In most states, the harsh weather of winter is subsiding, spring is in the air, flowers are blooming everywhere you look, migratory birds are returning to their homes to mate and nest, trees are bursting with new growth, buds and leaves, and misty rains are providing nourishment for all.
But the harsh storms and bad weather still loom as dermatologists in private practice battle with inconsistent carrier policies, unmanageable software changes and deadlines, reductions in reimbursement, and exhausting claims processing accompanying Medicare patients who are converting to Medicare Advantage plans.
The combination of all the forces impacting dermatology practices all at once is dynamic with many struggling to keep up and stay current while managing a changing labor force that’s often ill-equipped for such sophisticated and problematic issues. For most, it’s all quite overwhelming.
But, what you don’t know can hurt you, so here I’ll briefly review many of the issues, problems and concerns facing your practice in this time of inclement weather.
NPI (National Provider Identifier) Numbers
May 23, 2007, was supposed to have been the drop-dead deadline for all providers to have obtained and started using this new identification number, which is necessary to file claims to third-party carriers.
The NPI number will replace all other numbers that providers have been using in the past to bill carriers. The numbers it will replace include PINs, UPINs, Medicaid and Medicare numbers, just to name a few. This one unique number will be used by all providers and accepted by all carriers, with no exceptions. This number will follow each provider throughout his or her years in practice regardless of the state in which state he or she practices or the insurance carrier(s) with which he or she contracts.
Confusion Over Who Needs a Number. Although it really wasn’t — or isn’t — difficult to obtain the NPI number, the confusion was really more about who needed one. Most of us understood that if you were a solo practitioner, you obtained your own NPI number. They called this a Type I NPI number. If you practiced in a group, then the provider obtained his/her own NPI while the group obtained another. This group NPI number was categorized as a Type II NPI number.
But then everything hit the fan, and the questions began. What really defined a group? What if two doctors were in a group but didn’t have a Tax Identification Number? What if you were in solo practice, but were incorporated? It got more and more complicated.
Then, to make matters worse, CMS had not yet made any provisions for formulating a National Directory (like the UPIN Web site where providers could look up the numbers of referring providers when they needed a PIN number on a claim). Because no such national site was in the works, providers began scrambling in an effort to get the numbers of colleagues (who may have been hesitant to share this number because of the possibility of identity theft).
Extending the Deadline. So, close to when the deadline was to take effect, CMS decided to extend the deadline for 1 year, to May 23, 2008. The CMS did not maintain that providers shouldn’t continue moving forward with obtaining and using the new NPI numbers, the agency just stated that carriers cannot deny claims if the old PINs and UPINs (e.g., legacy numbers) are used instead of the NPIs. Big deal! One of the main problems with the entire matter is that many of the carriers aren’t ready to accept the new NPIs anyway.
What is the bottom line in all of this? It’s pretty much a mess, and everyone will just have to monitor carrier Web sites for updates and guidance.
CMS-1500 Forms
April 1, 2007, was the drop-dead deadline date when providers had to start billing claims using the newly revised, reformatted CMS-1500 form. The claim was basically revised to accommodate the new NPI number as well as to allow claims to differentiate between the ordering and the supervising providers in group practices where services are billed “incident to.”
Incorrect Forms Processed. CMS, however, determined that vendors who sell the CMS-1500 forms had received an incorrectly formatted version of the revised form from the authorized forms designer. This resulted in the sale of printer forms and negatives that do not comply with the form specifications.
As a result, the claims cannot be processed because of the formatting inconsistencies. Due to this huge oversight, CMS decided to extend the acceptance period of the CMS-1500 version beyond the original April 1, 2007, deadline while this situation is being resolved. A new date had not been announced as of press time.
Identifying Incorrect Forms. The best way to identify the incorrect forms is by looking at the upper right hand corner of the form. If the tip of the red arrow above the vertically stacked word “Carrier” is touching — or close to touching — the top edge of the form, the form is not printed to specifications. There should be approximately one-quarter inch “between the tip of the arrow and the top edge of the paper on properly formatted forms.”
Are they kidding? I can’t see if I am pushing the correct button on my remote. Now I have to measure little red arrows? I wonder if CMS is providing practices with rulers.
Medicare Advantage Plans
Medicare Advantage is a term referring to a managed care Medicare product that is offered by various carriers pursuant to a contract with CMS. It is distinct from Medicare’s “traditional” or “original” fee-for-service plans.
Do not confuse what I am about to discuss with the Medicare Part D drug demonstration program, which is a totally separate Pandora’s Box. Medicare beneficiaries themselves are totally confused when you ask them if they have changed their Medicare coverage. Many elderly confuse their Medicare Advantage plans with their newly purchased drug coverage.
First, understand that the terms “par” and “non-par” status only have meaning with respect to the “traditional” or “original” fee-for-service Medicare Part B. In Medicare Advantage plans, all physicians are effectively on a “non-par” status unless they agree, via a provider agreement or other contract with the carrier, that they will accept the carrier’s Medicare Advantage product.
Declining Medicare Advantage Plans. Just because you have a contract with United Healthcare doesn’t necessarily mean that you are obligated to accept the Advantage plans — unless there is something specific in your contract that addresses this issue. Have your contract attorney carefully review your contract, as you may be under the false impression that you are required to accept the Medicare Advantage product just because you have signed a contract with the carrier.
So let us assume that you do not have a contract with the Medicare Advantage plan and it is your office’s policy not to accept these plans. You are not required to do so. If you did not know that the patient had this coverage and you treated the patient and then found out that your bill for regular Medicare was not paid because the patient was covered by a Medicare Advantage plan, you can balance-bill the patient.
It is recommended that you send all your active Medicare patients some sort of letter notifying them that your office does not see patients who have Medicare Advantage coverage. You should make some provisions for patients who are under active therapy, allowing them time to find a new provider. In the letter, you should make it obvious that if they see you with this type of coverage, they may not receive the full coverage that they would receive if they were seeing a provider in the network.
What It Means to Be a “Deemed” Provider. Sounds easy enough, right? Well, it’s not. There is something in the CMS provisions for these plans that even healthcare attorneys are struggling with. It is the concept of something called a “deemed provider.” A physician can be “deemed” to have a contract with a carrier (even though the physician has no contract with the carrier to service Medicare Advantage plan patients) and therefore is required to accept the payment provided under the carrier’s Medicare Advantage product.
How can this be? A physician can be “deemed” to be a Medicare Advantage provider if, before providing the patient with services, he/she was:
1. informed of the patient’s enrollment with the Medicare Advantage plan, for example, via presentation of an enrollment card.
2. was informed (or given a “reasonable opportunity”) to obtain information regarding the terms and conditions of payment under the Medicare Advantage product.
In plain English, this means that if it is your office’s policy to verify the type of Medicare coverage Medicare patients have and they tell you that they are now covered by a Medicare Advantage plan and present you with a card and then you provide treatment, you are considered to be a deemed provider. You have no choice but to accept the Medicare Advantage plan’s payment and/or billing rules.
You must determine if they have changed coverage up front before they are seen and receive treatment. You could face state laws that address abandoning patients or could see your practice featured on the 11 p.m. nightly news if you just send off and refuse to see patients who appear in your office for treatment.
Unless you are providing emergency care to a patient (which is not usually often) or are totally unaware that the patient has this type of Medicare Advantage plan, you are considered “deemed.”
You can read more about Medicare Advantage plans and rules by logging onto: www.cms.hhs.gov/PrivateFeeforServicePlans.
Mohs and the Multiple Surgery Reduction Rule
Effective January 1, 2007, Medicare decided to subject Mohs CPT codes 17311 and 17313 to the multiple surgery reduction rule. (CPT codes 17312, 17314 and 17315 are add-on codes so they are never reduced.)
Mohs surgeons bolted like wild horses being ridden for the first time. Providers started limiting the number of cases they would treat in 1 day, delayed repairs, and outsourced repairs to other members of their group. It went on and on until CMS realized that not only was patient access being compromised, it would ultimately cost CMS more than if they had left the exemption in place.
Effective April 2, 2007, Medicare rescinded the rule and reinstated the Mohs multiple surgery reduction rule retroactive to January 1, 2007. However, it was decided not to automatically repay providers who were shortchanged when not only the Mohs stages were reduced in many cases, but also when repairs done after Mohs were also reduced. It is up to the provider to refile for incorrect payments between January 1 and April 2, 2007.
We suggest that you check your local carrier Web sites for updates on how to accomplish this. The American Academy of Dermatology has also released a memo with some helpful information. (Note: The Inga Ellzey newsletter will have a lengthy article on how to recoup this money in the May/June issue.)
Important to Remember: Providers should know that the ruling affects Medicare carriers only. Commercial, non-Medicare plans do not have to follow the CMS exemption for Mohs codes. Many have and do subject CPT codes 17311 and 17313 as well as repairs to the multiple surgery reduction rule. They are under no obligation to follow Medicare’s rulings and/or policy on the Mohs exemption.
Note: Providers should also be aware of the changes in definition for the codes. The Mohs codes are now defined by anatomical site. The definition change does not, however, change the National Mohs Policy guidelines, which require medical necessity criteria to be met before Mohs will be covered. The policy has not been changed and Mohs surgeons should follow the guidelines as they have in years past.
Destruction Changes (17000 to 17004, 17110 and 17111)
Effective January 1, 2007, CPT changed its definitions of the destruction codes impacting how dermatologists bill for benign lesions, such as warts and seborrheic keratoses. In the past, prior to January 1, 2007, dermatologists were paid per lesion for most benign lesions.
Starting in January 1, 2007, all benign lesions are now billed using CPT codes 17110 and 17111, which are lump codes. This means you get paid a lump fee, not per lesion.
The changes are summarized briefly like this:
1. CPT codes 17000, 17003 and 17004 can now be used only with an ICD-9 diagnosis code of 702.0. No other type of diagnosis will be accepted for these three codes. These codes are only to be used to bill for actinic keratoses. These codes are still billed per lesion up to 14 and then a flat fee (lump payment) if more than 14 lesions are treated on the same date of service.
2. CPT code 17110 is used when 14 or fewer lesions are treated by destruction.
3. CPT code 17111 is used when 15 or more lesions are treated by destruction.
4. Neither 17110 nor 17111 are billed in units. They are billed as one unit no matter how many lesions are actually treated.
5. The benign lesion codes 17110 and 17111 are used to bill many types of benign lesions such as warts, seborrheic keratoses, molluscum contagiosum lesions, and milia. Skin tags should not be billed using these codes. Skin tags must be billed using CPT codes 11200 and 11201.
Many other types of benign lesions exist. Providers must be aware that all Medicare and many commercial carriers have benign skin lesion removal policies that govern under which circumstances the treatment and/or destruction of benign lesions are medically necessary. It is of utmost importance that providers are aware of these policies and that their documentation supports medical necessity if the treatment of these benign lesions is to be billed to an insurance carrier. If the lesions are asymptomatic or fail to meet the carrier guidelines, then the patient should sign a waiver, and the patient should be billed for the service.
One major misconception that many dermatologists share is that the term “irritated” is a medical necessity criterion for the treatment of removal of benign lesions. This is not true. Very few, if any, carrier policies contain the symptom “irritated” as proving medical necessity. Most common are symptoms such as inflamed, bleeding, painful, edematous or erythematous, or lesions that are suspicious of malignancy. The wording changes from carrier to carrier, so intimate knowledge of your carriers’ local policies is vital.
I hope that this summary of some of the challenging issues in 2007 is helpful and will guide practices to a new level of awareness. After all, knowledge is power
In most states, the harsh weather of winter is subsiding, spring is in the air, flowers are blooming everywhere you look, migratory birds are returning to their homes to mate and nest, trees are bursting with new growth, buds and leaves, and misty rains are providing nourishment for all.
But the harsh storms and bad weather still loom as dermatologists in private practice battle with inconsistent carrier policies, unmanageable software changes and deadlines, reductions in reimbursement, and exhausting claims processing accompanying Medicare patients who are converting to Medicare Advantage plans.
The combination of all the forces impacting dermatology practices all at once is dynamic with many struggling to keep up and stay current while managing a changing labor force that’s often ill-equipped for such sophisticated and problematic issues. For most, it’s all quite overwhelming.
But, what you don’t know can hurt you, so here I’ll briefly review many of the issues, problems and concerns facing your practice in this time of inclement weather.
NPI (National Provider Identifier) Numbers
May 23, 2007, was supposed to have been the drop-dead deadline for all providers to have obtained and started using this new identification number, which is necessary to file claims to third-party carriers.
The NPI number will replace all other numbers that providers have been using in the past to bill carriers. The numbers it will replace include PINs, UPINs, Medicaid and Medicare numbers, just to name a few. This one unique number will be used by all providers and accepted by all carriers, with no exceptions. This number will follow each provider throughout his or her years in practice regardless of the state in which state he or she practices or the insurance carrier(s) with which he or she contracts.
Confusion Over Who Needs a Number. Although it really wasn’t — or isn’t — difficult to obtain the NPI number, the confusion was really more about who needed one. Most of us understood that if you were a solo practitioner, you obtained your own NPI number. They called this a Type I NPI number. If you practiced in a group, then the provider obtained his/her own NPI while the group obtained another. This group NPI number was categorized as a Type II NPI number.
But then everything hit the fan, and the questions began. What really defined a group? What if two doctors were in a group but didn’t have a Tax Identification Number? What if you were in solo practice, but were incorporated? It got more and more complicated.
Then, to make matters worse, CMS had not yet made any provisions for formulating a National Directory (like the UPIN Web site where providers could look up the numbers of referring providers when they needed a PIN number on a claim). Because no such national site was in the works, providers began scrambling in an effort to get the numbers of colleagues (who may have been hesitant to share this number because of the possibility of identity theft).
Extending the Deadline. So, close to when the deadline was to take effect, CMS decided to extend the deadline for 1 year, to May 23, 2008. The CMS did not maintain that providers shouldn’t continue moving forward with obtaining and using the new NPI numbers, the agency just stated that carriers cannot deny claims if the old PINs and UPINs (e.g., legacy numbers) are used instead of the NPIs. Big deal! One of the main problems with the entire matter is that many of the carriers aren’t ready to accept the new NPIs anyway.
What is the bottom line in all of this? It’s pretty much a mess, and everyone will just have to monitor carrier Web sites for updates and guidance.
CMS-1500 Forms
April 1, 2007, was the drop-dead deadline date when providers had to start billing claims using the newly revised, reformatted CMS-1500 form. The claim was basically revised to accommodate the new NPI number as well as to allow claims to differentiate between the ordering and the supervising providers in group practices where services are billed “incident to.”
Incorrect Forms Processed. CMS, however, determined that vendors who sell the CMS-1500 forms had received an incorrectly formatted version of the revised form from the authorized forms designer. This resulted in the sale of printer forms and negatives that do not comply with the form specifications.
As a result, the claims cannot be processed because of the formatting inconsistencies. Due to this huge oversight, CMS decided to extend the acceptance period of the CMS-1500 version beyond the original April 1, 2007, deadline while this situation is being resolved. A new date had not been announced as of press time.
Identifying Incorrect Forms. The best way to identify the incorrect forms is by looking at the upper right hand corner of the form. If the tip of the red arrow above the vertically stacked word “Carrier” is touching — or close to touching — the top edge of the form, the form is not printed to specifications. There should be approximately one-quarter inch “between the tip of the arrow and the top edge of the paper on properly formatted forms.”
Are they kidding? I can’t see if I am pushing the correct button on my remote. Now I have to measure little red arrows? I wonder if CMS is providing practices with rulers.
Medicare Advantage Plans
Medicare Advantage is a term referring to a managed care Medicare product that is offered by various carriers pursuant to a contract with CMS. It is distinct from Medicare’s “traditional” or “original” fee-for-service plans.
Do not confuse what I am about to discuss with the Medicare Part D drug demonstration program, which is a totally separate Pandora’s Box. Medicare beneficiaries themselves are totally confused when you ask them if they have changed their Medicare coverage. Many elderly confuse their Medicare Advantage plans with their newly purchased drug coverage.
First, understand that the terms “par” and “non-par” status only have meaning with respect to the “traditional” or “original” fee-for-service Medicare Part B. In Medicare Advantage plans, all physicians are effectively on a “non-par” status unless they agree, via a provider agreement or other contract with the carrier, that they will accept the carrier’s Medicare Advantage product.
Declining Medicare Advantage Plans. Just because you have a contract with United Healthcare doesn’t necessarily mean that you are obligated to accept the Advantage plans — unless there is something specific in your contract that addresses this issue. Have your contract attorney carefully review your contract, as you may be under the false impression that you are required to accept the Medicare Advantage product just because you have signed a contract with the carrier.
So let us assume that you do not have a contract with the Medicare Advantage plan and it is your office’s policy not to accept these plans. You are not required to do so. If you did not know that the patient had this coverage and you treated the patient and then found out that your bill for regular Medicare was not paid because the patient was covered by a Medicare Advantage plan, you can balance-bill the patient.
It is recommended that you send all your active Medicare patients some sort of letter notifying them that your office does not see patients who have Medicare Advantage coverage. You should make some provisions for patients who are under active therapy, allowing them time to find a new provider. In the letter, you should make it obvious that if they see you with this type of coverage, they may not receive the full coverage that they would receive if they were seeing a provider in the network.
What It Means to Be a “Deemed” Provider. Sounds easy enough, right? Well, it’s not. There is something in the CMS provisions for these plans that even healthcare attorneys are struggling with. It is the concept of something called a “deemed provider.” A physician can be “deemed” to have a contract with a carrier (even though the physician has no contract with the carrier to service Medicare Advantage plan patients) and therefore is required to accept the payment provided under the carrier’s Medicare Advantage product.
How can this be? A physician can be “deemed” to be a Medicare Advantage provider if, before providing the patient with services, he/she was:
1. informed of the patient’s enrollment with the Medicare Advantage plan, for example, via presentation of an enrollment card.
2. was informed (or given a “reasonable opportunity”) to obtain information regarding the terms and conditions of payment under the Medicare Advantage product.
In plain English, this means that if it is your office’s policy to verify the type of Medicare coverage Medicare patients have and they tell you that they are now covered by a Medicare Advantage plan and present you with a card and then you provide treatment, you are considered to be a deemed provider. You have no choice but to accept the Medicare Advantage plan’s payment and/or billing rules.
You must determine if they have changed coverage up front before they are seen and receive treatment. You could face state laws that address abandoning patients or could see your practice featured on the 11 p.m. nightly news if you just send off and refuse to see patients who appear in your office for treatment.
Unless you are providing emergency care to a patient (which is not usually often) or are totally unaware that the patient has this type of Medicare Advantage plan, you are considered “deemed.”
You can read more about Medicare Advantage plans and rules by logging onto: www.cms.hhs.gov/PrivateFeeforServicePlans.
Mohs and the Multiple Surgery Reduction Rule
Effective January 1, 2007, Medicare decided to subject Mohs CPT codes 17311 and 17313 to the multiple surgery reduction rule. (CPT codes 17312, 17314 and 17315 are add-on codes so they are never reduced.)
Mohs surgeons bolted like wild horses being ridden for the first time. Providers started limiting the number of cases they would treat in 1 day, delayed repairs, and outsourced repairs to other members of their group. It went on and on until CMS realized that not only was patient access being compromised, it would ultimately cost CMS more than if they had left the exemption in place.
Effective April 2, 2007, Medicare rescinded the rule and reinstated the Mohs multiple surgery reduction rule retroactive to January 1, 2007. However, it was decided not to automatically repay providers who were shortchanged when not only the Mohs stages were reduced in many cases, but also when repairs done after Mohs were also reduced. It is up to the provider to refile for incorrect payments between January 1 and April 2, 2007.
We suggest that you check your local carrier Web sites for updates on how to accomplish this. The American Academy of Dermatology has also released a memo with some helpful information. (Note: The Inga Ellzey newsletter will have a lengthy article on how to recoup this money in the May/June issue.)
Important to Remember: Providers should know that the ruling affects Medicare carriers only. Commercial, non-Medicare plans do not have to follow the CMS exemption for Mohs codes. Many have and do subject CPT codes 17311 and 17313 as well as repairs to the multiple surgery reduction rule. They are under no obligation to follow Medicare’s rulings and/or policy on the Mohs exemption.
Note: Providers should also be aware of the changes in definition for the codes. The Mohs codes are now defined by anatomical site. The definition change does not, however, change the National Mohs Policy guidelines, which require medical necessity criteria to be met before Mohs will be covered. The policy has not been changed and Mohs surgeons should follow the guidelines as they have in years past.
Destruction Changes (17000 to 17004, 17110 and 17111)
Effective January 1, 2007, CPT changed its definitions of the destruction codes impacting how dermatologists bill for benign lesions, such as warts and seborrheic keratoses. In the past, prior to January 1, 2007, dermatologists were paid per lesion for most benign lesions.
Starting in January 1, 2007, all benign lesions are now billed using CPT codes 17110 and 17111, which are lump codes. This means you get paid a lump fee, not per lesion.
The changes are summarized briefly like this:
1. CPT codes 17000, 17003 and 17004 can now be used only with an ICD-9 diagnosis code of 702.0. No other type of diagnosis will be accepted for these three codes. These codes are only to be used to bill for actinic keratoses. These codes are still billed per lesion up to 14 and then a flat fee (lump payment) if more than 14 lesions are treated on the same date of service.
2. CPT code 17110 is used when 14 or fewer lesions are treated by destruction.
3. CPT code 17111 is used when 15 or more lesions are treated by destruction.
4. Neither 17110 nor 17111 are billed in units. They are billed as one unit no matter how many lesions are actually treated.
5. The benign lesion codes 17110 and 17111 are used to bill many types of benign lesions such as warts, seborrheic keratoses, molluscum contagiosum lesions, and milia. Skin tags should not be billed using these codes. Skin tags must be billed using CPT codes 11200 and 11201.
Many other types of benign lesions exist. Providers must be aware that all Medicare and many commercial carriers have benign skin lesion removal policies that govern under which circumstances the treatment and/or destruction of benign lesions are medically necessary. It is of utmost importance that providers are aware of these policies and that their documentation supports medical necessity if the treatment of these benign lesions is to be billed to an insurance carrier. If the lesions are asymptomatic or fail to meet the carrier guidelines, then the patient should sign a waiver, and the patient should be billed for the service.
One major misconception that many dermatologists share is that the term “irritated” is a medical necessity criterion for the treatment of removal of benign lesions. This is not true. Very few, if any, carrier policies contain the symptom “irritated” as proving medical necessity. Most common are symptoms such as inflamed, bleeding, painful, edematous or erythematous, or lesions that are suspicious of malignancy. The wording changes from carrier to carrier, so intimate knowledge of your carriers’ local policies is vital.
I hope that this summary of some of the challenging issues in 2007 is helpful and will guide practices to a new level of awareness. After all, knowledge is power
In most states, the harsh weather of winter is subsiding, spring is in the air, flowers are blooming everywhere you look, migratory birds are returning to their homes to mate and nest, trees are bursting with new growth, buds and leaves, and misty rains are providing nourishment for all.
But the harsh storms and bad weather still loom as dermatologists in private practice battle with inconsistent carrier policies, unmanageable software changes and deadlines, reductions in reimbursement, and exhausting claims processing accompanying Medicare patients who are converting to Medicare Advantage plans.
The combination of all the forces impacting dermatology practices all at once is dynamic with many struggling to keep up and stay current while managing a changing labor force that’s often ill-equipped for such sophisticated and problematic issues. For most, it’s all quite overwhelming.
But, what you don’t know can hurt you, so here I’ll briefly review many of the issues, problems and concerns facing your practice in this time of inclement weather.
NPI (National Provider Identifier) Numbers
May 23, 2007, was supposed to have been the drop-dead deadline for all providers to have obtained and started using this new identification number, which is necessary to file claims to third-party carriers.
The NPI number will replace all other numbers that providers have been using in the past to bill carriers. The numbers it will replace include PINs, UPINs, Medicaid and Medicare numbers, just to name a few. This one unique number will be used by all providers and accepted by all carriers, with no exceptions. This number will follow each provider throughout his or her years in practice regardless of the state in which state he or she practices or the insurance carrier(s) with which he or she contracts.
Confusion Over Who Needs a Number. Although it really wasn’t — or isn’t — difficult to obtain the NPI number, the confusion was really more about who needed one. Most of us understood that if you were a solo practitioner, you obtained your own NPI number. They called this a Type I NPI number. If you practiced in a group, then the provider obtained his/her own NPI while the group obtained another. This group NPI number was categorized as a Type II NPI number.
But then everything hit the fan, and the questions began. What really defined a group? What if two doctors were in a group but didn’t have a Tax Identification Number? What if you were in solo practice, but were incorporated? It got more and more complicated.
Then, to make matters worse, CMS had not yet made any provisions for formulating a National Directory (like the UPIN Web site where providers could look up the numbers of referring providers when they needed a PIN number on a claim). Because no such national site was in the works, providers began scrambling in an effort to get the numbers of colleagues (who may have been hesitant to share this number because of the possibility of identity theft).
Extending the Deadline. So, close to when the deadline was to take effect, CMS decided to extend the deadline for 1 year, to May 23, 2008. The CMS did not maintain that providers shouldn’t continue moving forward with obtaining and using the new NPI numbers, the agency just stated that carriers cannot deny claims if the old PINs and UPINs (e.g., legacy numbers) are used instead of the NPIs. Big deal! One of the main problems with the entire matter is that many of the carriers aren’t ready to accept the new NPIs anyway.
What is the bottom line in all of this? It’s pretty much a mess, and everyone will just have to monitor carrier Web sites for updates and guidance.
CMS-1500 Forms
April 1, 2007, was the drop-dead deadline date when providers had to start billing claims using the newly revised, reformatted CMS-1500 form. The claim was basically revised to accommodate the new NPI number as well as to allow claims to differentiate between the ordering and the supervising providers in group practices where services are billed “incident to.”
Incorrect Forms Processed. CMS, however, determined that vendors who sell the CMS-1500 forms had received an incorrectly formatted version of the revised form from the authorized forms designer. This resulted in the sale of printer forms and negatives that do not comply with the form specifications.
As a result, the claims cannot be processed because of the formatting inconsistencies. Due to this huge oversight, CMS decided to extend the acceptance period of the CMS-1500 version beyond the original April 1, 2007, deadline while this situation is being resolved. A new date had not been announced as of press time.
Identifying Incorrect Forms. The best way to identify the incorrect forms is by looking at the upper right hand corner of the form. If the tip of the red arrow above the vertically stacked word “Carrier” is touching — or close to touching — the top edge of the form, the form is not printed to specifications. There should be approximately one-quarter inch “between the tip of the arrow and the top edge of the paper on properly formatted forms.”
Are they kidding? I can’t see if I am pushing the correct button on my remote. Now I have to measure little red arrows? I wonder if CMS is providing practices with rulers.
Medicare Advantage Plans
Medicare Advantage is a term referring to a managed care Medicare product that is offered by various carriers pursuant to a contract with CMS. It is distinct from Medicare’s “traditional” or “original” fee-for-service plans.
Do not confuse what I am about to discuss with the Medicare Part D drug demonstration program, which is a totally separate Pandora’s Box. Medicare beneficiaries themselves are totally confused when you ask them if they have changed their Medicare coverage. Many elderly confuse their Medicare Advantage plans with their newly purchased drug coverage.
First, understand that the terms “par” and “non-par” status only have meaning with respect to the “traditional” or “original” fee-for-service Medicare Part B. In Medicare Advantage plans, all physicians are effectively on a “non-par” status unless they agree, via a provider agreement or other contract with the carrier, that they will accept the carrier’s Medicare Advantage product.
Declining Medicare Advantage Plans. Just because you have a contract with United Healthcare doesn’t necessarily mean that you are obligated to accept the Advantage plans — unless there is something specific in your contract that addresses this issue. Have your contract attorney carefully review your contract, as you may be under the false impression that you are required to accept the Medicare Advantage product just because you have signed a contract with the carrier.
So let us assume that you do not have a contract with the Medicare Advantage plan and it is your office’s policy not to accept these plans. You are not required to do so. If you did not know that the patient had this coverage and you treated the patient and then found out that your bill for regular Medicare was not paid because the patient was covered by a Medicare Advantage plan, you can balance-bill the patient.
It is recommended that you send all your active Medicare patients some sort of letter notifying them that your office does not see patients who have Medicare Advantage coverage. You should make some provisions for patients who are under active therapy, allowing them time to find a new provider. In the letter, you should make it obvious that if they see you with this type of coverage, they may not receive the full coverage that they would receive if they were seeing a provider in the network.
What It Means to Be a “Deemed” Provider. Sounds easy enough, right? Well, it’s not. There is something in the CMS provisions for these plans that even healthcare attorneys are struggling with. It is the concept of something called a “deemed provider.” A physician can be “deemed” to have a contract with a carrier (even though the physician has no contract with the carrier to service Medicare Advantage plan patients) and therefore is required to accept the payment provided under the carrier’s Medicare Advantage product.
How can this be? A physician can be “deemed” to be a Medicare Advantage provider if, before providing the patient with services, he/she was:
1. informed of the patient’s enrollment with the Medicare Advantage plan, for example, via presentation of an enrollment card.
2. was informed (or given a “reasonable opportunity”) to obtain information regarding the terms and conditions of payment under the Medicare Advantage product.
In plain English, this means that if it is your office’s policy to verify the type of Medicare coverage Medicare patients have and they tell you that they are now covered by a Medicare Advantage plan and present you with a card and then you provide treatment, you are considered to be a deemed provider. You have no choice but to accept the Medicare Advantage plan’s payment and/or billing rules.
You must determine if they have changed coverage up front before they are seen and receive treatment. You could face state laws that address abandoning patients or could see your practice featured on the 11 p.m. nightly news if you just send off and refuse to see patients who appear in your office for treatment.
Unless you are providing emergency care to a patient (which is not usually often) or are totally unaware that the patient has this type of Medicare Advantage plan, you are considered “deemed.”
You can read more about Medicare Advantage plans and rules by logging onto: www.cms.hhs.gov/PrivateFeeforServicePlans.
Mohs and the Multiple Surgery Reduction Rule
Effective January 1, 2007, Medicare decided to subject Mohs CPT codes 17311 and 17313 to the multiple surgery reduction rule. (CPT codes 17312, 17314 and 17315 are add-on codes so they are never reduced.)
Mohs surgeons bolted like wild horses being ridden for the first time. Providers started limiting the number of cases they would treat in 1 day, delayed repairs, and outsourced repairs to other members of their group. It went on and on until CMS realized that not only was patient access being compromised, it would ultimately cost CMS more than if they had left the exemption in place.
Effective April 2, 2007, Medicare rescinded the rule and reinstated the Mohs multiple surgery reduction rule retroactive to January 1, 2007. However, it was decided not to automatically repay providers who were shortchanged when not only the Mohs stages were reduced in many cases, but also when repairs done after Mohs were also reduced. It is up to the provider to refile for incorrect payments between January 1 and April 2, 2007.
We suggest that you check your local carrier Web sites for updates on how to accomplish this. The American Academy of Dermatology has also released a memo with some helpful information. (Note: The Inga Ellzey newsletter will have a lengthy article on how to recoup this money in the May/June issue.)
Important to Remember: Providers should know that the ruling affects Medicare carriers only. Commercial, non-Medicare plans do not have to follow the CMS exemption for Mohs codes. Many have and do subject CPT codes 17311 and 17313 as well as repairs to the multiple surgery reduction rule. They are under no obligation to follow Medicare’s rulings and/or policy on the Mohs exemption.
Note: Providers should also be aware of the changes in definition for the codes. The Mohs codes are now defined by anatomical site. The definition change does not, however, change the National Mohs Policy guidelines, which require medical necessity criteria to be met before Mohs will be covered. The policy has not been changed and Mohs surgeons should follow the guidelines as they have in years past.
Destruction Changes (17000 to 17004, 17110 and 17111)
Effective January 1, 2007, CPT changed its definitions of the destruction codes impacting how dermatologists bill for benign lesions, such as warts and seborrheic keratoses. In the past, prior to January 1, 2007, dermatologists were paid per lesion for most benign lesions.
Starting in January 1, 2007, all benign lesions are now billed using CPT codes 17110 and 17111, which are lump codes. This means you get paid a lump fee, not per lesion.
The changes are summarized briefly like this:
1. CPT codes 17000, 17003 and 17004 can now be used only with an ICD-9 diagnosis code of 702.0. No other type of diagnosis will be accepted for these three codes. These codes are only to be used to bill for actinic keratoses. These codes are still billed per lesion up to 14 and then a flat fee (lump payment) if more than 14 lesions are treated on the same date of service.
2. CPT code 17110 is used when 14 or fewer lesions are treated by destruction.
3. CPT code 17111 is used when 15 or more lesions are treated by destruction.
4. Neither 17110 nor 17111 are billed in units. They are billed as one unit no matter how many lesions are actually treated.
5. The benign lesion codes 17110 and 17111 are used to bill many types of benign lesions such as warts, seborrheic keratoses, molluscum contagiosum lesions, and milia. Skin tags should not be billed using these codes. Skin tags must be billed using CPT codes 11200 and 11201.
Many other types of benign lesions exist. Providers must be aware that all Medicare and many commercial carriers have benign skin lesion removal policies that govern under which circumstances the treatment and/or destruction of benign lesions are medically necessary. It is of utmost importance that providers are aware of these policies and that their documentation supports medical necessity if the treatment of these benign lesions is to be billed to an insurance carrier. If the lesions are asymptomatic or fail to meet the carrier guidelines, then the patient should sign a waiver, and the patient should be billed for the service.
One major misconception that many dermatologists share is that the term “irritated” is a medical necessity criterion for the treatment of removal of benign lesions. This is not true. Very few, if any, carrier policies contain the symptom “irritated” as proving medical necessity. Most common are symptoms such as inflamed, bleeding, painful, edematous or erythematous, or lesions that are suspicious of malignancy. The wording changes from carrier to carrier, so intimate knowledge of your carriers’ local policies is vital.
I hope that this summary of some of the challenging issues in 2007 is helpful and will guide practices to a new level of awareness. After all, knowledge is power
