Medicare Medicaid
Information for psychiatrists who serve patients through Medicare, the federal health insurance program for the elderly and disabled; and Medicaid, the federally supported state-run health insurance programs for the poor.
Learn more about Medicare and Medicaid.
Information is available to Members through the Practice Management HelpLine by phone [800.343.4671] or email [hsf@psych.org]
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2012 Medicare Claims Should be Held Until January 18 [posted 01/05/2012]
Because Congress acted so late in 2011 to override the 27.4% cut in Medicare fees demanded by the Sustainable Growth Rate (SGR), Medicare contractors may not have their files ready to process claims at the correct fee rate until January 18. However, it is expected they will all have the correct fee schedule posted on their websites by January 11 (currently most of them have the fees in place from before Congress acted to override the cut). For nonparticipating providers, who bill their patients up-front for the entire fee, if you cannot wait until the new fees are posted, using the 2011 fee schedule may amount to a slight over- or undercharge that can be corrected in the future when the actual fees are posted.
Note: Congress provided for only a two-month fix; in March they will either issue a continuance of the temporary rate or provide a new fee schedule. The APA will provide an update here as soon as we have the information.
CMS Requires New ABN Form as of 1/1/2012
Starting January 1 The Centers for Medicare and Medicaid Services will require a new Advanced Beneficiary Notice of Noncoverage (ABN) form (CMS-R-131G). This is the form you need to use if you provide services to a Medicare beneficiary when you think there’s a possibility they won’t be covered for medical necessity or other reasons and you want the patient to understand they may be responsible for paying the entire fee.
If you do not fill out this form, the patient has no obligation to pay if Medicare rejects the claim. The new form and its instructions can be found on the CMS website at https://www.cms.gov/BNI/02_ABN.asp .
Medicare Providers: Compulsory Revalidation Period Extended to 2015 [updated 01/04/12]
As required by the Affordable Care Act, CMS began a revalidation program for Medicare providers on August 10, 2011.
Until March 2015, Medicare Carriers and Contractors will be sending out notices on a regular basis to all their providers who enrolled in Medicare prior to March 25, 2011. (Previously all revalidation was supposed to have been completed in early 2013.) The notice will explain that you are required to revalidate your enrollment information that resides in the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) and provide a deadline for when this needs to be accomplished. Note: Even providers who have opted out of Medicare are required to revalidate in order to maintain their ordering and referring privileges.
Note: Do not to attempt to revalidate you enrollment until after you receive the notice, but when you receive the notice you must revalidate within the timeframe provided. Any changes to your Medicare enrollment that occur before you receive your revalidation notice should continue to be made as they always have. The revalidation process is separate from any enrollment updates.
Your revalidation will be most easily accomplished using the Internet-based PECOS, which can be accessed at https://pecos.cms.hhs.gov. You will be able to review the information Medicare currently has on file for you, update as necessary and submit the revalidation. After completing the online process, you will have to submit a signed hard copy of the “certification statement” with any required documentation to the Medicare contractor that sent you the revalidation notice. Hopefully, all requirements will be clearly stated in the revalidation request you receive. Be sure to follow instructions, since failure to revalidate as requested may result in the deactivation of your Medicare billing privileges. For more information about this process, go to http://www.cms.gov/MLNMattersArticles/downloads/SE1126.pdf.
Although institutional providers and suppliers will be charged a fee to reapply, there is no cost for individual practices and physicians to revalidate
HIPAA 5011 Transactions Standard Enforcement Delayed 90 Days
Although the deadline for compliance with the new HIPAA 5010 transactions standard is still scheduled for January 1, 2012, CMS has said it will not begin enforcing compliance with the new standard until March 31, 2012. This 90-day grace period should give any HIPAA entities time to ensure they are able to effectively convert to the new HIPAA transactions standard before enforcement begins. After March 31, failure to use the new standards in electronic transactions will create problem with claims processing and reimbursement. More information about HIPAA 5010 can be found on the CMS website at https://www.cms.gov/ICD10/02b_Latest_News.asp#TopOfPage .
Important Electronic Prescribing Update, September 2011 [posted 9.2.2011]
Medicare/Medicaid Electronic Health Records (EHR) Incentive Payment Programs.
Reprocessing Claims Alert from CMS posted 2.8.2011: Adjustments to claims subject to retroactive payment changes in the first several months of 2010 are scheduled to begin in the near future, most of the adjustments will be made automatically but in some instances where the submitted bill was lower than the revised payment rate, physicians will need to request an adjustment. [Click to read more.]
Medicare Extender Act of 2010 stabilizes Medicare physician payments at current rates for 12 months, through the end of 2011.
In addition to providing a 12-month reprieve from the 25 percent Medicare physician payment cut that was scheduled to take effect on January 1, 2011, the law extends the 5% increase in payments for psychotherapy codes that first went into effect in 2008, and was retroactively reinstated for 2010 as part of the health reform legislation last March.
Although the bill essentially extended the current fee schedule, there may be some changes in fees allowed for specific procedures because of adjustments made to the conversion factor, work values of the codes, etc.
It is vital to check your Medicare Contractor’s website to be sure you have the correct 2011 fees. The AMA has more information about this at http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/payment-action-kit-medicare.shtml .
It is significant that the Extenders Act includes funds to enable Medicare contractors to reprocess claims for physician services affected by provisions of the Patient Protection and Affordable Care Act passed last spring with a retroactive effective date of January 1, 2010.
There had been some question as to what psychiatrists needed to do to receive their retroactive payments, and now it appears that the contractors should be taking care of this without the need to request that individual claims be reprocessed; for exceptions see http://www.psych.org/MainMenu/PsychiatricPractice/MedicareMedicaid/2010-Claims-Reprocessing.aspx.
We’ll post more information when it is available.
Reprocessing Claims Update from Jan 11: CMS announced they were “closer” to finalizing plans for reprocessing claims from the first half of 2010 to pay for the retroactive increases in physician payments—including the 5% increase in fees for psychotherapy services.
Medicare Claims Filing Reminder: Medicare claims now need to be filed in a much more timely manner than was required previously. If you see a patient in the first 9 months of a year, you have until December 31 of the following year to file a claim. If the service occurs from Oct-Dec, you have until December 31 of the second year. Note: after the deadline, no payment will be made.
If you’re new to Medicare you may bill back 30 days prior to the submission of an accepted enrollment application.
For additional information about the new maximum period for claims submission filing dates, contact your Medicare contractor, or review the MLN Matters articles listed below:
- MM6960 – “Systems Changes Necessary to Implement the Patient Protection and Affordable Care Act (PPACA) Section 6404 - Maximum Period for Submission of Medicare Claims Reduced to Not More Than 12 Months”
- M7080 – “Timely Claims Filing: Additional Instructions”
- Listen to the CMS podcast on timely claims filing.
Guidelines: Participating or Non-Participating provider in Medicare explained.
Know your options: Medicare participation guide from the AMA [posted 9.30.2010]
CMS to Review PECOS Enrollment Process [posted 6.30.10]:
Medicare is working with ordering and referring providers and supplies to streamline enrollment process to ensure that Medicare beneficiaries continue to receive the health care services and items they need.
CMS will, for the time being, not implement changes that would automatically reject claims based on orders, certifications, and referrals made by providers that have not yet had their applications approved by July 6, 2010.
Additionally, though CMS is taking a more deliberative approach to using the PECOS enrollment system, the agency will employ a contingency plan to meet the ACA requirement that written orders and critifications are only issued by eligible professionals effective July 1.
For more information read the CMS Press release issued June 30, 2010.
PECOS is the electronic system used to enroll physicians and eligible professionals into the Medicare program.
2010 Medicare News From HSF
Reminder: Consultation Code elimination: Medicare eliminated the use of all consultation codes except those for telemedicine. Physicians are to bill for these services using the "most appropriate" remaining evaluation and management codes.
If you have questions about coding under this new policy, please contact Ellen Jaffe at 703-907-8591.
2010 Fee Schedule
CMS Notices:
Scam Alert targeting physician offices [posted 6.18.2009]
Fact Sheet: 1500 At a Glance [pdf document]
CMS Form 1500 Web-based Tutorial
Letter from CMS’s National Correct Coding Initiative (CCI) re inappropriate use of the Advance Beneficiary Notice (ABN) for claims denials based on CCI Medically Unlikely Edits (MUEs) rather than medical necessity. [posted 04/16/2009]
New Profider Authentication Requirements for Medicare Contractor provider Telephone and Written Inquiries [posted 04.15.09]
Posted 02.20.2009:
Internet-based Medicare Enrollment
Tips for Enrolling in Medicare
Posted 9.17.2008:
Reporting Responsibilities for Individual Physicians Enrolled in the Medicare Program
Reporting Responsibilities for Physician Group Practices Enrolled in the Medicare Program