Not ePrescribing? Request Exemption From ePrescribing From CMS by Jan. 31

If you do not have an electronic prescribing (ePrescribing or eScribing) system yet in place, you better get a move on it fast. And if you have not filed for a Medicare ePrescribing hardship exemption, you should do it latest by January 31 or else be prepared to face the 1.5 percent payment penalty in 2013.
The physicians who missed the original June 30 deadline have one more chance to request exemption as the Centers for Medicare & Medicaid Services (CMS) has now reopened the Communications Support Web page at https://www.qualitynet.org/portal/server.pt/community/communications_support_system/234.
Note: Physicians who have made 25 claims using the e-prescribing code G8553 in 2012 will be eligible for avoiding payment adjustments for 2013. Also as a general rule of eligibility, you should remember that if you can’t write a prescription, you are not qualified to do ePrescribing.
Check Out the Hardship Exemptions
The physicians will be subject to the payment adjustment unless they start e-prescribing or meet any of the following exclusion criteria:

• The EP is not a physician (or MD, DO, podiatrist), nurse practitioner or a physician assistant.
• Your practice has Part B claims less than 10 percent of MPFS allowed charges for encounter codes mentioned in the eRx denominator for service dates between Jan.1, 2012 to June 30, 2012 (for 2013 payment adjustment) and Jan.1, 2013 to June 30, 2013 (for 2014 payment adjustments)
• Your practice doesn’t have 100 cases with eRx encounter codes for service dates between Jan.1, 2012 to June 30, 2012 (for 2013 payment adjustment) and Jan.1, 2013 to June 30, 2013 (for 2014 payment adjustments)
• Your practitioner doesn’t hold prescribing privileges and reports G8644 (Eligible professional does not have prescribing privileges) on a Part B claim between Jan.1, 2012 to June 30, 2012 (for 2013 payment adjustment) and Jan.1, 2013 to June 30, 2013 (for 2014 payment adjustments)
• Your practice is established in a rural area that has limited Internet access.  Report G8642 (The eligible professional practices in a rural area without sufficient high speed internet access and requests a hardship exemption from the application of the payment adjustment under section 1848[a][5][a] of the social security act) at least once.
• There are not enough pharmacies in the area here your practice is based that can do ePrescribing. Report G8643 (The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing and requests a hardship exemption for the application of the payment adjustment under section 1848[a][5][a] of the social security act) at least once.
• Your practice is unable to e-prescribe due to local, state or federal laws
• Your practice has less than 100 prescriptions in six months corresponding to the reporting period

Sequestration Budget: Brace Yourself for 2% Cuts Starting April 1

The sequestration budget cuts are here. And health care plans and drug plans will be reduced by 2% starting April 1.

March 1 has come and gone, but with no life-saving action from Congress to avoid $85 billion in federal spending cuts known as the sequester.

The 2% Medicare cut will affect physicians, hospitals, health care providers, health plans, and prescription drug plans, but will have no direct effect on Medicare beneficiaries. "Our lawmakers have failed to act, and Medicare patients and physicians will now feel real pain in the form of new cuts that come at an already difficult time for the nation's economy," AMA President Jeremy A. Lazarus, MD, said in a statement issued on March 1.

Although the 2% cut may not seem large if compared to the reductions in other federal agencies, physicians say it will still have a huge impact. “The across-the-board cut will hit physicians particularly hard because of the fundamentally flawed Medicare physician payment system. Since 2001 Medicare payments for physician services have only increased by four percent, while the cost of caring for patients has gone up by more than 20 percent. A two percent cut widens the already enormous gap between what Medicare pays and the actual cost of caring for seniors,” said Dr. Lazarus.

The present cuts could make it difficult for patients to get care, Lazarus said. “Physicians continue to face drastic cuts from the SGR, and an additional two percent cut coming from sequestration further threatens access to care for patients and prevents needed improvements in Medicare.”

"It’s a very difficult time to plan your practice and plan hiring new employees because you don’t understand what you’re going to be getting paid and what you can afford," said Dr. David L. Bronson, president of the American College of Physicians.

Other Medicare cuts

Federal law already triggers Medicare cuts every year to keep the program financially sound. As most practices would be aware, Congress has stepped in a number of times to eliminate those cuts. Congress voted earlier this year to eliminate a 27 per cent Medicare payment cut that was supposed to kick in for 2012. Even without the 27 per cent reduction, total Medicare reimbursements for many practices in 2013 have fallen at least 2 to 3 per cent from last year based on changes in the 2013 relative value units (RVUs).

CMS to Delay Setting Criteria for Stage 3 Meaningful Use

The Centers for Medicare & Medicaid Services (CMS) recently announced that it will delay setting the criteria and rules on stage 3 meaningful use of electronic health records until 2014.

At the HIMSS 2013 conference held earlier in March 2013 in New Orleans, Marilyn Tavenner, Acting CMS Administrator, announced that the rulemaking process for Stage 3 won't take place in 2013 as was the plan earlier. The agency would instead wait and measure the success of the existing stages and review any problems. The agency would also review the feedback received from healthcare professionals and physicians.

Tavenner said that CMS plans to use this delay to concentrate on accomplishing increased interoperability across EHR systems and enhancing the exchange of health information.

This has been proposed by the AMA (American Medical Association) and organized medicine. They suggested that the CMS should first review how stage 1 and stage 2 are rolling out before setting the rules and criteria for stage 3, which is supposed to be implemented in the year 2016.

AMA has expressed its appreciation over the CMS’ decision, and says that it had submitted formal comments on Stage 3 earlier in 2013, recommending that CMS should review the earlier stages of the meaningful use program and resolve any present problems before setting down new rules for the next stage.

"[I]t is a serious mistake to keep adding stages and requirements to the meaningful use program without evaluating Stage 1 of the program," AMA CEO and Executive Vice President James L. Madara, MD, wrote in the letter. "[A]n evaluation should occur between each stage of the meaningful use program and prior to finalizing the requirements for the next stage.

"It makes no sense to add stages and requirements to a program when even savvy EHR users and specialists are having difficulty meeting the Stage 1 measures."
Background:
The three stages of meaningful use program that had been decided are:

Stage 1: This stage started in the year 2011 and is the beginning point for all providers. “Meaningful use” includes transferring data to EHRs and being able to share info.
Stage 2: The rules for this stage have already been decided and it shall be implemented in the year 2014. “Meaningful use” will include standards such as allowing the patients to gain access to their health information and also allowing exchange of electronic health information between healthcare providers.
Stage 3: This stage is expected to be implemented in 2016. “Meaningful use” will comprise of showing that the quality of healthcare has been improved.

Fiscal 2014 Budget Offers Sequester and SGR Repeal

If the recent physician cuts have been giving you sleepless nights, there’s a ray of hope. Rather than facing more cuts, physicians will now be on the receiving end of some federal largesse.

On April 9, 2013, President Barack Obama released a budget proposal for fiscal 2014. The proposed budget assumes the repeal of Medicare's sustainable growth rate (SGR) formula and the 26.5% physician pay cut that it would trigger.

Sen. Patty Murray, chair of the Senate budget committee, presented his budget proposal, which factors in the $1.8 trillion cost of maintaining Medicare rates at their present level over a course of 10 years.

This budget also withdraws sequestration — the automatic, across-the-board cuts — that includes a 2% cuts in Medicare reimbursement for physicians. These cuts were scheduled for April 1 this year (Read our last month’s news story “Sequestration Budget: Brace yourself for 2% Cuts Starting April 1” on codinginstitute.com). The proposed budget gives out nearly $1 trillion to replace the sequester cuts.

The budget also offers a deficit-neutral reserve fund that will replace the SGR with a new payment plan. Under this plan, physician pay rates would be frozen at their present level.

AMA President Jeremy A. Lazarus, MD, said in a statement, "We are pleased that President Obama's 2014 budget recognizes the need to eliminate the broken Medicare physician payment formula known as the SGR and move toward new ways of delivering and paying for care that reward quality and reduce costs. The president's proposals align with many of the principles developed by the AMA and 110 other physician organizations on transitioning Medicare to include an array of accountable payment models." You can go to http://www.ama-assn.org/ama/pub/news/news/2013-04-10-statement-on-presidents-budget.page to read the statement given by Dr. Lazarus in its entirety.

Although Medicare spending would come down substantially, the cuts would also come at a cost — and will have maximum effect on hospitals, drug companies, nursing homes, and wealthy seniors, who would ultimately end up paying considerably higher premiums. The budget would reduce the deficit by raising an additional $580 billion in revenue over a period of 10 years; especially by closing tax loopholes and making some tax-code changes for the wealthy class.
"While eliminating the SGR would be a step forward, the budget takes a step backward by aiming to achieve more savings through the Medicare Independent Payment Advisory Board (IPAB), which would set another arbitrary spending target and rely solely on payment cuts to reach it," Dr. Lazarus further said in his statement. "The AMA strongly supports bipartisan proposals to eliminate this panel."

The plan offered by Senate is also similar to the president's plan, and it offers to reduce the deficit by $1.85 trillion over a period of 10 years with a combination of increasing revenue and reducing spending.

Bill EKG during any surgery or inparticular open heart surgery and post surgery (during recovery)?

EKG is usually done in continuous manner during a heart surgery, and therefore it's considered an integral part of the main surgery and so would not be paid separately. Physicians need to monitor patient's heart's electrophysiologic behavior throughout the procedure.

Electrocardiograms are considered incidental to a stress test, a cardiac test which
includes an ECG as part of the test, and as part of initial hospital care. A 3 lead ECG is considered
incidental to a 12 lead ECG. Separate reimbursement is not provided for ECGs which are considered incidental.
An ECG is considered mutually exclusive to provider services for cardiac rehabilitation (93797). Separate
reimbursement is not provided for ECGs which are considered mutually exclusive.

To bill ECG/EKG (93000-93010 / 93040-93042), the specific request for the procedure should come from the doctor. Check the CPT guidelines before code 93000:

"Codes 93040-93042 are appropriate when an order for the test is triggered by an event, the rhythm strip is used to help diagnose the presence or absence of an arrhythmia, and a report is generated. There must be a specific order for an electrocardiogram or rhythm strip followed by a separate, signed, written, and retrievable report. It is not appropriate to use these codes for reviewing the telemetry monitor strips taken from a monitoring system. The need for an electrocardiogram or rhythm strip should be supported by documentation in the patient medical record."

Also, EKG machine/electrodes come under "routine supplies" when done in a hospital. Routine supplies are items used during the normal course of treatment, which are directly related to and/or integral to the performance of separately payable therapy, treatments, procedures, or services. These supplies are customarily used during the course of treatment and are normally found in the floor stock, which are generally
used by all patients in that specific area/or location. Reusable supplies and equipment may also be considered routine.

Routine supplies should not be separately billed to a patient or a payor. When charging for routine supplies, hospitals have an option to include the charge in the charge of procedure/service, the accommodation charge, the operating room charge, or the E&M visit, or capture it on the hospital Cost Report.

The CCI bundling policy shows that CABG code (33510) bundles EKG code 93000 with a modifier indicator 1, suggesting you cannot bill EKG separately.

Difference from coding a "93015 and 93325 or a 93351?

report 93015 (Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report), 93350 (Echocardiography, transthoracic, real-time with image documentation [2D], with or without M-mode recording, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report), and add-on codes +93320 (Doppler echocardiography ...) and +93325 (Doppler echocardiography color flow velocity mapping ...) if the documentation supports that the physician performed these procedures. See the CPT statement in parentheses under the description of 93350: "The appropriate stress testing code from the 93015-93018 series should be reported in addition to 93350 to capture the exercise stress portion of the study."

Code 93350 describes stress echocardiography only and does not include the cardiovascular stress portion of the procedure. Consequently, you need to report 93015 to cover services for the cardiovascular stress component.

When a single physician performs a stress echo and a complete cardiovascular stress test, report 93351 (Echocardiography, transthoracic, real-time with image documentation [2D], includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with physician supervision).

Professional component only: If your cardiologist provides only the professional component of the stress test and stress echo (such as in a facility), CPT® guidelines instruct you to append modifier 26 (Professional component) to 93351.

This language brings the CPT® approach more in line with Medicare policy, which states that "93351 (26) is payable when performed by a physician in a facility setting" (www.cms.gov/MLNMattersArticles/downloads/MM6617.pdf).

Limited elements: In some cases, the cardiologist may perform a stress echo without performing all of the stress test's professional services. In those situations, CPT® indicates you should report:

93350 (Echocardiography, transthoracic, real-time with image documentation [2D], includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report) AND
Code(s) for the stress test element provided (choose from 93016-93018, Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress ...).
The Medicare Physician Fee Schedule lists both professional and technical services for 93350, so remember to append modifier 26 to 93350 when you're reporting professional services only.

Bill 99231 and another physician bill 99239 on the same day

Several physicians might be managing the care of a patient, and all might try to bill for the discharge -- but only the attending physician should bill for the discharge, CMS indicates.

The Medicare Claims Processing Manual notes, "Only the attending physician of record reports the discharge day management service. Physicians or qualified nonphysician practitioners, other than the attending physician, who have been managing concurrent health care problems not primarily managed by the attending physician, and who are not acting on behalf of the attending physician, shall use Subsequent Hospital Care (CPT® code range 99231- 99233) for a final visit."

The doctor cannot report an inpatient service unless a face-toface encounter occurs on that day. If the physician does not see the patient on the day of discharge, or any other day during the hospitalization, he may not report any E/M service. You should, however, report face-to-face services based on when the direct contact (face-to-face service) occurs. Here's how:

1. If the physician sees the patient the day prior to discharge, the physician can report the appropriate subsequent hospital care code (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...).

2. If the physician sees the patient on the day of discharge, he may choose the most appropriate code that represents the amount of floor/unit time the physician spends with the patient and other activities directed toward the discharge. For discharge services of 30 minutes or less, use 99238 (Hospital discharge day management; 30 minutes or less). Report discharge services taking more than 30 minutes as 99239 (... more than 30 minutes). The time spent with the patient and floor time must be documented in the chart along with what was done during that time. Keep in mind that if these services are performed during the postoperative global period of a procedure performed by the same provider, these would not be separately reportable.