Medicare Medical Billing Newsletter Has Important Information for Primary Care Physicians

As a Primary Care Physician you probably generate numerous claims for Annual Wellness Visits for your Medicare Beneficiaries. If you are an outpatient hospital/facility based provider, you need to be aware of the upcoming changes for the payment of HCPCS G0438 and G0439.

Under current claims reimbursement processes, a preventive service that has been submitted for both a “professional” service (the professional claim for the delivery of the service itself) and a “technical” service (the institutional claims for a facility fee)for the same day, payment is allowed for both. Review of this process has identified overpayments in some case and future recoupments will be initiated.

To remedy this, new claims processing regulations become effective for claims processed on or after April 1, 2013 allowing payment for either the practitioner or the facility for furnishing the AWV.

This regulation in based on the fact that codes G0438 and G0439 have no separate payment for a facility fee. The claim will be posted to the Medicare beneficiary's utilization history and processed/reimbursed as the “professional” service only, regardless of whether it is paid on a professional claim or an institutional claim. 

Note: Only one payment for the AWV will be allowed on the same date and paid on the first claim received. 

Recommendation: If you are performing AVW's in a facility, you should discuss these billing changes with them immediately. It is necessary to come to an amicable and mutally agreed upon approach to which entity will be submitting the claims for these services and how the reimbursement would be distributed to both parties. By planning ahead, you will be preventing any possible difficulties in your working relationship with the facility.

Medicare Payment Reductions for Diagnostic Cardiovascular, Imaging and Ophthalmology Proceduresvascular, Section 3134 of the Affordable Care Act added Section 1848(c)(2)(K) of the Social Security Act which specifies that the Secretary shall identify potentially misvalued codes by examining multiple codes that are frequently billed in conjunction with furnishing a single service. 

As a further step in implementing this provision, Medicare is making a change to the MPPR on the PC and TC of certain diagnostic imaging procedures and to the TC of diagnostic cardiovascular and ophthalmology procedures.

See below for details:                                             

Application of the Multiple Procedure Payment Reduction (MPPR) on Imaging Services to Physicians in the Same Group Practice 

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7747.pdf

Currently, the MPPR applies only when an individual physician furnishes multiple services to the same patient, in the same session, on the same day. 

The Centers for Medicare & Medicaid Services (CMS) is expanding the MPPR of imaging services by applying it to physicians in the same group practice (same Group National Provider Identifier (NPI)) who furnish multiple services to the same patient, in the same session, on the same day.

The MPPR on certain diagnostic imaging services applies to Professional Component (PC) and Technical Component (TC) services. It applies to both PC-only services, TC-only services, and to the PC and TC of global services. Full payment is made for each PC and TC service with the highest payment under the Medicare Physician Fee Schedule (MPFS). 

Payment is made at 75 percent for subsequent PC services furnished by the same physician group, to the same patient, in the same session, on the same day. Payment is made at 50 percent for subsequent TC services furnished by the same physician group, to the same patient, in the same session, on the same day. 

The individual PC and TC services with the highest payments under the MPFS of globally billed services must be determined in order to calculate the reduction.

The complete list of codes subject to the MPPR on diagnostic imaging can be found in Attachment 1 of CR7747, which is available on the CMS website at:

http://www.cms.gov

Multiple procedure payment reduction on the technical component of diagnostic cardiovascular and ophthalmology procedures

The MPPRs on diagnostic cardiovascular and ophthalmology procedures apply when multiple services are furnished to the same patient on the same day. The MPPRs apply independently to cardiovascular and ophthalmology services. The MPPRs apply to TC only services, and to the TC of global services.

For cardiovascular services, full payment is made for the TC service with the highest payment under the MPFS. Payment is made at 75 percent for subsequent TC services furnished by the same physician or physician group to the same patient on the same day.

For ophthalmology services, full payment is made for the TC service with the highest payment under the MPFS. Payment is made at 80 percent for subsequent TC services furnished by the same physician or physician group to the same patient on the same day.

The MPPRs do not apply to professional component (PC) of diagnostic cardiovascular and ophthalmology services.

The complete lists of codes subject to the MPPRs on diagnostic cardiovascular and ophthalmology procedures are in Attachments 1 and 2 of CR 7848 respectively. CR 7848 can be found on the CMS website at:

http://www.cms.gov

Billing Hint:

Medicare is applying the MPPR to physicians in the same group practice who furnish multiple services to the same patient, in the same session, on the same day. Medicare will assume procedures furnished on the same date of service were furnished in the same session unless the provider uses modifier 59 to indicate multiple sessions, in which case the reduction does not apply.  If multiple sessions did occur, explicit and detailed documentation will be required in case of an audit of the billed services.

Fee Schedule Information:

To accommodate implementation of this new proposal for certain bill types, the 2013 Medicare physician fee schedule will include the following changes:

1. A new multiple procedure (Field 21) value of ‘6’ will denote diagnostic cardiovascular services subject to the MPPR methodology.

2. A new multiple procedure (Field 21) value of ‘7’ will denote diagnostic ophthalmology services subject to the MPPR methodology.

Explanation of Benefits Information:

When payments are reduced due to the MPPR, you will receive a claim adjustment reason code of 59 (Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia,) 

Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.) and group code CO (contractual obligation).