NOA 3 rd Party Update 2012

1. NOA 3rd Party Update2012

2. Resource For This Presentation • NOA 3rd Party Web Page found at HTTP:// NEBRASKA.AOA.ORG/ PREBUILT/ NOA/ INDEX.HTM http://nebraska.aoa.org/prebuilt/NOA/index.htm

6. NOA 3rd Party Educational Videos http://nebraska.aoa.org/prebuilt/NOA/index_Page353.htm

8. 2012 3rd Party Update • HIPAA (Privacy, EDI, Security) • CMS Incentive Programs (EHR, eRx, PQRS) • CMS Quality Care – Pay For Performance • Medicaid • Coding • Office Procedures • BCBS

9. HIPAA Privacy Audits • For the first time, HIPAA Privacy audits are coming. • It is important that your staff annually review your HIPAA Privacy Manual and update personnel and other required information. • You should also review your HIPAA privacy policies during staff meetings at least twice a year.

10. HIPAA Privacy Audits • For the first time, HIPAA Privacy audits are coming. http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html

11. HIPAA Privacy Audits http://nebraska.aoa.org/prebuilt/noa/HIPAA%20NOA%20Manual.PDF

12. HIPAA Privacy Audits • The OCR director reinforced that it is a consumer’s legal right to obtain a copy of their health information. • Visit the OCR website to obtain a copy of the memo and for videos, pamphlets, frequently asked questions, etc. http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html

13. HIPAA EDI ICD-10 • ICD-10 codes provide more specific data to improve patient care & information exchange • ICD-10 used by rest of world for years. • HHS has postponed the date by which health care entities must comply with ICD-10 until October 2014 • ICD-10 HHS education can be found at http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD10/

14. HIPAA • HIPAA Security Reminder • Action Required • Manual http://www.aoa.org/documents/AOA_HIPAA_Security_Regulation_Manual.pdf

15. 2012 3rd Party Update • HIPAA (Privacy, EDI) • CMS Incentive Programs (EHR, eRx, PQRS, MOC) • CMS Quality Care – Pay For Performance • Medicaid • Coding • Office Procedures • BCBS

16. All CMS Incentives 2011-2019 http://nebraska.aoa.org/prebuilt/noa/2012-06-3RD-Party-Newsletter.pdf

17. EHR • CMS recommends that all eligible professionals register as early as possible for EHR Incentive Programs. • If you do not resolve registration problems in time, you will not be able to attest and could potentially miss out on a payment year. https://ehrincentives.cms.gov/hitech/login.action

18. EHR • 2012 is the last year you can earn the maximum incentive. • October 3rd is the Last Day for EPs to Begin their 90-Day Reporting Period for 2012 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/CMS_eHR_Tip_Sheet.pdf

19. EHR • CMS has posted a series of new videos about the Medicare EHR Incentive Programs to the CMS YouTube channel http://www.youtube.com/user/CMSHHSgov. • Make sure to visit the EHR Incentive Programs websitefor the latest news and updates on the EHR Incentive Programs. http://www.cms.gov/EHRIncentivePrograms/

20. EHR • The CMS EHR Incentive Program listserv provides timely information on program requirements and changes in the EHR Incentive Programs at https://www.cms.gov/EHRIncentivePrograms/65_CMS_EHR_Listserv.asp#opOfPage

21. EHR - Documentation • Do you take notes from a previous visit and “clone” them into the current visit? • If so, WPS reports that you may be the target of the Office of the Inspector General (OIG).

22. EHR - Documentation • A “cloned” entry (e.g., HPI) can lead to an erroneously high coding level, when a more abbreviated HPI would have been appropriate for the follow-up visit. • Regardless, WPS computers are looking for duplicate verbiage • between one patient’s multiple visits • between visits of multiple patients.

23. Meaningful Use Stage 2: Timeline • You start Stage 2 of Meaningful Use no sooner than 2014. • However, you must complete 2 years of Stage 1 before starting Stage 2. • In 2014, everone (stage 1 or 2) demonstrates for 90 days.

24. Meaningful Use Stage 2: Objectives • CMS created Stage 1 vs. Stage 2 Comparison Tables to help providers navigate the next Stage of meaningful use. • Providers will be able to see which measures are new, which ones are changing, and which ones are being removed. • Example below…

25. Meaningful Use Stage 2: CQMs • Beginning in 2014, the reporting of clinical quality measures (CQMs) will change for all providers, those participating in Stage 1 or Stage 2. • All providers must report on CQMs to demonstrate meaningful use. • All providers in their second year and beyond of demonstrating meaningful use must electronically report CQM data to CMS.

26. http://www.cms.gov/EHRIncentivePrograms/Downloads/MU_Stage1_ReqSummary.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/MU_Stage1_ReqSummary.pdf

27. http://www.cms.gov/EHRIncentivePrograms/Downloads/MU_Stage1_ReqSummary.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/MU_Stage1_ReqSummary.pdf

28. http://www.cms.gov/EHRIncentivePrograms/Downloads/MU_Stage1_ReqSummary.pdfhttp://www.cms.gov/EHRIncentivePrograms/Downloads/MU_Stage1_ReqSummary.pdf

29. Meaningful Use Stage 2 Not yet endorsed CQMs • GLC screening for adults • Closing the referral loop (letter to referrer) • Monitor for adverse drug event in chronic Rx med user

30. eRx • Optometrists can earn Medicare payment bonuses for prescribing pharmaceuticals electronically; • However, they are NOT subject to Medicare payment reductions for failure to e-prescribe according to CMS. • Watch Remittance Advice for erroneous negative adjustments containing: • LE • Reason Code 237 • Remark Code N545

31. AOA: PQRS Reporting Essentials: 1. Utilize on Medicare patients 2. Report with Quality Data Codes (QDCs) that include CPT II and G codes 3. May report with paper-based CMS 1500 claims 4. May report with electronic 837-P claims

32. AOA: PQRS 5. Must report QDC codes on the same claim as a CPT I code (charge as $0.01) 6. No penalty for more frequent reporting 7. AOA recommends submitting QDC for all reportable cases

33. PQRS • Need to report on 3 PQRS measures 50% of the time. • No need to report on more than three – only raises chances of failure to meet the 50% threshold. • Dr. Quack’s PQRS Traffic Sheet should help ease your reporting.

34. http://nebraska.aoa.org/prebuilt/NOA/2011-12_3RD_Party_Newsletter.pdfhttp://nebraska.aoa.org/prebuilt/NOA/2011-12_3RD_Party_Newsletter.pdf

35. 2012 3rd Party Update • HIPAA (Privacy, EDI) • CMS Incentive Programs (EHR, eRx, PQRS) • CMS Quality Care – Pay For Performance • Medicaid • Coding • Office Procedures • BCBS

36. QRUR: Quality and Resource Use Reports • Medicare is moving to tie doctors’ pay to quality and cost of care • Value-based QRUR for MDs will begin in 2015, probably based on performance in 2013. • It will take effect for optometry in 2017, perhaps based on performance in 2015.

37. QRUR: Quality and Resource Use Reports • The formula Medicare ultimately designs to judge and pay doctors could become a valuable asset for private insurers • It may be a tool that will be somewhat bulletproof; physicians been part of the process of development

38. CMS “Physician Compare” Information currently on the website includes: • Provider names, addresses, phone numbers, specialties, clinical training, and genders; • Whether provider write or speak languages other than English; http://www.medicare.gov/find-a-doctor/provider-search.aspx

39. CMS “Physician Compare” • Hospital affiliation • Whether provider accepts the Medicare-approved amount as payment in full. • Providers who participate in quality of patient care programs… • PQRS • E-Rx http://www.medicare.gov/find-a-doctor/provider-search.aspx

40. 2012 3rd Party Update • HIPAA (Privacy, EDI) • CMS Incentive Programs (EHR, eRx, PQRS) • CMS Quality Care – Pay For Performance • Medicaid • Coding • Office Procedures • BCBS

41. Medicaid • There is now Coverage of Unborn Children of Pregnant Women Not Otherwise Eligible for Medicaid • It is important to understand that this coverage is for the unborn child, not the mother. • Coverage of the mother is limited to only those diagnoses that might have an effect on the pregnancy or the unborn child.

42. Medicaid • Only 180 Days to File a Medicaid Claim Starting in January 2013. • This is instead of the current 12 month time limit.

43. Medicaid Medical Home • Nebraska Medicaid is doing a pilot project on the Medicaid Medical Home concept a clinic in Kearney, and in Lexington. • Although the NE Medicaid medical home physicians will not act as a true “gatekeeper” (cannot limit access to providers), s/he will have significant influence if a referral is needed for eye care. http://dhhs.ne.gov/medicaid/Pages/med_pilot_progress.aspx

44. Medicaid Medical Home • Thus, ODs must establish and maintain close relationships with PCPs to assure access to patients under the medical home concept. • Providing updates to the PCP via correspondence, copies of consultations, reports and test print-outs, plus necessary phone conversations, are ways to develop such relationships.

45. Medicaid Patients Rate Doctors • A New Provider Rating and Review System (PRRS) Website has been launched, which allows consumers to monitor and evaluate the quality of provider services. • Although the ratings may not directly affect optometry at this time, they will likely include all types of providers in the future. • The link to the Nebraska Medicaid Provider Rating and Review System is available at https://prrs.ne.gov/Scroll to the bottom of the page.

46. Medicaid now using… National Correct Coding Initiative • The National Correct Coding Initiative (NCCI) (also known as CCI) was implemented by CMS to control improper coding. • NCCI code pair edits are automated prepayment edits used when certain codes are submitted together for Part B-covered services. • You can find the NCCI edits for physicians, codes 90000-99999, in zip files at https://www.cms.gov/NationalCorrectCodInitEd/NCCIEP/list.asp?intNumPerPage=all&submit=Go

47. Medicaid now using… National Correct Coding Initiative NCCI edit examples: • Prevents payment for 92083 (fields) with 99211 (level 1 established E&M encounter) • Prevents payment for 92004 with 92002 (mutually exclusive exam codes) • Prevents payment for 92082 with 92083 (mutually exclusive fields codes)

48. National Correct Coding InitiativeResources • “How to Use the Searchable Medicare Physician Fee Schedule MLN Booklet” http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How-to-MPFS-Booklet-ICN901344.pdf • “How to Use the Medicare Coverage Database” http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedicareCvrgeDatabase_ICN901346.pdf • “How to Use the National Correct Coding Initiative (NCCI) Tools“ https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf

49. Medicaid: Medically Unlikely Edits • In addition to code pair edits, the NCCI includes a set of edits known as Medically Unlikely Edits (MUEs). • An MUE is a maximum number of Units of Service (UOS) allowable under most circumstances for a single HCPCS/CPT code billed by a provider on a date of service for a single beneficiary.

50. Medically Unlikely Edits • Examples of MUE maximum number of units: If NCCI or MUE would deny a code on a claim, the provider cannot utilize an Advance Beneficiary Notice (ABN) to seek payment from a Medicare patient. 92081 1 92082 1 92083 1 92100 1 92132 1 92133 1 92134 1