Thursday, February 26, 2015

Assistant surgery modifiers

Appropriate use of assistant at surgery modifiers and payment indicators

First Coast Service Options Inc. (First Coast) would like to remind providers within jurisdiction N (JN) of the appropriate use of assistant at surgery modifiers and payment under the Medicare physician fee schedule (MPFS).

An assistant at surgery is a provider who actively assists the physician in charge of a case in performing a surgical procedure. A physician, nurse practitioner, physician assistant or clinical nurse specialist who is authorized to provide such services under state law can serve as an assistant at surgery.

Medicare considers advanced registered nurse practitioner (ARNP), physician assistant (PA), and clinical nurse specialist (CNS) as non-physician practitioners. Medicare does not recognize a registered nurse first assistant (RNFA) as a qualified Medicare provider.

To report services of an assistant surgeon, the following surgical modifiers should be appended:
• 80 -- Assistant Surgeon: This modifier pertains to physician’s services only. A physician’s surgical assistant services may be identified by adding the modifier 80 to the usual procedure code. This modifier describes an assistant surgeon providing full assistance to the primary surgeon, and is not intended for use by non-physician providers.
• 81 -- Assistant Surgeon: This modifier pertains to physician’s services only. Minimal surgical assistance may be identified by adding the modifier 81 to the usual procedure code, and describes an assistant surgeon providing minimal assistance to the primary surgeon. This modifier is not intended for use by non-physician providers.
Note: This modifier is used in the private insurance industry and is not commonly used in Medicare billing.
• 82 -- Assistant surgeon (when a qualified resident surgeon is not available in a teaching facility): This modifier applies to physician’s services only. The unavailability of a qualified resident surgeon is a prerequisite for use of this modifier and the service must have been performed in a teaching facility. The circumstance explaining that a resident surgeon was not available must be documented in the medical record. This modifier is not intended for use by non-physician providers.
• AS -- Non-physician provider as assistant at surgery: This modifier applies when the assistant at surgery services are provided by a PA, ARNP, or CNS.

Payment information

Medicare reimburses services rendered for assistant at surgery by a physician performing as a surgical assistant at 16 percent of the MPFS amount. Services rendered for assistant at surgery by non-physician providers are reimbursed at 85 percent of 16 percent (i.e., 13.6 percent) of the MPFS amount.
When reporting services provided by non-physician practitioners acting as assistants at surgery, append modifier AS to the procedure code used to report the surgeon’s service.
If a physician appends modifier AS to procedure codes for which he/she acted as assistant at surgery, these codes will be denied (see above for modifiers that should be used by physicians).

Medicare physician fee schedule database (MPFSDB) assistant at surgery payment indicators


The MPFSDB is a file layout that carriers and A/B MACs use to display the total fee schedule amount, related component parts, and payment policy indicators. The assistant at surgery payment indicator describes when assistant at surgery may be paid or not. Valid indicators are:

• 0 = Payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity.

• 1 = Statutory payment restriction for assistants at surgery applies to this procedure. Assistant at surgery may not be paid.

• 2 = Payment restriction for assistants at surgery does not apply to this procedure. Assistant at surgery may be paid.

• 9 = Concept does not apply.

If multiple services are submitted with modifiers indicating assistants at surgery, each service is independently reviewed (based on the above-listed indicators) to determine payment.

Tuesday, February 17, 2015

Nursing Home Five-Star Rating System review

CMS Announces Two Medicare Quality Improvement Initiatives

Administration redoubles its efforts to improve quality of post-acute care for Medicare beneficiaries

Today, the Centers for Medicare & Medicaid Services (CMS) announced two initiatives to improve the quality of post-acute care.  First, the expansion and strengthening of the agency’s widely-used Five Star Quality Rating System for Nursing Homes will improve consumer information about individual nursing homes’ quality. Second, proposed new conditions of participation for home health agencies willmodernize Medicare’s Home Health Agency Conditions of Participation to ensure safe delivery of quality care to home health patients.
“We are focused on using as many tools as are available to promote quality improvement and better outcomes for Medicare beneficiaries,” said Marilyn Tavenner, CMS administrator. “Whether it is the regulations that guide provider practices or the information we provide directly to consumers, our primary goal is improving outcomes.”

Nursing Home Five-Star Rating System

Beginning in 2015, CMS will implement the following improvements to the Nursing Home Five Star Quality Rating System:

•    Nationwide Focused Survey Inspections: Effective January 2015, CMS and states will implement focused survey inspections nationwide for a sample of nursing homes to enable better verification of both the staffing and quality measure information that is part of the Five-Star Quality Rating System. In Fiscal Year (FY 2014), CMS piloted special surveys of nursing homes that focused on investigating the coding of the 
Minimum Data Set (MDS), which are based on resident assessments and are used in the quality measures.

•    Payroll-Based Staffing Reporting: CMS will implement a quarterly electronic reporting system that is auditable back to payrolls to verify staffing information. This new system will increase accuracy and timeliness of data, and allow for the calculation of quality measures for staff turnover, retention, types of staffing, and levels of different types of staffing. Implementation will be improved by funding provided in the recently enacted, bipartisan Improving Medicare Post-Acute Care Transformation Act (IMPACT) of 2014.

•    Additional Quality Measures: CMS will increase both the number and type of quality measures used in the Five-Star Quality Rating System. The first additional measure, starting January 2015, will be the extent to which antipsychotic medications are in use. Future additional measures will include claims-based data on re-hospitalization and community discharge rates.

•    Timely and Complete Inspection Data: CMS will also strengthen requirements to ensure that States maintain a user-friendly website and complete inspections of nursing homes in a timely and accurate manner for inclusion in the rating system.

•    Improved Scoring Methodology: In 2015, CMS will revise the scoring methodology by which we calculate each facility’s quality measure rating, which is used to calculate the overall Five Star rating.  We also note that sources independent of self-reporting by nursing homes already are weighted higher than self-reported components in the scoring methodology.

“Nursing homes are working to improve their quality, and we are improving how we measure that quality,” said Patrick Conway, M.D., deputy administrator for innovation and quality and CMS chief medical officer. “We believe the improvements we are making to the Five Star system will add confidence that the reported improvements are genuine, are sustained, and are benefiting residents.”

Home Health Conditions of Participation

The proposed Home Health Conditions of Participation would improve the quality of home health services for Medicare and Medicaid beneficiaries by strengthening patient rights and improving communication that focuses on patient wellbeing. Currently there are more than 5 million people with Medicare and Medicaid benefits that receive home health care services each year from approximately 12,500 Medicare-certified home health agencies.

The proposed regulation, to be displayed Monday, October 6, at the Federal Register, would modernize the home health regulations for the first time since 1989 with a focus on patient-centered, well-coordinated care. Elements in the regulation include expansion of patient rights requirements; refocusing of the patient assessment on physical, mental, emotional, and psychosocial conditions; improved communication systems and requirements for a data-driven quality assessment; and performance improvement (QAPI) program.


Thursday, February 12, 2015

Non practitioners billing - Incident service - Medicare guidelines

"Incident to" and the Initial Visit - Evaluation & Management (E/M) Service Guidelines

Novitas Solutions Medical Review (MR) Department has observed a continued trend of the utilization of non-physician practitioners to perform initial office visits as "incident to" services. Documentation reviewed by the MR Department indicates that a non-physician practitioner performs the initial visit and the supervising physician documents a note in the medical record similar to the following:

"I have reviewed the Physician Assistant's note, examined the patient and agree with..."

“Nurse practitioner performed the history and physical and I was present for the entire encounter and my treatment plan is as follows……”

This is incorrect use of the non-physician practitioner and incorrect billing under the "incident to" guidelines. This article explains the Medicare definition of "incident to" services and the criteria that must be met to properly bill "incident to" services.

An initial history and physical performed by a non-physician practitioner, although the physician is documented as being present or in the office suite and immediately available, is not covered under the "incident to" guidelines. As outlined below, the physician MUST perform the initial service. This includes the history and physical, examination portion of the service, and the treatment plan. It is expected that the physician will perform the initial visit on each new patient to establish the physician-patient relationship.

Novitas Solutions MR will deny or down code claims for initial office visits billed as "incident to" when a non-physician practitioner performs the initial history and physical .

CMS defines "incident to" services as “services or supplies furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.”

In order to be covered as "incident to" the physician’s service, the following criteria must be met:

services must be an integral, although incidental, part of the physician’s professional service,commonly rendered without charge or included in the physician’s bill,of a type that are commonly furnished in physician’s offices or clinics, and furnished by the physician or by auxiliary personnel under the physician’s direct supervision "Incident to" services must be performed under the direct supervision of the physician. CMS directs that “Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.”

CMS further indicates, under direct supervision, “This does not mean, however, that to be considered "incident to", each occasion of service by auxiliary personnel (or the furnishing of a supply) need also always be the occasion of the actual rendition of a personal professional service by the physician. Such a service or supply could be considered to be "incident to" when furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency which reflects his/her active participation in and management of the course of treatment.” Hospital and skilled nursing facility services cannot be billed as "incident to" at any time.

Tuesday, February 3, 2015

Additional Services covered during wellness visit




Medicare covers a one-time only Abdominal Aortic Aneurysm (AAA) Screening for at-risk members when a referral for the screening is received as a result of the wellness exam. In 2014, this service is subject to member cost-sharing in most plans.

Medicare covers a one-time only Electrocardiogram (EKG) Screening for Medicare members. In 2014, this service is subject to member cost-sharing in most plans.
Any clinical laboratory tests or other diagnostic services that CMS recognizes and defines as medically necessary (as opposed to preventive) performed at the time of the wellness visit may be subject to a copayment or coinsurance. Refer to the CMS Policy that defines these guidelines, e.g., refer to the Medicare Physician Fee Schedule to determine if a service is covered by Medicare. A Status Indicator of ‘N’ reflects non-coverage. Therefore, the member is required to sign the Advanced Notice of Non Coverage (ANN) form prior to the service being provided by a contracting lab. Other reference sources in addition to Medicare Physician Fee Schedule include: National Coverage Determinations, Local Coverage Determinations, and NCCI Policy.

In general, screening lab work is not covered by Medicare (with a few exceptions as outlined in the list of covered preventive services below) and therefore not covered by our plan.

Common Preventive Services and Screenings
Physicians and other health care professionals may also provide and bill separately for screenings and other preventive services. All Medicare Advantage plans insured by UnitedHealthcare cover the following Medicare-covered preventive services at the same frequency as covered by original Medicare, except where otherwise noted, for a $0 copayment:

•    Alcohol misuse screening and counseling
•    Hepatitis B immunization
•    Bone mass measurement HIV screening
•    Breast cancer screening (mammograms)
•    Cardiovascular screening
•    Intensive behavioral therapy to reduce cardiovascular disease risk
•    Cervical and vaginal cancer screening (Pap test and pelvic exam)2
•    Medical nutrition therapy services
•    Obesity screening and counseling1
•    Colorectal cancer screening3 Pneumococcal shot
•    Depression screening Prostate-specific antigen (PSA) test4
•    Diabetes screening
•    Flu shot
•    Glaucoma tests (for those at high risk)
•    Tobacco use cessation counseling
•    Sexually transmitted infections screening and counseling

1 In accordance with Medicare guidelines, covered only in the primary care setting.
2 In 2014, coverage periodicity follows Medicare guidelines: covered annually for those at high risk and every two years for all other women.
3 For all Medicare Advantage plans insured by UnitedHealthcare, a colonoscopy that begins as a Medicarecovered screening service is subject to the $0 screening cost-share regardless of whether a polyp is found and/or removed during the procedure.
4 A DRE is subject to cost-sharing.

Sunday, January 25, 2015

Preventive Services and Screenings Covered by Medicare and Waiver of Coins/Copay/Dedt



•    Abdominal Aortic Aneurysm Screening
•    Alcohol Misuse Screening and Behavioral counseling Intervention in Primary Care
•    Annual Wellness Visit (Including Personalized Prevention Plan Services)
•    Bone Mass Measurements
•    Cancer Screenings
•    Breast Cancer (mammograms and clinical breast exam)
•    Cervical and Vaginal Cancer (pap test and pelvic exam [includes the clinical breast exam])
•    Colorectal Cancer
             o    Fecal Occult Blood Test
             o    Flexible Sigmoidoscopy
             o    Colonoscopy
             o    Barium Enema
•    Prostate (PSA blood test and Digital Rectal Exam)
•    Cardiovascular Disease Screening
•    Depression Screening in Adults
•    Diabetes Screening
•    Diabetes Self-Management Training
•    Glaucoma Screening
•    Human Immunodeficiency Virus (HIV) Screening
•    Immunizations (Seasonal Influenza, Pneumococcal, and Hepatitis B)
•    Initial Preventive Physical Examination (IPPE) (also commonly referred to as the “Welcome to Medicare” Preventive Visit)
•    Intensive Behavioral Therapy for Cardiovascular Disease
•    Intensive Behavioral Therapy for Obesity
•    Medical Nutrition Therapy (for beneficiaries with diabetes or renal disease)
•    Sexually Transmitted Infections (STIs) Screening and High-Intensity Behavioral Counseling (HIBC) to prevent STIs
•    Tobacco-Use Cessation Counseling

As a result of the Affordable Care Act, Medicare now covers many of these services without cost to patients, including the Annual Wellness Visit that was created under the Affordable Care Act.
Waiver of Coinsurance,Copayment and Deductible for Preventive Services and Screenings

The coinsurance or copayment represents the beneficiary’s share of the payment to the provider or s
upplier for furnished services. Coinsurance generally refers to a percentage (for example, 20 percent) of the Medicare payment rate for which the beneficiary is liable and is applicable under the PFS, while copayment generally refers to an established amount that the beneficiary must pay that is not necessarily related to a particular percentage of the Medicare payment, and is applicable under the hospital Outpatient Prospective Payment System (OPPS).

Not all preventive services allowed in Medicare and recommended by the USPSTF have a Grade of A or B, and therefore, some of the preventive services do not meet the criteria in sections 1833(a)(1) and (b)(1) of the Act for the waiver of deductible and coinsurance.

For Carriers/AB MACs, Part B of Medicare pays 100 percent of the Medicare allowed amount for pneumococcal vaccines and influenza virus vaccines and their administration. Part B deductible and coinsurance do not apply for pneumococcal and influenza virus vaccine.

Part B of Medicare also covers the hepatitis B vaccine and its administration. Part B deductible and coinsurance do apply for hepatitis B vaccine. State laws governing who may administer pneumococcal and influenza virus vaccinations and how the vaccines may be transported vary widely. Medicare contractors should instruct physicians, suppliers, and providers to become familiar with State regulations for all vaccines in the areas where they will be immunizing.

Medicare physician fee schedule - Quick overview

Medicare Part B pays for physician services based on the PFS, which lists the more than 7,400 unique
covered services and their payment rates. Physicians’ services include the following:

* Office visits;
* Surgical procedures;
* Anesthesia services; and
* A range of other diagnostic and therapeutic services.


Medicare Physician Fee Schedule Payment Rates

Payment rates for an individual service are based on
three components:
1) Relative Value Units (RVU)
2) Conversion Factor (CF)
3) Geographic Practice Cost Indices (GPCI)


Medicare Physician Fee Schedule Payment Rates Formula


The Medicare PFS payment rates formula is shown below:

[(Work RVU x Work GPCI) + (PE RVU x PE GPCI) +
(MP RVU x MP GPCI)] x CF

Medicare fee schedule download