New Medicare Annual Wellness Visits

Effective Jan. 1, 2011, providers (physicians, physician assistants, nurse practitioners, or clinical nurse specialists or other medical professional working under the direct supervision of a physician) may report two new HCPCS G-codes for annual wellness visits (AWV) for Medicare beneficiaries. In order to report codes G0438 (annual wellness visit; includes a personalized prevention plan of service [PPPS], first visit); and G0439 (…, subsequent visit), documentation must show that the elements of the service were provided. These include:

• Establish/update individual medical and family history. At a minimum, CMS requires documentation of a patient’s “past medical and surgical history, experiences with illnesses, hospital stays, operations, allergies, injuries and treatments, use or exposure to medications and supplements, including calcium and vitamins, and medical events experienced by the beneficiary’s parents and any siblings and children, including diseases that may be hereditary or place the individual at increased risk.”
• Track care and drugs. Create/update list of patient’s regular providers and suppliers of medical care, and medications, including supplements such as vitamins.
• Physical assessment. Measure height, weight, body mass index (BMI) or waist circumference, blood pressure and other routine measurements as appropriate, based on the patient’s medical and family history.
• Check for signs of cognitive impairment. CMS defines this as “assessment of an individual’s cognitive function by direct observation, with due consideration of information obtained by way of patient report, concernsraised by family members, friends, caretakers or others.”
• Establish/update a schedule of screening services. This should be a written schedule, such as a checklist, that sets patient-appropriate tests for the next 5-10 years, based on government recommendations and the patient’s own health status, screening history and age-appropriate preventive services that Medicare covers.
• Establish a list of risk factors and conditions for which interventions are recommended or already underway. These include any mental health conditions or risk factors/conditions identified through an initial preventive physical exam, along with a list of treatment options and associated risks and benefits.
• Furnish personalized health advice and referral where needed to health education or prevention counseling services or programs. CMS clarifies that physicians may separately bill for all preventive services (those covered without requiring a copay in the final rule) in the same encounter or day as the AWV.
• Screen for depression. This should include a review of the patient’s current or past experiences with depression or other mood disorders, based on use of an appropriate screening instrument. Depression screening is only required during the initial AWV (G0438).
• Screen for functional status. The clinician may use direct observation or tests to check for (at a minimum) hearing impairment, fall risk, home safety and the ability to successfullyperform the activities of daily living. Functional status screening is only required during the initial wellness visit.

New Medicare Annual Wellness Visits

Effective Jan. 1, 2011, providers (physicians, physician assistants, nurse practitioners, or clinical nurse specialists or other medical professional working under the direct supervision of a physician) may report two new HCPCS G-codes for annual wellness visits (AWV) for Medicare beneficiaries. In order to report codes G0438 (annual wellness visit; includes a personalized prevention plan of service [PPPS], first visit); and G0439 (…, subsequent visit), documentation must show that the elements of the service were provided. These include:

• Establish/update individual medical and family history. At a minimum, CMS requires documentation of a patient’s “past medical and surgical history, experiences with illnesses, hospital stays, operations, allergies, injuries and treatments, use or exposure to medications and supplements, including calcium and vitamins, and medical events experienced by the beneficiary’s parents and any siblings and children, including diseases that may be hereditary or place the individual at increased risk.”
• Track care and drugs. Create/update list of patient’s regular providers and suppliers of medical care, and medications, including supplements such as vitamins.
• Physical assessment. Measure height, weight, body mass index (BMI) or waist circumference, blood pressure and other routine measurements as appropriate, based on the patient’s medical and family history.
• Check for signs of cognitive impairment. CMS defines this as “assessment of an individual’s cognitive function by direct observation, with due consideration of information obtained by way of patient report, concernsraised by family members, friends, caretakers or others.”
• Establish/update a schedule of screening services. This should be a written schedule, such as a checklist, that sets patient-appropriate tests for the next 5-10 years, based on government recommendations and the patient’s own health status, screening history and age-appropriate preventive services that Medicare covers.
• Establish a list of risk factors and conditions for which interventions are recommended or already underway. These include any mental health conditions or risk factors/conditions identified through an initial preventive physical exam, along with a list of treatment options and associated risks and benefits.
• Furnish personalized health advice and referral where needed to health education or prevention counseling services or programs. CMS clarifies that physicians may separately bill for all preventive services (those covered without requiring a copay in the final rule) in the same encounter or day as the AWV.
• Screen for depression. This should include a review of the patient’s current or past experiences with depression or other mood disorders, based on use of an appropriate screening instrument. Depression screening is only required during the initial AWV (G0438).
• Screen for functional status. The clinician may use direct observation or tests to check for (at a minimum) hearing impairment, fall risk, home safety and the ability to successfullyperform the activities of daily living. Functional status screening is only required during the initial wellness visit.

10/30/09: FTC Extends Enforcement Deadline for Identity Theft Red Flags Rule

The Federal Trade Commission (FTC) is delaying enforcement of the “Red Flags” Rule until June 1, 2010. As part of the Federal Trade Commission's (FTC's) implementation of the Fair and Accurate Credit Transactions (FACT) Act of 2003, most medical providers would have needed to comply with the "Red Flags" rule November 1, 2009. The rule requires "creditors" – which the FTC defines to include most health care providers – to establish a program to prevent identity theft in their practices.

Medicare Legacy Provider IDs Not To Be Reported on UB-04 Claims

Effective May 23, 2008, the Centers for Medicare & Medicaid (CMS) has mandated that Provider Legacy Identifiers (PINs, UPINs, or National Supplier Clearinghouse numbers) are not to be reported on CMS-1500 forms (for billing physician services) or on UB-04 claims. Nor are they to be used on the electronic HIPAA equivalents of these forms—the 837P and the 837I. Only National Provider Identifiers (NPIs) are to be reported. Claims containing Provider Legacy Identifiers will be returned as unprocessable.

Effective Date: May 23, 2008

Sources:

• MLN (Medicare Learning Network) Matters Number MM5858
• Related Change Request Transmittal # R1432CP
• Related Change Request (CR) #5858

Note: The UB-04 examples and case studies presented in the Hospital Billing student text/workbook were prepared during the NPI implementation period, during which time CMS (Centers for Medicare and Medicaid) and the NUBC (National Uniform Billing Committee) recommended providers include both NPI and legacy numbers on all hospital claims. Therefore, the UB-04 claims used in the textbook provide both numbers. However, as of May 23, 2008, this requirement officially changed. Beginning May 23, 2008, only NPI numbers are to be reported.

New Value Code FC to Report Patient Prior Payments

The NUBC (National Uniform Billing Committee) created new value code FC (Patient Paid Amount) to enable hospitals to report patient prior payments on the UB-04. On the previous UB form, the UB-92, FL 54 (Prior Payments—Payers and Patient) was available to report prior payments from payers as well as patients. With the implementation of the UB-04, “Patient” was eliminated from this field. New value code FC will enable hospitals to continue to report patient prior payment amounts.

New Code: Value Code FC

Title: Patient Paid Amount

Definition: The amount the provider has received from the patient toward payment of this bill.

Effective Date: July 1, 2008

Sources:

• http://www.nubc.org/subscribers/subscribers.html “UB-04 Manual—Version 2.00 Clarifications/Errata/Updates” (available to the public)
• MLN (Medicare Learning Network )Matters Number MM5882

New Value Code FD to Report Credit Received from the Manufacturer for a Replaced Medical Device

New Code: Value Code FD

Title: Credit Received from the Manufacturer for a Replaced Medical Device

Definition: The amount the provider has received from a medical device manufacturer as credit for a replaced device.

Effective Date: July 1, 2008

Source:http://www.nubc.org/subscribers/subscribers.html
“UB-04 Manual—Version 2.00 Clarifications/Errata/Updates” (available to the public)

New Condition Codes for Indicating Duplicate Claims and Appeal Claims

Identity-Theft Red Flag Requirements

The Federal Trade Commission requires healthcare organizations that provide credit to patients to comply with identity-theft red flag rules. The organization must set up a process to find "red flags"--actions that might indicate an attempt to steal the person's personal data for illegal use.

The FTC released the final rules on what it calls “identity theft red flags” on November 9, 2007 in the Federal Register (72FR63718). Essentially, the requirement calls for the creditor (healthcare organization, office, or practice) to set up a process so that its staff can determine or identify possible identity theft “red flags” and respond. The rules are flexible, but do require identification of the potential problem areas, what action is to be taken, and a means to revisit the protocol and update as needed. The final rule and other guidance from the FTC provide suggestions for the flags that might be established.

After a number of delays, the rule takes effect Nov. 1, 2009

For further information read the current information at www.ftc.gov/redflagsrule. The rule contains an appendix (72FR63774) to assist businesses to set up the red flags. Helpful information is also offered on the American Medical Association website at

www.ama-assn.org/ama/no-index/physician-resources/red-flags-rule.shtml

HIPAA AND HITECH Update (50.0K)

Red Flag Update 6/2010

The Federal Trade Commission will temporarily exempt physicians from the “Red Flags” rule, pending the outcome of an ongoing court case. The rule requires creditors and financial institutions with "covered accounts" to implement written programs to help detect and respond to practices and activities that could indicate identity theft by Dec. 31. FTC identified Dec. 31as the starting date for enforcement after several previously announced delays. The American Medical Association, American Osteopathic Association and Medical Society of the District of Columbia in May filed a federal lawsuit seeking to prevent the FTC from extending the rule to physicians. Last November, the U.S. District Court for the District of Columbia ruled that the FTC may not apply the rule to attorneys, but the FTC has appealed that decision. Until the court reaches a decision in the case, which was brought by the American Bar Association, the FTC has agreed not to enforce the rule for physicians. The agreement is pending the approval of the D.C. Circuit Court of Appeals.--From the AHA News Now

UPDATE ON RED FLAGS RULE: IT DOES NOT APPLY TO PHYSICIANS

In September of 2008, I first posted information on the Red Flags Rule, which requires lenders to develop plans to ensure that consumers’ financial information is kept secure. Its implementation, however, has been much debated by the health care industry, particularly the AMericna Medical Association (AMA), which declared that the rule was not appropriate for physicians. Now, due to an end-of-year action by Congress soon to be signed into law by the President, it is clear that this rule will not apply to physicians.

The rule, separate from HIPAA patient-privacy rules, required creditors to demonstrate a protocol “for detecting identify theft red flags, preventing and responding to identity theft, and for keeping their programs up to date.” Under the Federal Trade Commission’s interpretation, physicians had been considered creditors if they bill patients for fees not collecteda t the time of service—which applied to almost all practices. The new interpretation exempts physicians from the category of “creditors.”

Physicians, of course, are given credit/debit card and banking information by patients and must still be careful to secure this financial data. However, formall steps outlined int eh Red Flags Rule are now not required.

Cynthia Newby, CPC, CPC-P
December 14, 2010