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Congressional Deadlock

Help with Physician Prices, Fee Schedules, and Managed Care Contracts

Help with HIPAA 5010

Revalidate Your Medicare Enrollment

HIPAA Privacy & Security Audits Coming Soon

Help to Challenge Unfair Rankings

DPS Backlog of Controlled Substance Certificate Renewals

Medicaid HMO Expansion Begins Sept. 1

New Member Benefit for PQRS

Unraveling Modifier 25

Buyer Beware in EHR Vendor Contracting

Medicare RAC Audits Now in Texas

Atlantic Health Partners Lower Vaccine Costs

New Texas Medicaid ID Card

TMB to Resume Death Registration Fines June 1

Bruce Malone, MD Installed as TMA President

E-Prescribe Now to Avoid 2012 Penalty

HIPAA Version 5010 and ICD-10 Deadlines

TCMS DocBookMD app is free!

EHR Incentive Registration Begins

Medicare Bonuses for Primary Care

Congressional Deadlock

A congressional deadlock over how long to extend the payroll tax cut means the government likely will cut physicians' Medicare payments 27.4% on Jan 1. Democrats back a temporary payroll tax extension to give Congress time to reach a long-term deal, while Republicans want to extend the cut for a year. For more, visit http://www.texmed.org/Template.aspx?id=23262.

How will this affect your practice?

Physician Prices, Fee Schedules, and Managed Care Contract Offer and Acceptance

Many health plans send out new insurance contracts/fee schedules at the end of the year. Get help with this new TMA Whitepaper. For other whitepapers, contact the TMA Knowledge Center at 512-370-1550.

Help With HIPAA 5010 Looming Deadline

That Doomsday headline will come true if you do not upgrade your electronic billing systems to comply with the HIPAA 5010 electronic claims standards. If you don’t do so by Jan. 1, Medicare, Medicaid, and the commercial insurance carriers will not pay your claims.

Visit the following sites for transition assistance: www.texmed.org/5010; www.texmed.org/podcast; www.ama-assn.org/resources/doc/washington/5010-toolkit.pdf; and http://www.cms.gov/Versions5010andD0/40_Educational_Resources.asp#TopOfPage.

Revalidate Your Medicare Enrollment

Physicians who signed up for the Medicare program before March 25, 2011, must revalidate their enrollment with TrailBlazer Health Enterprises over the next year-and-a-half. The health system reform bill Congress passed last year requires it to reduce Medicare fraud, waste, and abuse. Physicians who enrolled on or after March 25, 2011, do not need to revalidate.

TrailBlazer will send notices to physicians between now and March 2013. Begin the revalidation process as soon as you get the notice. You have 60 days to complete the enrollment forms or Medicare may deactivate your billing privileges. Do not submit a revalidation application unless you've received a revalidation request letter from TrailBlazer. The easiest and quickest way to revalidate your enrollment information is by using the Provider Enrollment, Chain, and Ownership System  (PECOS). After updating PECOS, be sure to sign the certification statement and mail it to TrailBlazer.

The Centers for Medicare & Medicaid Services (CMS) began using new screening criteria in the Medicare provider/supplier enrollment process on March 1. CMS places new and revalidating providers and suppliers in one of three screening categories – limited, moderate, or high. CMS says each category represents the level of risk to the Medicare program for the particular category of provider/supplier, and the agency determines the degree of screening that TrailBlazer and other Medicare administrative contractors processing the enrollment applications will perform. Physicians are in the "limited" risk category.

The Texas Medical Association's Payment Advocacy staff reminds physicians that they should keep their Medicare enrollment information up to date through PECOS. TMA will ask CMS officials for more information on the revalidation program when TMA staff meets with them in the fall. Action will publish more information on the process as soon as it is available.

For more information about provider revalidation, review the Medicare Learning Network's Special Edition Article #SE1126, titled "Further Details on the Revalidation of Provider Enrollment Information."

HIPAA Privacy and Security Audits Coming Soon

A whole new round of audits — for compliance with HIPAA data security and privacy requirements — are set to begin in late 2011 or early 2012. 

The Department of Health and Human Services (HHS) has contracted with Booz Allen Hamilton and KPMG to audit physician practices and other entities under the auspices of the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act.

The audits will consist of a site visit that includes interviews with key practice staff, an inspection of office set-up and operations regarding privacy and security, and an assessment of your compliance of regulations and your own policies. Reports will include recommendations for correcting compliance problems with an action plan. Some kind of enforcement action against practice violations may occur.

Here are some steps you can take towards compliance:

• Adopt comprehensive privacy policies and procedures that are up to date and specific to your practice.
• Carefully train everyone on your staff, especially new hires, according to your policies and procedures.
• Perform a risk analysis on your practice’s data security, and set up reasonable safeguards as necessary.
• Develop a risk management plan to ensure ongoing security.
• When staff violate your practice’s policies and procedures, take appropriate action, and document it.  

TMA can help. Here’s how:

• TMA’s 2011 edition of TMA’s Policies & Procedures: A Guide for Medical Practices includes a comprehensive, customizable HIPAA and HITECH privacy and security section.
• TMA Practice Consulting offers on-site policies and procedures, and HIPAA training for your practice. For information, call (800) 523-8776.
• TMA’s one-hour recorded webinar, HIPAA/HITECH Compliance, explains what the HIPAA privacy and security rules mean to your practice and how to become compliant.
• The TMA website’s Hot Topics Bibliography on HIPAA and HITECH offers a variety of useful links, including FAQs, guidelines, and informational articles.

Help to Challenge Unfair Rankings

The Texas Medical Association has developed a 2 page guide to help physicians appeal a health plan ranking or tiering based off of HB 1888 which passed in the 2009 Texas Legislative Session. Physicians should use this information in developing an appeal to a health plan if they disagree with a ranking or tiering status.

Click here for 2 page guide.

For more information, visit www.texmed.org/practicehelp.

DPS Tries to Catch Up on Controlled Substance Certificate Renewals

The Texas Department of Public Safety (DPS) is working to eliminate a backlog of physicians' applications to renew their Controlled Substance Certificates. Based on information received by the Texas Medical Association staff, there are at least 3,000 applications for renewal by the end of July and another 4,500 for August.

After inquiries by TMA to DPS and Gov. Rick Perry's office, DPS officials said the Controlled Substance Division staff worked last weekend and at night this week to process the backlog of applications, caused by the agency's new computer system not working as fast as expected. This will continue until the application processing is up to date.

You can check the status of your application online at http://www.txdps.state.tx.us/csr/index.aspx. Enter your DPS number. This should bring up your record. If the expiration date is in 2012, DPS has renewed your certificate. DPS updates the database nightly.

DPS will mail a renewal confirmation, but TMA suggests you print a copy of the registration page showing the new 2012 expiration date to prove you have a current DPS registration number. For more information from TMA, visit

http://www.texmed.org/Template?.aspx?id=22105.

If you need to fax a renewal form application, fax it to (512) 424-5373. You can email questions to DPS by logging on to https://www.txdps.state.tx.us/RegulatoryServices/prescription_program/precontact.htm.

Medicaid HMO Expansion Begins Sept. 1

On Sept. 1, the Texas Health and Human Services Commission (HHSC) will begin Phase I of its Medicaid HMO expansion, converting the Medicaid Primary Care Case Management model to the Medicaid HMO model in the 28 counties contiguous to the current Medicaid HMO service delivery areas of Bexar, El Paso, Harris, Lubbock, Nueces, and Travis counties. As part of the conversion, the state also will create a new service delivery area – Jefferson -- consisting of 11 counties in Southeast Texas. 

A list of counties included in Phase I and health plans providing coverage in those counties is posted online [PDF]. 

HHSC proposed the Medicaid HMO expansion last summer to reduce Medicaid costs. The Texas Legislature recently approved the change as part of a multipronged Medicaid cost containment initiative. Officials expect Phase I to save about $35 million, and Phase II, which will convert all remaining Texas counties to the HMO model in March 2012, to save an additional $385 million.

Medicaid-enrolled children, pregnant women, and low-income parents living in one of the 28 contiguous counties must select a STAR HMO, while adult Medicaid enrollees with disabilities who reside in the community must select a STAR+PLUS HMO. STAR+PLUS plans also will provide long-term care services for patients dually eligible for Medicaid and Medicare (Medicare will continue to cover acute care services). Children with disabilities receiving Supplemental Security Income (SSI) benefits may voluntarily enroll in STAR+PLUS. (STAR Health, which provides coverage for children in foster care, is not affected by the changes.) 

In June, the state mailed enrollment packets to Medicaid patients in the 28 counties. Patients must select a health plan and primary care physician by Aug. 12. Patients who do not select a plan will be assigned one by the state.

For more information about the contiguous county expansion, including sample enrollment packets sent to patients, visit the HHSC website.

Unraveling Modifier 25

When UnitedHealthcare (UHC) recently researched its appealed claims, it found that the absence of modifier 25 from the initial claim was frequently the reason the claim had been denied. And, Texas emerged as the No. 1 state in appealed claims due to the missing modifier 25.

TMA regularly receives calls, emails, and Hassle Factor Logs related to the proper usage of modifier 25. For that reason, TMA has teamed up with UHC and the American Medical Association to offer this free webinar on using modifier 25 correctly. The 38-minute, archived presentation applies to all payers, not just UHC. A second webinar on modifier 59 will follow. 

Here are a few reminders about using modifier 25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service):

• Use modifier 25 with E&M codes only.
• Modifier 25 is not restricted to a specific level of E&M service.
• Do not use modifier 25 to report an E&M service that results in a decision to perform a major (i.e., 90-day global period) surgery.
• You may use modifier 25 to report a problem-oriented E&M service you provide on the same day as a preventive-medicine E&M service.
• The E&M service may be prompted by the symptom or condition for which you performed the other service or procedure. Different diagnoses are not required for reporting the service or procedure and the E&M service on the same date.

If you need more in-depth training on modifier use after viewing the webinar, contact TMA Practice Consulting at (800) 523-8766 or practice.consulting@texmed.org. Having trouble appealing a claim dealing with modifier 25 — or any other reason? Report your problem to the TMA Hassle Factor Log, and TMA will help you resolve it.

Buyer Beware in EHR Vendor Contracting

Electronic health record (EHR) contracts are typically written in a manner favorable to the vendor. A solid contract is critical to a successful long-term relationship and helps ensure that your EHR lives up to its advertised potential.

To help physicians navigate the EHR contract, TMA has developed eight key considerations in EHR Buyer Beware: Issues to Consider When Contracting with EHR Vendors [PDF]. The white paper is not an exhaustive list of considerations. TMA advises you to have your area regional extension center (REC) or an attorney carefully review your final contract before signing.

Texas has seen a record number of EHR purchases in 2011. Incentives are available to eligible physicians who "meaningfully use" a certified EHR – up to $44,000 under Medicare or up to $63,750 under Medicaid.

Recognizing the challenges associated with implementing or upgrading EHRs, the federal government established RECs to give physicians access to technical consultants and on-site help. REC consultants can help you evaluate EHRs, negotiate a contract, and select an EHR system to fit your practice's needs and budget, all for only $300 per primary care physician. REC pricing for specialists varies. Contact your area REC for more information. Even if you already have an EHR system in place, you likely will face challenges in reaching "meaningful use." Visit TMA's REC Resource Center for more information.

If you have questions about the white paper, federal incentives, or REC services, contact the TMA Health Information Technology helpline at (800) 880-5720 or HIT@texmed.org. 

Medicare RAC Audits Now in Texas

Medicare Recovery Audit Contractor
Connolly Healthcare

TMA has received calls from physician offices that have received audit letters from Connolly Healthcare, the Medicare Recovery Audit Contractor (RAC) working in Texas. So, now that we know the auditor is active in Texas, what’s next? How can physicians avoid an audit?

Here are some pointers from TMA staff:

• All office staff who potentially open mail should be aware of the name “Connolly Healthcare” and be familiar with its logo.
• Designate someone on staff to be the contact person with Connolly. If you have multiple practice locations, you could have one person serve as contact across the board, or you could have separate contacts for each location. Notify the RAC about your designee(s) using Connolly’s Provider Contact Form.
• If your practice receives a request for medical records from Connolly, be sure the designated person sees the letter immediately, and takes action right away.
• Verify that the issue for which you are being audited is actually one the Centers for Medicare & Medicaid Services (CMS) has approved. Connolly must get all audit issues approved by CMS before it can audit for them.
• Make sure the number of records the RAC is requesting is within these CMS-specified limits:

-Example 1: Group ABC has 65 physicians who billed Medicare fee-for-service last year. The maximum additional documentation requests (ADRs) for the group is 50 every 45 days.  

Atlantic Health Partners
Lower Vaccine Costs

Lower your vaccine costs with Atlantic Health Partners! Atlantic, a physician buying group, helps TCMS physicians save money and advocates on your behalf with payers and manufacturers. Now is the best time to join the nation’s leading vaccine buying group, so you get the lowest prices before the back to school peak vaccine season!

Atlantic works with Sanofi Pasteur and Merck to provide TCMS members with the lowest vaccine prices and most favorable payment terms for all size practices.

And, Atlantic has obtained an even lower Tdap vaccine price for Sanofi’s Adacel. This is especially timely given the recent ACIP expanded indications for Tdap vaccine along with the pertussis outbreak in several states. 

Additional benefits offered by Atlantic:

Please contact Jeff Winokur or Cindy Berenson at 800-741-2044 or info@atlantichealthpartners.com for additional information and to join the nearly 10,000 physicians nationwide already benefiting from Atlantic’s savings and support. www.atlantichealthpartners.com

Monthly Prize Drawing – June Winners Announced

Each month, TCMS physician members and their office staff can register to win one of several prizes by visiting the TCMS website. Congratulations to the June winners! Sandra Esparza, MD of ABC Medical Center and Ginger Douglas of Austin Children’s Chest Associates each won a $50 gift certificate to restaurant.com. Yvonne Leza of Central Texas Colon & Rectal Surgeons won a Flip Video Camera.

Visit the TCMS website often and register for the monthly prize drawing. Browse the website for information about upcoming educational events, compliance regulations, practice management tips, community events, and much more. Check back frequently for new and updated information.

New Texas Medicaid ID Card

In June 2011, the Texas Health and Human Services Commission (HHSC) will begin issuing a new Medicaid ID card to Texas Medicaid clients. The new ID – Your Texas Benefits Medicaid Card – is a plastic, magnetic-striped card that will replace the current paper Medicaid ID (Form 3087).

For more information about the Your Texas Benefits Medicaid ID card and provider website, read the “Frequently Asked Questions: Providers.” Additional resources can be found at www.hhsc.state.tx.us/medicaid/index.html and www.tmhp.com.

TMB to Resume Death Registration Fines June 1

On June 1, the Texas Medical Board (TMB) will resume disciplining physicians who do not use the Texas Electronic Registrar (TER) Death Registration system to register patient deaths, TMB Executive Director Mari Robinson, JD, told the TMA Patient-Physician Advocacy Committee at TexMed 2011. The fine is $500.

Last November, TMB refunded money to more than 100 physicians who had already been fined and suspended pending cases because of physicians' complaints about the registration system. TMB said the delay in disciplining physicians would last until the 2011 session of the Texas Legislature ends this month.

If you haven't registered and aren't using the system, now is a good time to do so. Here's what TMB said in the January TMB Bulletin: "It's important to note that electronic death certification is here to stay. The health department adopted this system because it is faster for all parties involved, and it's less susceptible to fraud than paper."

Bruce Malone, MD

Installed as TMA President

Travis County Medical Society member, C. Bruce Malone, MD was installed as the 146th president of the Texas Medical Association on May 14. TMA is the largest state medical society in the nation. Adapting to health system reform will be an important focus during Dr. Malone’s one-year term as TMA president. He says, “If we lose the ability of the patient to interact with the doctor and to decide what’s best for that patient’s care one-on-one without interference by corporations or bureaucracy, we’ve lost the heart of American medicine.” Congratulations, Dr. Malone!

E-Prescribe Now to Avoid 2012 Penalty

To avoid penalties in 2012 (1 percent of Medicare Part B claims), TMA recommends all physicians report e-prescribing via claims on at least 10 unique Medicare encounters by June 30, 2011 and report at least 25 unique Medicare encounters during the full 2011 year to qualify for the 2011 incentive (1 percent of Medicare Part B claims).

The Centers for Medicare & Medicaid Services (CMS) has offered the e-prescribing incentive since 2009 to encourage the use of e-prescribing to improve the efficiency and safety of health care. E-prescribing is a way to prevent medication errors that arise due to difficulties in reading or understanding handwritten prescriptions.   

If you plan to apply for the Medicare EHR incentive in 2011, note that you can't receive the e-prescribing incentive in the same year. Physicians enrolled in the federal Medicare EHR incentive program can still be penalized in 2012 if they do not report 10 e-prescriptions via claims method using G-code G8553. Part of the “meaningful use” criteria set for the federal EHR incentives requires e-prescribing.

Physicians applying for the Medicaid EHR incentive are still eligible for e-prescribing incentive payments.  

What type of encounter will count as an event?  
A physician must generate at least one electronic prescription using a qualified system during a patient visit from a set of defined services. Multiple prescriptions to the same patient will constitute only one event. 

How do I report e-prescribing data?
To avoid the penalty in 2012, physicians must report by using G-code G8553 on claims. The incentive, however, gives physicians three options for reporting data.

Visit the "Getting Started" webpage on the CMS website for more information. CMS also maintains lists of qualified e-prescribing registries [PDF] and qualified EHR vendors [PDF]. 

Do you need technical consulting help? The Texas regional extension centers support primary care physicians with individualized on-site services, technical assistance, guidance, and ongoing support.  Visit  TMA's Texas REC Resource Center for more information.

HIPAA Version 5010 and ICD-10 Deadlines

Why You Want to Be on Board With Version 5010 by Jan. 1, 2012

ICD-10 will replace ICD-9 in 2013, and to use the new coding system in electronic transactions, you must convert to HIPAA Version 5010 software standards — or you won’t get paid. But that is not the only reason to upgrade to Version 5010.

You might think of Version 5010 not as the next step down a long, straight road under HIPAA but as the first step in a new direction into medicine’s future. Embracing the standard by fully integrating it into your work systems and workflow — rather than merely complying with it — will put your practice on the right track. Here’s why:

• Version 5010 corrects many of the flaws of the current 4010 version. Since Version 4010’s launch in 2003, software developers have tweaked and patched it to its limits. Version 5010 incorporates hundreds of changes the medical industry has asked for.
• You can begin to realize the administrative simplification and subsequent savings that HIPAA promised. For example, authorizations will be streamlined, saving time and hassle on the phone for you and your staff.
• Version 5010 is a vital component for true standardization and interoperability, smoothing the way for widespread use of electronic health records.
• It will facilitate reporting of clinical data for quality performance measures, which are poised to become a driving factor for payment of claims and performance bonuses.

By now you should be talking to your vendors and taking other steps for the conversion to Version 5010 — deadline is Jan. 1, 2012 — and to ICD-10. TMA can help you ease the way to ICD-10 adoption with boot camps and webinars that examine all angles of the task ahead. Register now.

Also, go to the TMA coding page to find more information, including links to free webinars from Blue Cross and Blue Shield of Texas, April 21-29, 2011.

TCMS DocBookMD
Free - courtesy of Texas Medical Liability Trust

TCMS members can now download – for free – the DocBookMD app to their iPhone, iTouch, and soon their iPad. Texas Medical Liability Trust, a loyal supporter of Texas physicians and organized medicine has partnered with TCMS and DocBookMD to provide this application at no cost to TCMS members.

A first-of-its-kind, DocBookMD was designed by physicians for physicians as a flexible, efficient, and easy-to-use communication tool that allows a TCMS member to search for another member and then text, call, or e-mail them with just one touch. You can see the physician’s picture, get to a map by clicking the practice address, go directly to their web site, and even look up contact information for pharmacies. TCMS DocBookMD is secured through the highest levels of encryption and verification and may be activated only by TCMS members with a unique access number provided by the Society.

For your access number and download instructions, contact the Society at 206-1252 or shinojosa@tcms.com.

Created in 1979, TMLT has grown to be the largest and most respected medical liability provider in the state, protecting more than 14,500 Texas physicians. TMLT is a unique, not-for-profit health care liability claim trust owned by its physician policyholders. TMLT is not an insurance company, but a self-insured trust established to provide coverage against health care liability claims to members of the Texas Medical Association – no matter what your specialty, practice type, or location.

For a DocBookMD demonstration, visit www.docbookmd.com.

To learn more about Texas Medical Liability Trust, visit www.tmlt.org.

EHR Incentive Registration Begins

Starting in 2011, significant incentives are available for physicians who "meaningfully use" an electronic health record (EHR). You must register to participate. To enroll, visit the Centers for Medicare & Medicaid Services (CMS) registration and attestation web page.

Have your tax identification and National Provider Identifier numbers handy when registering and be prepared to select one of the two available programs, Medicare or Medicaid. The Medicare incentives are up to $44,000 over five years. Medicaid incentives are up to $63,750 over six years but require a threshold of 30 percent Medicaid encounters (20 percent for pediatricians).

"With the start of registration, these landmark programs get under way, and patients, providers, and the nation can begin to enjoy the benefits of widespread adoption of electronic health records," said CMS Administrator Donald Berwick, MD.

For physicians planning to participate in the Medicaid EHR incentive program, in addition to the CMS registration, there also are Texas Medicaid enrollment requirements. Texas Medicaid will host a webinar demonstration of the enrollment process. The webinar will be on Thursday, Feb. 3, at 1 pm and 6:30 pm. For details and to register, click here. 

Regional extension centers (RECs) provide federally subsidized consulting to help physicians select and implement an EHR system and to meet federal "meaningful use" requirements for EHR incentive eligibility. Primary care physicians and specialists who can attest to providing primary care services are eligible for the consulting services, which cost $300 per year (valued at $5,000). For more information, visit TMA's Texas Regional Extension Center Resource Center. 

For answers to questions on these programs or other health information technology (HIT) issues, contact TMA's HIT experts by calling (800) 880-5720 or by e-mailing HIT@texmed.org.

Medicare Primary Care Bonuses Kick In

Medicare has begun paying primary care physicians a 10-percent bonus for providing primary care services. The Primary Care Incentive Payment (PCIP) program is part of the Affordable Care Act, otherwise known as health system reform that Congress passed last year.

The payments will be made quarterly and equal 10 percent of the payment amount for primary care services under Medicare Part B. Primary care physicians — those enrolled in Medicare with a primary specialty of family medicine, internal medicine, geriatrics, or pediatrics — and nonphysician practitioners  — those enrolled in Medicare as physician assistants, nurse practitioner, or clinical nurse specialists — who furnish the following primary care services from Jan. 1, 2011, through Dec. 31, 2015, are eligible for the payments.
 
The primary care service codes involved are:

     99201–99215

     99304–99340

     99341–99350 

The Centers for Medicare & Medicaid Services (CMS) says physicians should remember these key points:

Primary care services must account for at least 60 percent of the allowed charges under Part B for the physician or NPP in a prior period.

If a group or practice bills for a primary care service, one of the eligible physicians or NPPs must render the primary care professional service, which must be reflected by the rendering National Provider Identifier (NPI) for the claim detail.

CMS will extract eligible providers by rendering NPI and give contractors the information at the beginning of each year in these files:

PCIP Eligibility File — Lists qualifying NPIs. Medicare contractors will post this file on their websites by the end of January of each year. The incentive will be calculated on the amount paid for each quarter for the codes billed by the Provider Transaction Access Numbers associated with each qualifying NPI listed on the file.

Physician/Specialty File — Lists physician/NPP information by NPI.

In addition to the bonuses, Medicare began paying physicians for an annual checkup, or wellness visit, for beneficiaries. This also is part of the health system reform bill.

Finally, the Affordable Care Act waives copayments for most preventive services. Medicare will pay 100 percent of the cost of these services. 

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