Palm Beach County Medical Society

Reimbursement, Coding and Billing
 
News

Consultation Crosswalk

Access the latest industry news here:
Coding and Billing for H1N1 Vaccine

Articles
Medicare Pay-For-Reporting Effort Draws Fire From Frustrated Doctors - (amednews.com - October 6, 2008)
CMS Announces Medicare Premiums, Deductibles for 2009 - (September 19, 2008)
Medicare 10.6% Pay Cut Reversed as Congress Overrides Bush Veto - (amednews.com - July 28, 2008)

Coding
Coding and Compliance: 2009 Presentation
HCPCS - General Information
HCPCS Release & Code Sets
ICD-9-CM
ICD-10
Medically Unlikely Edits (MEU) program has been developed by CMS to reduce the paid claims error rate for Medicare claims. MUEs are designed to reduce errors due to clerical entries and incorrect coding based on anatomic considerations, HCPCS/CPT code descriptors, CPT coding instructions, established CMS policies, nature of a service/procedure, nature of an analyte, nature of equipment, and unlikely clinical treatment.
National Correct Coding Initiative (NCCI) was developed by CMS to prevent improper payment when incorrect code combinations are reported. NCCI edits identify pairs of Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Level II codes that normally a physician should not bill for the same patient on the same day.

E-prescribing Incentive Program
http://www.cms.hhs.gov/pqri/
Medicaid
Medicare

National Provider Identifier (NPI)
The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. Beginning May 23, 2007 (May 23, 2008, for small health plans), the NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions. Learn more about NPI and how it will affect you below.

The Who, What, When, Why & How of NPI: Information for Health Care Providers
Tips from CMS on how to Apply for NPI
National Plan and Provider Enumeration System (NPPES)

Physician Quality Reporting Initiative (PQRI)
PQRI establishes a financial incentive for eligible professionals to participate in a voluntary quality reporting program. Eligible professionals who successfully reported PQRI quality measures on claims for dates of service from July 1 through December 31, 2007, may earn an incentive, subject to a cap, of 1.5% of total allowed charges for covered Medicare physician fee schedule services furnished July 1 through December 31, 2007.

For 2008, eligible professionals who meet the criteria for satisfactory submission of quality measures data for services furnished during the reporting period, January 1, 2008 - December 31, 2008, will also earn an incentive payment of 1.5 percent of their total allowed charges for Physician Fee Schedule (PFS) covered professional services furnished during that same period (the 2008 calendar year). 

2008 PQRI consists of 119 quality measures, including 2 structural measures.  One structural measure conveys whether a professional has and uses electronic health records and the other electronic prescribing. 

CMS PQRI Webpage
CMS 2008 PQRI Fact Sheet.pdf
PQRI Validation Process
http://www.texmed.org/uploadedFiles/Practice_Management/Medicare/PQRIModuleVI121907.pdf
Participation tools: Medicare Physician Quality Reporting Initiative (PQRI) – American Medical Association
Quality Measures for 2008 PQRI - American Medical Association

In 2007, PQRI reporting is based on 74 unique measures associated with clinical conditions that are routinely represented on Medicare Fee-for-Service claims through the use of diagnosis codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)and procedure codes from the Healthcare Common Procedure Coding System (HCPCS).

2007 Physician Quality Reporting Initiative (PQRI) Feedback Reports User Guide (PDF) 
2007 PQRI Measures List
2007 PQRI Fact Sheet
Program Overview: 2007 Physician Quality Reporting Initiative (PQRI)

E-prescribing Incentive Program

  
Products and Services
PBCMS Endorsed Services
Acevedo Consulting - www.acevedoconsultinginc.com
Avisensa - ww.avisena.com

 
Links
Agency for Health Care Administration
AMA CPT®: Current Procedural Terminology
Centers for Medicare & Medicaid Services
First Coast Service Options is the Medicare Administrative Contractor (MAC) for Florida and provides services to Florida’s Medicare beneficiaries and health care professionals

 Tools
National Technical Information Service (NTIS) is CMS’s authorized distributor of Correct Coding Products
National Plan and Provider Enumeration System (NPPES)