE1126 that it

may be appropriate to delay provider enrollment revalidation process through 2015. However, this delay has not been formally

announced by CMS. If CMS were to delay the final compliance date of revalidation into 2015, the process will still continue. If you have received a revalidation notice from your contractor, you are still required to complete your enrollment forms through Internet-based PECOS or by completing the appropriate 855 application form. Read more

Remittance Changes for Part B Overpayments began January 1,

2012. Withholdings and overpayments shown on the remittance advice with PLB adjustment reason code “WO” and forwarding balances with PLB reason code “FB” will no longer have the beneficiary’s HICN on the remittance advice alongside the FCN. If your office submits claims with the Patient Account Number field completed, this field of the remittance advice will now contain the patient account number instead. If you do not submit claims with the patient account number field completed, this change will not affect you, and you will continue to see the HICN on your remittance advice. This change will only impact remittance advice and claims submitted in Version 5010A1and does not apply to standard paper remittance or Version 4010A1 transactions. MM7499, MM6870, and Change Request (CR) 7068.

Advanced Diagnostic Imaging Accreditation Potential for Denials Providers experiencing denials for non-ADI accreditation will see

remark code N290 on their remittance advice for claims submitted for or including the technical component of an ADI procedure. MLN Matters article SE1122

CMS Has Issued a Final Rule Updating Medical Loss Ratio (MLR) to Account for ICD-10 Conversion Costs MLR is the ratio of

total losses paid in insurance claims divided by the total earned premiums collected by insurers. Insurers may shift some of the costs associated with the ICD-10 conversion to the category of clinical cost, which will be considered as quality improvement activity. This will allow up to 0.3% of earned premiums in the relevant state market to be counted as quality improvement activity. ICD-10 maintenance costs and claims adjudication system costs are still considered to be administrative, and thus will fall under the MLR restriction on non-clinical spending limits.

Non-Specific Procedure Code Description Requirement for HIPAA Version 5010 Claims MLN Matters Number: SE1138

ICD10 Implementation Guide for Small to Medium

Practices From CMS

YouTube Video Slideshow

Presentation from the

November 17th ICD-10

National Provider Call

4 Podcasts from the ICD-10

Provider call are now

available under the

“downloads” section on this

page

1: Introduction, General ICD-

10 Requirements, and CMS

Implementation Planning.

2: General Implementation

Planning and Strategies.

3: NCVHS Meeting Update

and Medicare FFS Claims

Processing, Billing, and

Reporting Guidelines.

4: Question and Answer

Session.

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Prompt Payment Interest Rate Revision - The new rate of 2.0 percent is in effect through June 30, 2012. Medicare must pay

interest on clean claims if payment is not made within the applicable number of calendar days, after the date of receipt. This rate is determined by the Treasury Department on a six-month basis, effective every January and July 1.

Medicare and Medicaid EHR Incentive Programs Payment and Registration Data CMS has created a new webpage where you can find

Medicare and Medicaid Electronic Health Record (EHR) Incentive Program payment and registration data.

Proposed Meaningful Use Timeline Changes Encourage Adoption of EHRs HHS announced its intention to delay the start of Stage

2 meaningful use for the Medicare and Medicaid EHR Incentive Programs for a period of one year for those first attesting to meaningful use in 2011. CMS intends to propose such a delay in the Stage 2 meaningful use Notice of Proposed Rulemaking (NPRM), which is scheduled to be published in February 2012.

APPEALS FOR GLYCATED HEMOGLOBIN A1C TESTS - PROCEDURE CODE 83036 must describe the patient's condition and

include documentation, such as the A1C test results, to support the medical necessity for providing this service more frequently than once every three months. NCD 190.21 provides the medical necessity criteria.

CMS Requires Adoption of HIPAA Standards for Electronic Payments and Remittance Advice

New standards for electronic funds transfers, required by the Affordable Care Act, will reduce up to $4.5 billion off administrative costs. The standards build upon regulations published earlier that set industry-wide standards for how health providers use electronic systems to quickly and easily determine a patient’s eligibility for health coverage and check on the status of a health claim.

2012 ICD-10-CM Code Updates Now Available The 2012 ICD-10-CM files contain information on the new diagnosis coding system, ICD-10-CM, that is being developed as a replacement for ICD-9-CM, Volumes 1 and 2. To access the files, scroll to the bottom of the page to the "Downloads" section

This Bulletin provides information

regarding the prohibition on "balance-billing" Qualified

Medicare Beneficiaries (QMB) for Medicare cost-sharing, including

deductible, coinsurance, and copayments.

What You Need to Know About Medicare Time Limit Regulations The Affordable Care Act

reduced the maximum period for submission of all Medicare claims to no more than 12 months or one calendar year after the date of service. Exceptions to the one calendar year time limit for filing claims:

Administrative Error Retroactive Medicare Entitlement Involving State

Medicaid Agencies Retroactive Disenrollment from a Medicare

Advantage (MA) Plan or Program of All-inclusive Care of the Elderly (PACE) Provider Organization

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Implementation of an effective compliance plan is currently not mandatory for those participating in the Medicare and Medicaid programs.

However, the Affordable Care Act gave the Secretary

of the Department of HHS the authority to require the implementation of an effective compliance plan and/or program of all participating providers and suppliers.

The Federal Register, page 42411, states: “The OIG, for example, will consider the existence of an effective compliance program that pre-dated any governmental investigation when addressing the appropriateness of administrative sanctions. The burden is on the provider to demonstrate the operational effectiveness of a compliance program.”

Be proactive and become familiar with what would likely be required for a compliance plan/program for individual and small group physician

practices.

11 Videos and audio podcasts (averaging about 4 minutes each) are

part of the award-winning Health Care Fraud Prevention and Enforcement Action Team (HEAT) Provider Compliance Training. They cover major health care fraud and abuse laws, the basics of health care compliance programs, and what to do when a compliance issue arises. Topics include: Physician Self Referral False Claims Act Anti Kickbacks Exclusion Authorities and Effects of Exclusion Compliance Program Basics Importance of Documentation

For disclaimer and more information

Healthcare Professionals

Selected for the New

Innovation Advisors

Program to Improve

Care for Patients

The Centers for Medicare

and Medicaid Services

(CMS) announced that it

has selected 73 individuals

from 27 states and the

District of Columbia for its

Innovation Advisors

program. The list of

advisors can be found here.

2012 Physician Quality

Reporting System

Educational Products Are

Now Available!

Measure Specifications Manual for Claims and Registry Reporting of Individual Measures

Implementation Guide

Measures List

Quality-Data Code (QDC) Categories

Single Source Code Master Measure Specification

Release Notes Further information on the 2012 Physician Quality Reporting System may be found in the final 2012 Medicare Physician Fee Schedule rule with comment period that was published in the Federal Register on November 28, 2011.

Q. What are the penalties for violations of

the Health Insurance Portability and Accountability Act (HIPAA) regulations for transactions & code sets, and unique identifiers?

A. The HIPAA legislation permits civil

monetary penalties of not more than $1.5 million per calendar year for a violation of an identical provision.

FREE

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Submitting Documentation: Provider Responsibilities CERT takes a random sample of claims submitted for payment each day and reviews them for appropriate documentation and content. When a claim is pulled in the sample, the CERT Documentation Contractor (CDC) may contact the provider who submitted that claim to request additional medical documentation to support the claim. What are your responsibilities as the provider when you receive a request for additional documentation from the CDC?

Respond to the request within 75 days of receipt of the original request letter

Include all documentation: signed and dated physician orders, signed and dated clinician notes, diagnostic codes, test reports, operative reports

Submit documentation for all dates of service on the claim

Ensure all copies are clear - check for double sided records

Records must provide proof that the service was rendered, justification of medical necessity as well as indicate the correct date of service

Documentation must be LEGIBLE and there must be a LEGIBLE physician signature or the claim will be denied

The preferred method of submitting records is to fax - fax number: 240-568-6222

Include both the bar code cover sheet which will accompany the request letter and the CID (Claim Identification Number)

Submitting documentation does not violate the HIPAA Privacy Rule. The CMS 1500 Claim Form states that the patient signature authorizes any entity to release to Medicare medical and non-medical documentation

DME MAC CERT Education Task Force is asking for the cooperation of the physician community. If a supplier contacts your office to request additional clinical documentation, partner with the supplier to establish what clinical records are needed. CERT requires that suppliers provide written detailed orders, verification of continued medical need and comprehensive medical records, among other documents, to support that the service/item that you ordered is medically necessary

Medicare Program Integrity Manual Chapter 12 – The Comprehensive Error Rate Testing Program

UnitedHealth Group internal business teams are updating internal processes to accommodate the CMS extended enforcement period and will NOT reject 4010 transactions until April 1, 2012. Per the original mandate, UnitedHealth Group will also accept transactions using the 5010 standards.

UnitedHealth Group's health benefit businesses - Commercial, Medicare and Medicaid - are aligning to support a single brand that people can turn to for health care benefits at all stages of life. Through this brand transition, United Healthcare, United Healthcare Community Plan, United Healthcare Medicare Solutions and United Healthcare Military & Veterans Services are now sharing the United Healthcare brand name.

Preventive Services Billing Guide

December 2011

This electronic Code of Federal Regulations is current as of

January 4, 2012

§ 410.18 Diabetes screening tests § 410.141

Outpatient diabetes self-management training § 410.31 Bone mass measurement: Conditions for coverage

and frequency standards

OIG Most Wanted Healthcare Fugitives

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As we welcome 2012, we are also celebrating January as the 18th annual AACE Thyroid

Awareness Month!

AACE strives to be “the voice of clinical endocrinology”, and promoting Thyroid

Awareness is a great way to make our voices heard. AACE is rolling out an updated

Thyroid Awareness campaign and introducing the blue paisley ribbon as the lasting icon

for Thyroid Awareness.

A variety of resources are available specifically to help you share the Thyroid Awareness

message with your patients and the public at large:

New website – www.ThyroidAwareness.com

EmPower Magazine – 100 copies of Thyroid Awareness issue to be mailed to

AACE members

Thyroid Neck Check™ cards – 100 copies in blue paisley theme to be mailed to

AACE members

Blue Paisley Merchandise (lapel pins, magnets, etc.) – available by request

Thyroid Fact Sheets – for downloading and printing in revised blue paisley theme

Thyroid Public Service Announcement Videos

AACE and Thyroid Awareness on Facebook and Twitter

Promotion of AACE Thyroid Awareness Month is happening in a variety of ways,

including a satellite media tour, interviews with national magazines, a video in New

York’s Times Square, a social media campaign, participation in health fairs, partnerships

with thyroid patient organizations, press releases and much more. Be sure to read AACE

Online News for weekly updates on the campaign.

If you have questions or need any additional information, please contact Karen Pan,

AACE Public Relations Project Manager, at kpan@aace.com or (904) 353-7878 ext. 147.

Don’t forget to request your blue paisley merchandise here.

Thank you for your support and please keep promoting the power of the paisley!

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Coding TRAC

Tips on Reimbursement And Coding

The New HCPCs Code for Prolia (Denosumab, 1mg) is J0897

The drug denosumab has two brand names with two different indications. The brand names and their indications are:

Prolia® – indicated to treat osteoporosis in women after menopause.

Xgeva® – indicated for the prevention of skeletal-related events (SREs)

Please also indicate in the comment section of the claim which drug is being administered, Prolia

® or Xgeva

®.

Note: When denosumab (Prolia

® or Xgeva

®) is reported for Medicare payment,

the medical record must clearly demonstrate the patient has, in fact, been so diagnosed. Indicate in the comment section of the claim which drug is being administered, Prolia

® or Xgeva

®.

**Drugs should only be reported if the physician purchased the drugs. **Check with your commercial and federal carriers to determine if there are any specific administration or coding guidelines.

CPT® code 96372 should be reported as well when a subcutaneous or intramuscular injection of Prolia®/Xgeva® is administered.

**Documentation should support the indication for the drug, the location of the administration, the person (and their credentials) who administered the drug, positive OR negative reactions, and any instructions/information provided to the patient regarding the drug and/or side effects.

According to CMS’ Web site, “Carriers and A/B Medicare Administration Contractors are to continue reviews using both the 1995 and 1997 documentation guidelines (whichever is more advantageous to the physician).” History, exam and medical decision making are the 3 key components for an E/M service for both sets of guidelines. The history element for E/M services is the same for both guidelines.

Which guidelines are you following and do you know the difference?

In this month’s edition of Endonomics we

will discuss the key component of history.

Medicare Updates for 2012 Webinar February 23 12:00 – 1:30 pm ET

Fundamentals and

Advanced Endocrine Coding Course

March 16-17 New Orleans November 9-10 Philadelphia Presenters: Anita Henderson-Sumpter, MHA,

MBA, CHC, CPC, CMOM

Vanessa Lankford, CMCO, CPC,

CMOM, AACE-CEC

All courses are subject to change.

For more information and registration, please visit

https://www.aace.com/coding/courses-and-webinars

or contact vlankford@aace.com

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History Element of an E/M Service There are 3 parts that make up the history component of an E/M; HPI (history of presenting illness), ROS (review of systems), and PFSH (past, family, social history).

I. 8 Elements of HPI: 1. Location- area of the body (neck) 2. Quality- quality of symptoms (pain, ache, throbbing) 3. Severity- level or magnitude of problem (scale of 1-10 pain level, worse or better) 4. Duration – how long problem experienced (3 days, since Monday) 5. Timing- when problem occurs (worse in AM or PM) 6. Context – situation in which problem occurred/occurs 7. Modifying factors – type of intervention tried by patient whether or not it was successful (eat or drink something, aspirin, hot shower) 8. Associated signs and symptoms – additional problems described by the patient (nausea, feet go numb, dizzy)

*Brief HPI consists of one to three elements of the HPI and an extended HPI consists of four or more elements of the HPI

II. Review of Systems is an inventory of body systems obtained through a series of questions seeking to identify signs

and/or symptoms which the patient may be experiencing or has experienced. For purposes of ROS, the following systems are recognized:

*Problem pertinent ROS is related to the patient’s positive responses & pertinent negatives for the system related to the problem. *Extended ROS inquires about the system directly related to the problem(s) in the HPI and a limited number of additional systems. (2-9 systems should be

documented) *Complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems (10 systems must be

reviewed). Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least 10 systems must be individually documented.

III. Past, Family and/or Social History (PFSH) consists of a review of 3 areas.

Past history is the patient’s past experiences with illnesses, operational, injuries, and treatments. Current medications • Allergies • Age-appropriate immunizations status

• Age-appropriate feeding/dietary status • Past injuries, operations, or illnesses

Family history is a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk.

•Health status or cause of death of parents/siblings/children • Specific diseases related to the problems identified in the chief compliant, HPI or ROS • Diseases of family members that

may be hereditary or place the patient at risk Social history is an age appropriate review of past and current activities.

Marital status • Employment • Occupational history • History of drugs, alcohol and tobacco • Education level • Sexual history

A pertinent PFSH requires at least 1 specific item from any of the 3 history areas be documented. A complete PFSH is of a review of two or all three of the PFSH history areas, depending on the category of the E/M service. A review of all three history areas is required for services that by their nature include a comprehensive assessment or reassessment of the patient. A review of two of the three history areas is sufficient for other services. A complete PFSH for the following categories of E/M services requires 2 of 3 areas must be documented: • Office or other outpatient services established patient • emergency department • subsequent nursing facility care, domiciliary care, established patient• home care, established patient A complete PFSH for the following categories of E/M services requires at least 1 specific item from each of the three history areas: • Office or other outpatient services, new patient • hospital observation services • hospital inpatient services, initial care • consultations • comprehensive nursing facility assessments • domiciliary care, new patient • home care, new patient

Musculoskeletal

Integumentary (skin and/or breast)

Neurological

Psychiatric

Endocrine

Hematologic/Lymphatic

Allergic/Immunologic

Constitutional symptoms (e.g., fever, weight loss)

Eyes

Ears, Nose, Mouth, Throat

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

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All medical coding must be supported with documentation and medical necessity. **While this document represents our best efforts to provide accurate information and useful advice, we cannot guarantee that third-party payers will recognize and accept the coding and documentation recommendations. As CPT

®, ICD-9-CM and HCPCS codes change annually, you should reference the current CPT

®, ICD-9-CM and HCPCS

manuals and follow the "Documentation Guidelines for Evaluation and Management Services" for the most detailed and up-to-date information. This information is taken from publicly available sources. The American Association of Clinical Endocrinologists cannot guarantee reimbursement for services as an outcome of the information and/or data used and disclaims any responsibility for denial of reimbursement. This information is intended for informational purposes only and should not be deemed as legal advice, which should be obtained from competent local counsel. Current Procedural Terminology (CPT

©) is copyright and trademark of the 2010 American Medical

Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT©. The AMA

assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

So how do you calculate all this to determine

the level of history? Find out in February’s issue!

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AACE's Socioeconomic and Member Advocacy Department's goal is to reach out into the endocrinology business world and become the one- stop- shop, not only for endocrinology clinicians, but their support staff as well. Currently, Endonomics is a free newsletter for both members and non members. Interested parties should send an e-mail to Endonomics@aace.com with their name, phone and fax numbers, location and preferred e-mail address to be added to our Practice Support Network database.

We wish you and your

fami ly hea l th , happ iness

and success in the coming year !