THE HEALTH CARE REFORM

LAW: HOW IT AFFECTS

YOUR MEDICARE PAY
PREPARE YOUR PRACTICE
FOR THE CHANGES
Link to Slides at :
www.scribd.com/doc/30938016/PPCA-Impact-on-Medicare-Pay

Torrey Kim, MA, CPC

Editor-in-Chief
Part B Insider
torreyk@inhealthcare.com
2

Torrey Kim, MA, CPC

Editor-in-Chief, Part B Insider
 When I’m not working on Part B Insider, I’m trying to
 wrangle my three boys!
3

Patient Protection and Affordable Care

Act – Signed Into Law March 23


Coding and billing staffers may feel like the woman on the right
when they think about how the law might create systems
confusion
 Agenda
4

qWhat Is the PPACA?

qHow Will the PPACA Impact
Medicare?
qWhat Are the Implementation
Timelines?
qWho is Responsible for Making
Changes to Your Systems?
qWhat Steps Should You Take Now?
qHealth Care Reform Resources

 What is the PPACA?
5

 The Patient Protection and Affordable Care Act, also known

as the PPACA, HR 3590, or simply the “health care
reform law,” includes over 2,000 pages of health care-
related provisions that will take effect over the next four
years.


 Many of the PPACA’s other provisions, such as pre-existing

condition coverage, have received widespread media
attention, but some practices are still unclear of how it
impacts Medicare


 Today’s presentation will break down a few of the most

important factors involving Medicare pay that the PPACA
has in store

 How Will The PPACA Impact
Medicare?
6

 Annual Wellness Visits (Sec. 4103)

 Every year other than the patient’s first year on Medicare,
beneficiaries will benefit from a “health risk
assessment,” not subject to their deductible or
coinsurance, which includes an exam of height, weight,
blood pressure, and other routine measurements


 Based on the results of the health risk assessment, the

provider will:
 Provide a screening schedule for the next 5 to 10 years
 Create a list of risk factors, counseling services, and referrals to
other professionals to provide interventions on such issues as
weight loss, smoking cessation, nutrition, fall prevention, and
physical activity


 The wellness visits will take effect as of Jan. 1, 2011

 How Will The PPACA Impact
Medicare?
7

10% Bonus for Primary Care (Sec. 5501)



 Effective Jan. 1, 2011, primary care practitioners

“shall be paid (on a monthly or quarterly basis) an
amount equal to 10 percent of the payment amount
for the service,” in addition to their normal fees
 Who qualifies? Doctors, nurse practitioners, clinical
nurse specialists, or physician assistants with the
primary specialty designation of family medicine,
internal medicine, geriatric medicine, or pediatrics
qualify for the bonus.
 The catch: These practitioners will have to bill at
least 60 percent of their allowed charges as
‘primary care services,’ which are defined by codes
99201-99215, 99304-99340, or 99341-99350.

 How Will The PPACA Impact
Medicare?
8

You Have One Year to Submit Claims (Sec.

6404)
q
 In the past, Part B providers had 15 months or
more to submit their claims to Medicare, but
the new legislation requires you to submit
your claims “one calendar year after the date
of service” for services provided on or after
Jan. 1, 2010.

 Caveat: The legislation states that “the
Secretary may specify exceptions to the 1
calendar year period,” but does not yet
indicate what types of situations might
qualify for exceptions.
 How Will The PPACA Impact
Medicare?
9

 Health Professional Shortage Area (HPSA) Bonuses

(Sec. 5501)


 Major surgical procedures performed between Jan. 1, 2011

and Dec. 31, 2015 by a general surgeon in a health
professional shortage area will qualify for a 10 percent
bonus
 The 10% payment will be disbursed “on a monthly or
quarterly basis”
 A general surgeon is defined as a doctor who has
designated specialty code 02 (General surgery) as their
primary specialty
 “Major surgical procedures” are those with 10- or 90-day
global periods
 HPSA basics: Medicare will adjust your payment
accordingly if you provide services in a ZIP code that
falls within a pre-designated HPSA county; however, if
 How Will The PPACA Impact
Medicare?
10

Outpatient Therapy Cap Exceptions



Extension (Sec. 3103)


 The law extends the exceptions process for
outpatient therapy caps, which means that these
therapy providers may continue to submit claims
with the KX modifier (Specific required
documentation on file) when an exception is
appropriate, for services furnished between Jan. 1
and Dec. 31, 2010


 The current outpatient therapy cap is $1,860 for

physical therapy and speech language pathology
services combined, and a separate $1,860 limit
for occupational therapy services provided in a
 How Will The PPACA Impact
Medicare?
11

Labs Can Bill TC for Hospital



Patients (Sec. 3104)



 Effective retroactive to Jan. 1, 2010,

independent labs can submit claims
to Medicare for the technical
component of physician pathology
services furnished to hospital
patients, whether the patient was an
inpatient or an outpatient
 Labs that were previously denied for
such services should contact their
 How Will The PPACA Impact
Medicare?
12

Extension of 5% Mental Health Bonus (Sec.



3107)


 Three years ago, CMS reduced Part B payments for

mental health services during what it called a “Five
Year Review” period. Congress gave mental health
providers a 5 percent bonus payment in 2008 to
make up for these cuts, but that expired on Dec.
31, 2009. The PPACA restores the 5 percent bonus
payment through Dec. 31


 The law makes the 5 percent bonus retroactive to

Jan. 1, 2010
 How Will The PPACA Impact
Medicare?
13

PQRI Program Extended (Sec. 3002)



 The following PQRI incentives/reductions are now

applicable through 2016 and beyond:

 2011: Incentive payment of a 1 percent bonus
 2012 through 2014: Incentive payment of a 0.5 percent
bonus
 2015: Penalty of 1.5 percent
 2016 and beyond: Penalty of 2 percent


 The PPACA calls for an informal appeals process to

be in effect as of Jan. 1, 2011 for providers “to
seek a review of the determination that an eligible
professional did not satisfactorily submit data on
quality measures”
 How Will The PPACA Impact
Medicare?
14

Timeliness of Refunding Overpayments (Sec.



6402)
 If you receive an overpayment from Medicare, you

must report and return the overpayment within 60

days after the overpayment was identified, or the
date any corresponding cost report is due
(whichever is later)
 You must notify the secretary, state, intermediary,

carrier, or contractor in writing and inform them of

the reason for the overpayment
 “Overpayment” refers to “any funds that a person
receives or retains…to which the person, after
applicable reconciliation, is not entitled”

 How Will The PPACA Impact
Medicare?
15

Other Ways the Legislation Will Affect Medicare:



 Effective Jan. 1, 2011, your claims must include an

NPI (Sec. 6402)

 Any applicable manufacturer must submit a report

on March 31, 2013 and on the 90th day of each

calendar year thereafter that includes information
regarding “transfers of value” that they made to
covered recipients (including physicians). These
include cash, items, services, consulting fees, gifts,
entertainment, education, travel, and other fees
(Sec. 6002)
 The PPACA expands the Recovery Audit Contractor

(RAC) program and rolls it out into Medicare Parts

C and D by the end of 2010 (Sec. 6411)
 What Are the Implementation
Timelines?
16

 Question: The healthcare reform bill included several

pay boosts that were retroactive to Jan. 1. When will
the fee schedule incorporate those retroactive
changes?

 Answer: “There’s a complex calculation of a variety
of those changes that we are going through to put
them together,” said CMS’s Amy Bassano during
an April 13 CMS Open Door Forum. CMS must
prepare before it incorporates the pay boosts, which
could take “a month or two,” she said

 Plus: Even after CMS releases the new rates, “We still
have our Medicare contractors do extensive tests
on those to make sure they are correct, so that
takes a little bit of time as well,” said CMS’s
Stewart Streimer on the April 13 call.
 Who Is Responsible for Making
Changes to Your Systems?
17

 Billing Dept: If your practice chronically

submits claims more than one year after
the date of service, talk to your billing
department or outsource company about
how to make claims processes more
efficient


 Front and Back Office: Prepare to

institute internal systems that will allow
for annual wellness visits without
collecting deductibles or coinsurance,
effective in 2011

 Practice Manager/Physicians: If you
don’t have an NPI yet, enroll via the
 Steps to Take Now
18

 Be ready for questions from Medicare

patients, who may expect changes to
be in effect immediately
 Tighten up your billing systems or talk to
your billing outsource companies to
prepare for the new 1-year deadline for
claims filing


 KEEP IN MIND :
CMS staffers don’t even have all of the answers yet, so you may not eithe
 H e a lth C a re R e fo rm
19 R e so u rce s
 You can read the entire PPACA law (2,393
pages) at www.opencongress.org/bill/111-
hh3590/show
 To determine whether your area qualifies as a
health professional shortage area, visit
www2.cms.gov/HPSAPSAPhysicianBonuses
 To obtain an NPI, visit
www.cms.gov/NationalProvidentStand/03_app
ly.asp
 Updates are continuing in Part B Insider and via
our webinars, visit our Web site at
www.supercoder.com
 Email me any time at
torreyk@inhealthcare.com
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