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Blue Cross & Blue Shield of Texas - Changes with Modifier 22
Texas Medical Board - Seminar on Professional Accountability
Stop the Medicare Meltdown Petition Drive
Medicare No Longer Pays for CPT Consultation Codes
Medicare Extends Enrollment Deadline
Are You Receiving Remark Codes N264 and/or N265 on Medicare EOBs?
FTC Delays Red Flay Rules-June, 2010
Health Care Workers: H1N1 Vaccines
Blue Cross & Blue Shield of Texas - Changes with Modifier 22
Texas Medical Association's work on behalf of physicians paid dividends again as Blue Cross and Blue Shield of Texas (BCBSTX) agreed with the association's payment advocacy staff and changed the way it processes claims with a modifier 22. The modifier indicates that the procedure on the patient was more complicated than expected and that the physician requests additional payment beyond the contracted allowable.
Acting on complaints an Austin surgical practice submitted through the Hassle Factor Log program, TMA persuaded BCBSTX to examine its process for handling such claims. The insurer discovered that it often didn't make the additional payment because of an error in its claims-processing system. As a result, BCBSTX is instituting new procedures, including not automatically processing the claims as soon as they are submitted and looking for the additional documentation the practice sends in to support the modifier 22. More information on the modifier 22 processing change will be posted on the BCBSTX website and in its next network newsletter when the changes are complete.
Texas Medical BoardAugust 3, 2010 6:00 pm - 8:00 pm Seton Family Hospital Adm. in St. Vincent De Paul Aud. Rm. 100 1345 Philomena Street
Upholding Professional Accountability: What You Need to Know About Physician Licensure, Discipline and Regulation in Texas
Presented by Mari Robinson, J.D. – Executive Director, and Jaime Garanflo – Director of Licensure
Agenda: A) Overview of TMB Licensure and Registration Processes B) Overview of Complaint, Investigation, and Disciplinary Processes C) Review of Board Rules and Common Violations D) Question and Answer Session
For more information contact Michelle Green, TMB Outreach Coordinator at michelle.green@tmb.state.tx.us or (512) 305-7113.
TCMS DocBook
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Medicare Extends Enrollment Deadline to Match Fee-Cut Delay
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Are you receiving remark codes
N264 and/or N265 on your Medicare EOBs?
Physicians SHOULD NOT be directed to automatically update their information in PECOS without following the other steps first. There are over 40,000 physicians not in the PECOS system and if TrailBlazer suddenly is inundated with unnecessary applications it will slow down the process for those MDs that do actually need to send in a new or updated application.
On October 5, 2009 Medicare began phase I of their Expanded Editing of Ordering/Referring Providers change request by issuing informational edits N264 (Missing/Incomplete/Invalid ordering provider name) & N265 (Missing/Incomplete/Invalid ordering provider primary identifier) on Medicare EOBs that contained names and NPIs of referring physicians who are not enrolled in the Medicare program. It is very important that you read your Medicare EOBs correctly to see if you are receiving these informational edits because as of 1/4/2010 these informational edits will turn into rejections.
If you are getting either of these edits, please follow these steps (in order):
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Verify that the services you are billing require a referring/ordering physician (see pages 26-29 of TrailBlazer’s CMS-1500 Manual).
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Verify that the referring/ordering physician’s legal business name and NPI are correct. The best way to do this is to replicate the information that is on file for this physician with NPPES, the NPI enumerator: https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do.
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If the services being billed require a referring/ordering physician and the referring/ordering physician’s name and NPI are correct then you will need to contact the physician and notify him/her that he/she needs to complete a Medicare enrollment form if he/she wants to continue to refer Medicare beneficiaries to you because as of 1/4/2010 your claims (the claims of the billing physician) will deny. (References for this discussion: CMS Change Request 6417 and link to TrailBlazer’s Provider Enrollment department.) If the referring physician has any additional questions they may call Provider Enrollment Customer Service at (866) 539-5596 or TMA members may also contact Erin Gregorcyk at erin.gregorcyk@texmed.org or (800) 880-1300 x 1407.
Phases for CR 6417:
Phase 1 (October 5, 2009 – January 3, 2010)
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If an ordering/referring provider is present on the claim, Medicare will verify the provider is enrolled in PECOS and is eligible to order or refer Medicare services.
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If the ordering/referring provider is not enrolled in PECOS, Medicare will search its claims system. If the provider is not in the claims system, the claim will continue to process and the ordering/referring provider will receive a warning message on the Remittance Advice (RA).
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If the ordering/referring provider is enrolled in PECOS or in the claims system but is not eligible to order or refer, the claim will continue to process and the ordering/referring provider will receive a warning message on the RA.
Phase 2 (Beginning January 4, 2010)
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If the billed service requires an ordering/referring provider and none is present, the claim will not be paid.
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If an ordering/referring provider is present on the claim, Medicare will verify the provider is enrolled in PECOS and is eligible to order or refer Medicare services.
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If the ordering/referring provider is not enrolled in PECOS, Medicare will search its claims system. If the provider is not in the claims system, the claim will not be paid.
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If the ordering/referring provider is in PECOS or the claims system but is not eligible to order or refer, the claim will not be paid.
What is PECOS and why might a name check be needed?
PECOS (Provider Enrollment, Chain and Ownership System )is the enrollment system that Medicare transitioned to in November 2003. Currently, approximately 75% of physicians and healthcare providers, who are enrolled in the Medicare program, are in PECOS. However, if a physician has been enrolled in the Medicare program prior to Nov. 2003 and has not made any enrollment changes since that date, then he or she is not in the PECOS system. This is ok. TrailBlazer’s system is set-up to first verify if the name and NPI of the referring/ordering physician is in PECOS, if yes, claims process as normal and no informational edits are issued. If the physician is not in PECOS then a name check (1st letter of first name, 1st four of last name) and NPI are verified against the information in TrailBlazer’s claim system. If the referring physicians information cannot be verified then the above mentioned edits will appear.
Do you send patients for DME products?
CMS issued a similar change for DMEPOS, MM6421. Unlike CR 6417, Cigna Government Services, will not do a name check if the referring/ordering physician is not in PECOS. This means, that anyone who sends patients for DME products will need to populate PECOS by completing (a) CMS-855 enrollment application(s).
Genevieve E. Davis
Director - Payment Advocacy
512/370-1416 (phone)
512/370-1632 (fax)
FTC Delays Red Flags Rule
Until June 2010
Congressional pressure has prompted the Federal Trade Commission (FTC) to delay implementation of its "red flags rule" until June 1, 2010. Agency officials said in a news release it postponed the rule at the request of members of Congress. It had been scheduled to take effect Nov. 1, 2009.
Meanwhile, a bill making its way through Congress exempts small physician and accounting practices from the rule. The U.S. House of Representatives passed HR 3763 on Oct. 20. It amends the Fair Credit Reporting Act to exclude physician and accounting practices with 20 or fewer employees from the FTC's definition of a creditor.
The bill went to the Senate Committee on Banking, Housing, and Urban Affairs after House passage. The Senate had not voted on the bill as this notice was being prepared. When and if the rule ever takes effect, TCMS and TMA's Red Flags Rule Webinar will answer physicians' questions about it.
The original rule defines physicians who regularly bill their patients for services (including billing for copayments and coinsurance) as creditors. The FTC thus requires them to develop and implement written identity theft prevention programs for their practices. Such programs must identify and respond to patterns, practices, or specific activities known as "red flags" that could indicate identity theft.
Earlier this year, the FTC delayed the rule after TCMS, TMA, the American Medical Association, and 25 other medical societies told the agency that they believe physicians should not be subject to the rules because they are not creditors.
Influenza
The Centers for Disease Control and Prevention and the Texas Department of State Health Services (DSHS) are projecting that this could be a very busy and long flu season in Texas. TCMS and TMA are working to bring you useful information for you and your patients as it becomes available. TMA’s Committee on Infectious Diseases is helping by monitoring key recommendations and highlighting the information most critical for physicians.
Flu Fighters' Tips On Fighting the Flu
Physicians and patients battling H1N1 flu and the seasonal flu this season have someone in their corner. A subcommittee of the TMA Committee on Infectious Diseases, known as the Flu Fighters, will keep practitioners up to date on H1N1 flu and seasonal flu information. The Flu Fighters have developed several recommendations to help physicians respond to outbreaks of flu.
- Report Vaccination Information to the State Immunization Registry (Oct. 14, 2009)
- Health Care Provider Reporting for Novel Influenza A (H1N1) (Oct. 14, 2009)
- Five Things to Consider This Flu Season (Oct. 6, 2009)
- How to Triage Your Flu Patients (Oct. 6, 2009)
- Patients With Influenza-Like Illness — Testing, Treatment, and Prophylaxis (Oct. 6, 2009)
Health Care Workers: H1N1 Vaccines
The Centers for Disease Control and Prevention (CDC) has identified health care workers as a priority group for H1N1 vaccination. You and your staff should get vaccinated for the H1N1 flu and soon. Why?
- Health care personnel are likely to be exposed to the novel H1N1 influenza and spread it to patients, family, coworkers, and friends. Yet fewer than half of the health care workers in the United States are immunized each year for the seasonal flu.
- The H1N1 vaccine is safe. This is a safe vaccine that has been tested in adults and children and is produced in the same manner as the seasonal flu vaccine. The National Institutes of Health is conducting a number of studies across the country at special vaccine evaluation sites it has had set up for 40 to 60 years, and it has enrolled several thousand patients in those studies. The clinical trial sites include the Baylor College of Medicine and The University of Texas Medical Branch at Galveston. No deaths, serious adverse events, or adverse events of special interest have been reported in these early trials. Local discomfort, headache, and fever have been reported. But nearly all events were mild to moderate in intensity. The safety of the H1N1 flu vaccine and seasonal flu vaccines are constantly monitored through the National Vaccine Adverse Event Reporting System and other CDC studies.
It is essential that each health care worker receive his or her vaccination for H1N1 as soon as possible. Health care workers who are healthy, not pregnant, and under age 50 can receive LAIV (FluMist®), which is available in more communities right now. Patients and colleagues in your community will need your continued care for many weeks to come.
Update From DSHS on Use and Availability of H1N1 Vaccine
The H1N1 vaccine allocated to Texas so far has been less than expected. While DSHS is distributing vaccine based on the number of high priority patients providers plan to vaccinate, officials are urging physicians to use their clinical judgment on the best use of vaccine.
H1N1 Information
Providing and Reporting H1N1 Vaccine
Physicians providing patients H1N1 vaccine can go to DSHS’ H1N1 Vaccine Provider Information page to access critical information on ordering and administering vaccine. State law also requires vaccine providers to report H1N1 vaccine information to the state’s immunization registry, ImmTrac. Find out more about the ImmTrac process.
H1N1 Reporting Information
Keep up with the latest H1N1 influenza information and guidance at:
H1N1 flu virus
4300 N Lamar, PO Box 4679, Austin, Texas 78765 (512) 206-1249
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