Denver Medical Bulletin
DENVER MEDICAL BULLETIN Official Publication of The Denver Medical Society
Volume 104/Number 1 January 2014
Important Medicare Date: January 6, 2014
p until now, physicians and health care providers who bill Medicare were required to list the name and National Provider Identifier (NPI) of the ordering/referring physician or health care provider on their claims in order to be paid. Starting Jan. 6, 2014, if the ordering/referring physician or health care provider listed on the claim is not enrolled in Medicare OR does not have a valid opt-out affidavit on file, then the billing physician’s claims will be denied. This requirement was originally scheduled to go into effect in 2010, but the American Medical Association and Medical Group Management Association (MGMA) successfully convinced the Center for Medicare & Medicaid Services (CMS) to delay this several times so that more time could be given for physicians to enroll or opt-out.
Services NOT impacted
• Imaging • Clinical laboratory services • DMEPOS • Home health services
• Referrals to physician specialists • Part D or B drugs
Opt-out physicians To be clear, physicians who validly opt-out of Medicare are NOT required to enroll in Medicare for purposes of the ordering and referring enrollment requirement. A valid opt-out record with Medicare will meet the requirement. If you privately contract with Medicare patients and enroll in Medicare instead of filing an opt-out affidavit for purposes of meeting the ordering and referring requirements, you may incur legal penalties for privately contracting with your Medicare-covered patients. As a general matter, physicians who privately contract are required to have a valid opt-out affidavit on file with their local Medicare contractor. This is a long-standing policy that has been in effect long before the ordering/referring policy. When an affidavit is filed with Medicare, the contractor manually enters the physician’s information into the Medicare enrollment centralized database known as the Provider Enrollment Chain Ownership System (PECOS). If a physician who has opted out of the program is unclear as to whether or not they are in PECOS and have a valid opt-out affidavit on file, they are strongly urged to check http://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/ MedicareProviderSupEnroll/ MedicareOrderingandReferring.html
Legislative Night 2014. . .Page 3
DMS Bulletin Now Electronic Beginning with the January 2014 issue, the Denver Medical Bulletin will be published and delivered in an electronic format. After 103 years of publication, the new electronic format will better meet the expectations of our members in 2014. Please be sure to add our email address to your contacts to ensure delivery. If we do not have a current email address for you, please send it to us at [email protected]
so that you don’t miss any issues of the Bulletin. If you would prefer to continue to receive a hard copy of the Bulletin, please let us know at [email protected]
Denver Medical Bulletin
to see if their name is included. Opt-out affidavits are valid for two years.
Q. Will my appeal rights be retained on denied claims? A. Yes. Since CMS will be “denying” rather than “rejecting” the claims, appeal rights remain intact.
Where to go for more information • h t t p : / / w w w . a ma -a s s n . o r g / a ma / p u b / p h ys i c i a n resources/solutions-managing-your-practice/codingbilling-insurance/medicare/medicare-enrollmentprocess.page • http://www.mgma.com/toolkit/
Q. What instructions does CMS have for how to list the ordering/referring physician’s name on the claim? A. When submitting the CMS-1500 form please only include the first and last names as they appear on the ordering and referring file found at http://www.cms.gov/ M e d i c a re / P ro v i d e r -E n ro l l m e n t - a n d - C e r t i f i c a t i o n / MedicareProviderSupEnroll/MedicareOrderingandRefer ring.html. The edits will compare the first four letters of the last name. If they do not match the information in the file then your claims could be denied. Middle names (initials) and suffixes (such as MD, RPNA, etc.) should not be listed in the ordering/referring fields. Also, be careful to include the ordering/referring provider’s individual NPI on the claim and do not use an organizational NPI.
http://www.cms.gov/Medicare/Provider-Enrollment-and -Certification/MedicareProviderSupEnroll/ MedicareOrderingandReferring.html http://www.cms.gov/Outreach-and-Education/Medicare - L e a rn i n g - N e t w o rk - M L N / M L N M a t t e rs A rt i c l e s / Downloads/SE1305.pdf
Frequently asked questions on the Medicare ordering/referring enrollment policy
Q. How do I know a claim is denied as a result of the ordering/referring edits? A. Prior to Jan. 6, CMS is issuing warnings for claims that fail to meet the criteria and would be denied on or after Jan. 6. For Part B providers and suppliers who submit claims the warning codes are: • N264: Missing/incomplete/invalid ordering physician provider name • N265: Missing/incomplete/invalid ordering physician primary identifier
General questions Q. What is CMS’ ordering and referring provider enrollment requirement? A. Physicians, non-physician providers, and suppliers who order and refer imaging, clinical laboratory services, durable medical equipment (DME), and Part A home health (HHA) claims must be enrolled in Medicare or have a valid Medicare opt-out record to avoid a denial of claims submitted by the billing provider.
For DMEPOS suppliers they are: • N544: Alert: Although this was paid, you have billed with a referring/ordering provider that does not match our system record. Unless corrected, this will not be paid in the future.
Q. When does this requirement come into effect? A. CMS announced that, effective Jan. 6, 2014, it will turn on the edits to deny claims if the ordering or referring provider does not meet the criteria outlined above. This means that the billing provider will not be paid for the services provided or items furnished based on the order or referral. CMS planned on activating the ordering/referring edits several times since 2010, but the AMA and MGMA were successful in convincing CMS to hold off until physicians and other providers had more time to get enrolled.
Beginning Jan. 6, Medicare Administrative Contractors (MACs) will use the following denial edits for Part B providers and suppliers who submit claims to carriers and/or MACs, including DME MACs: • 254D: Referring/Ordering Provider Not Allowed To Refer • 255D: Referring/Ordering Provider Mismatch • 289D: Referring/Ordering Provider NPI Required • CARC code 16 and/or the RARC code N265, N276 and
Q. Does this requirement apply for referrals to physician specialists? A. No. The enrollment requirement does not apply to referrals to specialists.
(Continued on page 7)
Denver Medical Bulletin: Aris M. Sophocles, Jr., MD, JD, DMS President and Publisher / Curtis L. Hagedorn, MD, Chair of the Board / Aaron J. Burrows, MD, President Elect / Stephen V. Sherick, MD, Treasurer / Kathy Lindquist-Kleissler, Executive Director. The Bulletin is the official publication of the Denver Medical Society, established April 11, 1871, as the first medical society in the Rocky Mountain West. Published articles represent the opinions of the authors and do not necessarily represent the official policy of the Denver Medical Society. All correspondence concerning editorial content, news items, advertising and subscriptions should be sent to: The Editor, Denver Medical Bulletin, 1850 Williams Street, Denver, CO 80218. Phone (303) 377-1850. Fax (303) 331-9839. Web www.denvermedsociety.org. Email [email protected]
Postmaster: Send address changes to 1850 Williams Street.
Denver Medical Bulletin
Legislative Night 2014 Thursday, January 30, 2014 6:30 – 8:00 pm Cocktails and Hors d’oeuvres
Warwick Hotel – Millennium Ballroom 1776 Grant Street, Denver The Denver, Arapahoe-Douglas-Elbert, Aurora-Adams County and Clear Creek Valley Medical Societies in conjunction with the Colorado Medical Society are proud to team up and present a night of informal discussions with our Denver Metro State Legislators. We hope you will take advantage of this opportunity to meet some of your legislators and offer your insight, as they face enormous challenges in the coming legislative session. In order for us to best prepare for this evening, your reservation is required no later than Friday, January 24th. RSVP by email to [email protected]
, call us at 303-377-1850, or fax your reservation to 303-331-9839. Please give us your name and specialty when you RSVP. Name _________________________ Specialty _______________________
Denver Medical Bulletin
Denver Medical Society and Arapahoe-Douglas-Elbert Medical Society in collaboration with the AMA have proudly teamed up to present. . .
Negotiate with Confidence: Know What’s In Your Contract Learn what to expect in an employment contract, before you have to negotiate or sign one! Wes Cleveland, J.D., with the American Medical Association (AMA), will bring a national perspective, and Kari Hershey, J.D., Hershey Decker, PLLC, will bring a local Colorado perspective to contracting. Both will address such topics as: What to do before signing your contract How much you can and can’t negotiate Why you should retain a lawyer to review the contract Important contract terms such as: duties and non-compete covenants
Thursday, February 13, 2014 6:00PM Reception/Cash Bar 6:30PM Buffet Dinner 7:00PM-8:15PM Program
Wellshire Inn 3333 S. Colorado Blvd., Denver CO 80222 In order for us to best prepare for this evening your reservation is required. Email your reservation to [email protected]
or call (303) 377-1850 no later than Friday, February 7th.
Denver Medical Bulletin
Colorado Physicians Seek to Improve Healthcare for LGBT Patients
sexual patients. Again, however, they felt their staff n 2013, the Denver Medical Society was pleased to was less comfortable serving transgender patients. participate with the Colorado Medical Society and 3. Colorado physicians reported they are more comfortOne Colorado in a partnership to better understand able with patients self-disclosing their sexual orientaand meet the healthcare needs of the Colorado LGBT tion or gender identity and expression, and less comcommunity. The partnership grew out of the work by fortable asking their patients directly. One Colorado in 2011 which produced the report Invisi4. The survey showed that a number of physicians and ble: The State of LGBT Health in Colorado based on a care systems are already taking steps to create pracsurvey of nearly 1200 LGBT Coloradans and 10 focus tices that are LGBT-friendly—such as the developgroups. That report found that many LGBT Coloradans ment of written policies prohibiting discrimination, felt alienated from the healthcare system and that the providing domestic partner coverage options, and majority of LGBT Coloradans are not open with their using LGBT-friendly forms. Unfortunately, those alhealthcare provider about their sexual orientation or genready moving in the direction of LGBT inclusivity reder identity and expression. Additional barriers to getting main the minority. But most physicians expressed the healthcare this community needs include access to much willingness to take additional steps to be more providers that understand the specific health needs of LGBT-friendly. LGBT individuals. On a positive note, those who per5. Colorado physicians generally believe ceived their provider to be LGBT-friendly are they are already treating their LGBT pamore likely to report participating in health tients equally to their other patients, and promoting activities such as visiting a primary LGBT patients should feel comfortable. care physician and receiving wellness and However, equal treatment does not preventive services. mean LGBT Coloradans are getting the As a result of the 2011 report, DMS, care they need. CMS, and One Colorado embarked on a pro6. Primary care physicians were more ject to measure and impact physician knowllikely than their specialty care counteredge and treatment of LGBT Coloradans. parts to acknowledge the role that sexThe project was supported by the Community ual orientation and gender identity and First Foundation and Denver Health. An adexpression play in patient health. And visory group of physicians, led by Mark similarly, they were more likely or more Thrun, MD (a DMS member and Director of willing to be taking steps to be more HIV Prevention and STD Control for Denver LGBT-friendly. Public Health), interested and experienced in 7. The survey revealed a greater interest in LGBT health, worked with experts to develop Mark Thrun, MD, led advisory becoming more LGBT-friendly among physia comprehensive survey that was sent to physicians across the state and included group in developing survey cians practicing in the Denver metro area, among younger physicians in the state, and questions about attitudes, knowledge, and among male physicians. willingness to improve care for their LGBT communities. The results of the survey were highly encouraging, showThere is clearly an opportunity for the healthcare ing that Colorado physicians are committed to serving community to partner with LGBT advocates to bridge the the needs of all of their patients and overwhelmingly recgap between “treating everyone equally” and the percepognize that sexual orientation and gender identity and tions and experiences of actual patients. As a result of expression are part of individual health. There is strong our partnership, an accredited online CME program has interest in taking steps to eliminate and lessen the fears been created for Colorado physicians and other health that LGBT individuals and their families experience when providers entitled “Health and Healthcare for the LGBT accessing the healthcare system. Major findings of the Community: Identifying and Minimizing Disparities”. This physician survey are: training can be accessed at http://cms.org/resources/ 1. Colorado physicians overwhelmingly reported high levels of comfort in serving lesbian, gay, and bisexhealth-and-health-care-for-the-lgbt-community. ual patients. They reported being comfortable if and In addition to encouraging physicians and other prowhen a patient discloses their sexual orientation. viders to participate in various training opportunities, Physicians reported slightly lower numbers with reother recommendations generated by the survey results, spect to serving transgender patients, but still, a suand which will inform further action, include simple per-majority reported they are comfortable. changes physicians can implement in their practices. 2. Colorado physicians believe their staff members are generally comfortable serving lesbian, gay, and bi(Continued on page 6)
Denver Medical Bulletin
Obama Signs Budget Deal, Stopping the 24% SGR Cut
LGBT Patients (Continued from page 5) Office policies such as utilizing forms that are gender neutral and recognize diverse family reporting options, clear anti-discrimination policies that include sexual orientation and gender identity, and LGBT-friendly practices such as appropriate signs and brochures can go a long way to making LGBT individuals comfortable. Partnering with advocacy organizations to identify and implement next steps in this process can help us achieve the goal of improving health equity in Colorado. Finally, physicians and other health providers should routinely ask questions about sexual orientation and gender identity and expression. 2011 survey results indicate that this one action can make a major difference in providing a comfortable environment for the patient seeking healthcare services. The full report, “Becoming Visible: Working with Colorado Physicians to Improve LGBT Health” can be accessed at http://www.one-colorado.org/news/new-onecolorado-report-on-lgbt-health-becoming-visible/.
President Obama signed the Pathway for SGR Reform Act of 2013 into law on Dec. 26, 2013, preventing a scheduled 24% payment reduction for physicians who treat Medicare patients from taking effect on Jan. 1, 2014. The new law provides for a 0.5% update for claims with dates of service from Jan. 1 through March 31, 2014. The update is intended to avoid disruptions to the Medicare program while Congress resumes its work on legislation to repeal the Sustainable Growth Rate in early 2014. Committees in both houses have passed legislative proposals to repeal the SGR and transition to a new Medicare physician payment system. Both versions would consolidate and restructure existing quality improvement incentive programs and allow for bonus payments for high-performing practices and lessen potential penalties. The deadline to modify your participation status with Medicare has been extended to Jan. 31, 2014.
Denver Medical Bulletin
practical matter, CMS is in the process of revalidating all enrolled physicians and including their information in PECOS, so you may already have a record in PECOS. Physicians who have updated their enrollment since late 2003 should be in PECOS.
Medicare Date (Continued from page 2) MA13 will be used for rejected claims due to the missing required NPI.
Q. Does the Medicare Ordering and Referring File include physicians who are both enrolled in older Medicare contractor databases AND the newer centralized enrollment database known as PECOS? A. No. However, Medicare’s revalidation effort (aimed at asking physicians and other providers to validate their enrollment information on file with Medicare) has resulted in most physicians being in the newer PECOS system. Nonetheless, Medicare has said their edits should account for anyone who is enrolled no matter which system.
For warnings and denial edits impacting home health claims, please see http://www.cms.gov/Outreach-andEducation/Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/SE1305.pdf. Enrollment questions Q. How do I enroll in Medicare solely for purposes of ordering and referring? A. You need to fill out the 855-O form at http://www. cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/ cms855o.pdf. Once you’ve submitted the form, you can check CMS’ website at http://www.cms.gov/Medicare/ Provider-Enrollment-and-Certification/ M e d i c a r e P r o v i d e r S u p E n r o l l / MedicareOrderingandReferring.html to see if your name appears on the list of physician applications pending contractor review and, once you’ve been enrolled, your name will appear on the Medicare Ordering and Referring File. The 855-O only allows a provider to order and refer services and does not allow a provider to directly bill Medicare for any services he or she furnishes.
Q. I am completing my residency. Should I enroll for purposes of ordering and referring? A. State-licensed residents may enroll to order and/or refer and may be listed on claims. Claims for covered items and services from un-licensed interns and residents must still specify the name and NPI of the teaching physician. However, if states provide provisional licenses or otherwise permit residents to order and refer services, CMS will allow interns and residents to enroll to order and refer, consistent with state law. Privately contract/opt-out questions Q. How do I know if my local Medicare contractor has me on file as having a valid opt-out affidavit? A. You can call your Medicare contractor and check this or go online to view the Medicare Ordering and Referring File and see if you are listed. The online file contains physicians who are enrolled in PECOS as well as those who have a valid opt-out affidavit on file. To view the file go to http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/MedicareProviderSupEnroll/ MedicareOrderingandReferring.html.
Q. How long does it usually take CMS to process enrollment applications? A. CMS estimates that it takes 45 days to process applications submitted online and 60 days for those submitted on paper. These estimates are for “clean applications”; those that require contractor requests for additional information may take longer. Q. I submitted my enrollment application on Dec. 15, 2013, but my enrollment wasn’t approved and effective until Feb. 5, 2014. The patient I referred was seen by the billing provider on Jan. 15, 2014. Will the claim for that patient be paid if submitted by the billing provider on Jan. 30, 2014? A. No, the claim will be denied. CMS looks at the date of service when determining whether the ordering and referring enrollment requirement has been met, not the date that the claim is billed.
Q. I do not participate in Medicare and I privately contract with my patients. Should I enroll to satisfy this ordering and referring enrollment requirement? A. No. You should file an opt-out affidavit with your local MAC and it should include your NPI. Having a valid opt-out record will satisfy the requirement. The AMA link http:// www.ama-assn.org/ama/pub/physician-resources/solutions -managing-your-practice /coding-billing-insurance/ medicare/medicare-enrollment-process.page should be helpful to you. Keep in mind that opt-out records are effective on a quarterly basis and must be filed 30 days in advance of the next quarter before they can become effective. If you privately contract with Medicare patients and enroll with Medicare instead of filing an opt-out affidavit for purposes of meeting the ordering and referring require-
Q. I enrolled many years ago with Medicare before the PECOS enrollment system was created. Do I need to enroll in PECOS? A. No, you do not need to enroll in PECOS to satisfy the ordering and referring enrollment requirement. If you have an enrollment record in the older, legacy Medicare enrollment system, that is sufficient. The Medicare legacy system refers to Medicare enrollment record systems maintained by individual Medicare contractors that have not yet transferred these records into PECOS. However, as a
(Continued on page 8)
Denver Medical Bulletin
component of imaging services. However, if billing globally, both components will be impacted by the edits and the entire claim will be denied if it doesn’t meet the ordering and referring requirements. It is recommended that providers and suppliers bill the professional and technical components separately to prevent a denial for the professional component.
Medicare Date (Continued from page 7) ments, you may incur legal penalties for privately contracting with your Medicare covered-patients. Q. How long is a Medicare opt-out affidavit valid? A. Two years.
Q. Does this requirement apply to the technical and professional component of clinical laboratory services? A. No. This requirement only applies to the technical component of clinical laboratory services.
Q. Will my Medicare contractor notify me when my affidavit expires? A. No.
ABN/patient billing questions Q. I privately contract with Medicare patients and I have never submitted an affidavit to Medicare. What should I do? A. Physicians who privately contract with Medicare patients may not realize that they are required to file an affidavit with their local contractor. Medicare has said these physicians should file their affidavit before the edits are turned on starting Jan. 6, 2014.
Q. Are physicians and other providers permitted to use an Advance Beneficiary Notices (ABN) solely for the purpose of obtaining reimbursement from patients because they expect their claim(s) to be denied because the ordering/ referring provider is not enrolled (or had a valid opt-out affidavit on file) with Medicare? A. If the services being ordered/referred are for services covered by Medicare which are considered medically necessary, then no, an ABN cannot be used.
Imaging, drug and lab order services questions
Q. Can a provider bill a Medicare patient directly for services which will be denied because the ordering or referring provider has not enrolled and does not have an optout affidavit on file? A. No. Medicare has said it has a long standing policy which precludes this.
Q. Does this requirement apply to orders for prescription drugs? A. All claims for drugs are excluded from the ordering and referring edits. Q. Does this requirement apply to the technical and professional component of imaging services? A. This requirement only applies to orders for the technical
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