3 FQHC What makes a CHC unique Encounter Rate Face-to-face with core provider Fixed Rate of Reimbursement vs. FFS So why is coding important? Appropriate capture of breadth & scope of service Commercial FFS maximization Managed Medicaid with Encounter Rate secondary Data collection for PPS change for Medicare in data is being collected as of 1/1/11 Cost Based Oversimplified $100,000 to see 1,000 visits PPS- Method of reimbursement in which payment is made based on a predetermined, fixed amount.
4 FQHC - Core Provider Medicare s definition of a visit or billable encounter is: A face-toface encounter in an outpatient setting between a patient and a FQHC Core Practitioner. Medical Doctor (MD, DO) Optometrist Podiatrist Chiropractor Physician s Assistant (PA) Certified Midwife (CNM) Nurse Practitioner (NP) Clinical Psychologist (CP) Licensed Clinical Social Worker (LCSW) Certified Diabetic Educator
5 FQHC Medicare Encounter Rate Unique Medicare Benefits Deductible waived (EXCEPT Part B) Preventive Visits (e.g., 99387/99397) covered Expanded to include Annual Well Visit (AWV) Encounter Rate (Typically 80% of rate below) Rural: $109.24; Urban: $ Co-pay based on FFS charges has charge of $45 co-pay is $9 NOT 20% of encounter rate Coinsurance waived on some preventive services Additional Encounter Rate Scenarios Nursing Facilities & Homebound patients
6 FQHC COINSURANCE WAIVER Effective for dates of service on or after January 1, 2011, coinsurance and deductible are being waived for all Preventive Services as enacted in section 4104 of the Affordable Care Act Medicare will provide 100 percent payment (in other words, will waive any coinsurance or copayment) for the: Initial Preventive Physical Examination (IPPE) Annual Wellness Visit (AWV), and Those preventive services that are identified with a grade of A or B by the United States Preventive Services Task Force (USPSTF) for any indication or population and are appropriate for the individual
7 Annual Wellness Visit (AWV) Personalized Prevention Plan Services (PPPS) (1 of 4) Effective 1/1/11, Medicare covers AWV NOT interchangeable with Preventive E&M (i.e., ) Co-pay and deductible waived in all POS (Not just FQHC) Note: 993XX at FQHC only deductible, not co-pay, waived MD, DO, PA, NP, CNS, health educator, RD, nutritionist, or combination team may provide AWV services G0438 for First visit & G0439 for Subsequent G0438 is allowed once per patient per lifetime G0439 is allowed every 12 months after either 1. a IPPE (Welcome to Medicare) or, 2. Initial AWV Note: Benefit is per patient not per provider G0439 and G0438 are not allowed within 12 months of the patients initial enrollment into Medicare. Bill an IPPE (G0402).
8 Annual Wellness Visit (AWV) Personalized Prevention Plan Services (PPPS) (2 of 4) Initial: G0438 and Subsequent: G0439 Required Services/Documentation (Subsequent parenthetical) Establishment (Update) of medical/family history Establishment (Update) of a list of current providers and suppliers that are regularly involved in providing medical care Measurement (Update) of height, weight, BMI (or waist circumference), BP, and other data as deemed appropriate Detection (Update) of cognitive impairment Review of the individual s potential (risk factors) for depression, including current or past experiences with depression or other mood disorders Review of the individual s functional ability and level of safety based on direct observation, or the use of appropriate screening questions or a screening questionnaire
9 Annual Wellness Visit (AWV) Personalized Prevention Plan Services (PPPS) (3 of 4) Initial: G0438 and Subsequent: G0439 Required Services/Documentation (Subsequent parenthetical) Review of the individual s potential (risk factors) for depression, including current or past experiences with depression Review of the individual s functional ability and level of safety based on direct observation, or the use of appropriate screening questions or a screening questionnaire (Update) Establishment (Update) of a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or/are underway Furnishing of personalized health advice to the individual and a referral, as appropriate... see actual document for specifics (Update)
10 Annual Wellness Visit (AWV) Personalized Prevention Plan Services (PPPS) (4 of 4) Initial: G0438 and Subsequent: G0439 Required Services/Documentation (Subsequent parenthetical) Voluntary advance care planning (as defined in this section) upon agreement with the individual (Update) Any other element(s) determined appropriate by the Secretary of Health and Human Services through the National Coverage Determination (NCD) process (Update) Source: MBPM Pub , Transmittal 134, Change Request 7079, Reissued Revisions: 12/14/11
11 FQHC Covered Preventive Services Billable to Part B The technical component of the following specific preventive services (the professional component is an RHC/FQHC service if performed by a RHC/FQHC physician or non-physician practitioner) Screening pap smears and screening pelvic exams; Prostate cancer screening; Diabetes outpatient self-management training services; Colorectal cancer screening tests; Screening mammography; Bone mass measurements; and Glaucoma screening. Medicare Benefit Policy Manual Chapter 13, Section 30.3
12 FQHC Covered Preventive Services (1 of 2) The following preventive primary services may be covered and billed to the intermediary when provided by FQHCs to Medicare beneficiaries: Medical social services; Nutritional assessment and referral; Preventive health education; Children s eye and ear examinations; Prenatal and post-partum care; Prenatal services; Well child care, including periodic screening; Immunizations, including tetanus-diphtheria booster and influenza vaccine; Voluntary family planning services; Taking patient history;
13 FQHC Covered Preventive Services (2 of 2) The following preventive primary services may be covered and billed to the intermediary when provided by FQHCs to Medicare beneficiaries: (continued) Blood pressure measurement; Weight measurement; Physical examination targeted to risk; Visual acuity screening; Hearing screening; Cholesterol screening; Stool testing for occult blood; Dipstick urinalysis; Risk assessment and initial counseling regarding risks; and For women only: Clinical breast exam; Referral for mammography; and Thyroid function test.
14 Medicare Reporting: 2011 Changes (1 of 5) For dates of service on or after January 1, 2011, when billing services on a 77X type of bill, all services provided should be listed with the appropriate revenue code and HCPCS code for each line. For each billable visit, FQHCs must submit the appropriate revenue code and a valid HCPCS code for all claims. In addition, FQHCs must submit separate service lines with revenue codes and HCPCS codes to reflect any cost associated with all FQHC covered services provided by the FQHC but not reflected on the service line submitted for the billable visit Pneumococcal, influenza and hepatitis B vaccine and their administration should be reported separately with the appropriate HCPCS code and revenue codes.
15 Medicare Reporting: 2011 Changes (2 of 5) The only types of services payable on TOBs 77x: Professional or primary services not subject to the Medicare outpatient mental health treatment limitation are bundled into line item(s) using revenue code 052x; An additional payment maybe received for professional and primary services furnished on the same day at different times. These services should be billed using revenue code 052x and modifier 59.
16 Medicare Reporting: 2011 Changes (3 of 5) Services subject to the Medicare outpatient mental health treatment limitation are billed under revenue code 0900; Telehealth originating site facility fees are billed under revenue code 0780 and HCPCS code Q3014; Diabetes Self Management Training (DSMT) billed under revenue code 052x and HCPCS code G0108 and Medical Nutrition Therapy (MNT) billed under revenue code 052x and HCPCS code 97802, 97803, or G0270; and FQHC supplemental payments are billed under revenue code 0519, effective for dates of service on or after 01/01/2006.
17 Medicare Reporting: 2011 Changes (4 of 5) 0521 = Clinic visit by member to RHC/FQHC; 0522 = Home visit by RHC/FQHC practitioner; 0524 = Visit by RHC/FQHC practitioner to a member in a covered Part A stay at the SNF; 0525 = Visit by RHC/FQHC practitioner to a member in a SNF (not in a covered Part A stay) or NF or ICF MR or other residential facility; 0527 = RHC/FQHC Visiting Nurse Service(s) to a member s home when in a home health shortage area; and 0528 = Visit by RHC/FQHC practitioner to other non RHC/FQHC site (e.g., scene of accident) 0519 = Clinic, Other Clinic (only for the FQHC supplemental payment)
18 Medicare Reporting: 2011 Changes (5 of 5) For dates of service on or after January 1, 2011, all except the following revenue codes may be used when billing for services provided in a FQHC: 002x-024x, 029x, 045x, 054x, 056x, 060x, 065x, 067x-072x, 080x-088x, 093x, or x. NOTE: This information is being captured for data collection and gathering purposes only.
19 Smoking Cessation 2011 Coding Update (1 of 2)
20 2011 Coding Update (2 of 2) Q Codes for Flu Vaccine
21 Production Alerts NGS and MAC Production Alerts Lists resolved and unresolved processing issues for Medicare claims Recent Issues Preventive services coinsurance calculating incorrectly Misplaced decimal on number of units Invalid diagnosis code RTP Crossover claims not processing to secondary payer
22 Application Fee for 855A Effective Friday, March 25, 2011, Medicare Administrative Contractors (MACs) will begin collecting application fees with certain provider/supplier enrollment applications (both paper and online applications) as described below. The application fee is currently $505 for CY2011; however, this fee will vary from year-toyear based on adjustments made pursuant to the Consumer Price Index for Urban Areas (CPI-U). Note that these application fees do not apply to physicians, nonphysician practitioners, physician organizations, and non-physician organizations. All institutional providers of medical or other items or services or suppliers must pay the application fee. ( Institutional provider includes any provider or supplier that submits a paper Medicare enrollment application using the CMS-855A
23 ICD-10: Timelines for Change Jan 2009 Revised Federal Register Update: 5010: Jan 2012 ICD-10: Oct : To Do list for providers Transition team development & needs assessment Individual plan creation & Launch Jan 2011 Testing of 5010 by CMS Must use clearinghouse vs. direct submission by Jan 2012
24 Summary Read, understand and implement changes Sign up for List serve Monitor Medicare for updates Commit to Educate (Top down)
27 FQHC Resources USPSTF Grades of Preventive Services Deductible_and_Coinsurance_for_Preventive_Services.pdf/$File/CR701 2-Deductible_and_Coinsurance_for_Preventive_Services.pdf 2011 to FQHC Yearly Payment Limits Implementation of Application Fees for Medicare Institutional Provider/Supplier Enrollment Production Alerts LLM9MSSzPy8xBz9CP0os3gDr2BnRzdTEwMDs1BHA09HD0ffIFdzY2dP E_2CbEdFAKVSEXA!/?attestation=Accept
28 Speakers: Ray Jorgensen, MS, CPC, CHBME Raymond T. Jorgensen is President and CEO of Priority Management Group, Inc. (PMG). Ray is responsible for oversight of consulting operations as well as coding, reimbursement, and payer related issues for the out-sourced billing component of PMG s services (more than 850,000 annual encounters). He has personally trained thousands of providers from over 35 states on coding, billing, and reimbursement in addition to authoring two books and dozens of articles. Ray s health care experience and education is unique in that he was schooled by the payers. Having worked for Blue Cross and Blue Shield as well as United HealthCare Corporation, primarily in professional relations and contracting, Ray has an understanding and perspective on the payer s objectives and process unlike other medical business consultants groomed from the provider side. BA from The College of the Holy Cross (Worcester, MA) MS from Northeastern University (Boston, MA) CPC from the American Academy of Professional Coders (Salt Lake City, UT) CHBME from the Healthcare Billing & Management Association (Laguna Cliffs, CA)
29 Speakers: Caroline Peucker, CPC, CPC-H, CPC-I PMG s Vice President, Consulting and Compliance Caroline has more than 25 years experience in the physician billing and coding industry. Her extensive experience includes serving as the Vice President, Coding and Compliance, Manager of coding and Billing Operations Manager for physician billing companies that serviced a wide range of specialties and practice types. She has broad experience with hospital-based physician and private practice where she was integral to coding and compliance education and training for clinical providers, practice and billing office staff members. She has performed and managed chart audits with objective of both compliance and optimizing reimbursement through correct coding and thorough documentation. Caroline holds a Bachelor of Science degree in Health Service Administration from Providence College. She is an AAPC certified coder and PMCC instructor.
30 Speakers: Robert Skeffington, CHBME Robert Skeffington a founding partner and Executive VP of Sales and Marketing for Priority Management Group, Inc. (PMG). Responsible for PMG s overall business development strategy, Robert also works with staff to assess the impact of Health Care Reform on PMG and its hundreds of clients. Robert works diligently to enhance relationships with the National Association of Community Health Centers, state and regional CHC organizations, and individual community health sites. In addition to his role in PMG Billing, Robert also leads marketing and sales efforts for PMG Consulting which provides CHC centric education, operational assistance, and training services around revenue cycle management, coding, and other health care finance related matters. During his more than 17 years in health care Robert has worked with CHCs in the 48 contiguous states with an exclusive focus on revenue cycle management for the past 12 years with PMG. He is a speaker for NACHC and other regional CHC associations on a variety of health care revenue cycle related topics. BS from Salve Regina University (Newport, RI) CHBME from the Healthcare Billing & Management Association (Laguna Cliffs, CA)
31 Disclaimer: 1. The coding guidelines, interpretations, and recommendations set forth as part of this training session are presented as a guide only. Attendees understand and recognize that actual coding decisions are the sole liability and responsibility of the provider(s) and respective billing staff. Priority Management Group, Inc. does not accept any liability or responsibility in this regard. 2. The presentation today includes discussion about a particular commercial product/service and the presenter has significant financial interest/relationship with the organization that provides this product/service.
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