CMS Announces CAP Enrollment Extension & Plans to Streamline Medicare Enrollment Process

CMS just announced an extension to the physician election period for the Medicare Part B Drug Competitive Acquisition Program (CAP). The CAP is a voluntary program that offers physicians an option to acquire many drugs they use in their practice from approved CAP vendors. Rather than purchasing these drugs from distributors and being reimbursed by Medicare, the physician would order the drug from an approved vendor and administer it to the beneficiary, but the vendor would be responsible for billing Medicare for the drug and collecting the coinsurance from the beneficiary.

The CAP physician election period's extension will begin on June 3, 2006 and continue through June 30, 2006. Physicians whose completed physician election forms are received by their local carrier and are postmarked on or after June 3, but no later than June 30, 2006, will be enrolled to participate in the CAP beginning August 1, 2006.

Initial CAP implementation is still scheduled for July 1, 2006. Physicians whose completed CAP election forms are received by their local carrier and are postmarked on or before June 2, 2006 will be enrolled to participate in the CAP beginning July 1, 2006.

Please see the Medicare Part B Drug CAP Website's Information for Physicians page

(http://www.cms.hhs.gov/CompetitiveAcquisforBios/02_infophys.asp#TopOfPage ) for additional information about CAP physician election. The physician election form may be downloaded from this page. Completed forms must be returned by mail to the physician's local carrier.

Please note that participation in the CAP is voluntary and that no action is required from physicians who do not wish to participate.

In May, the Centers for Medicare & Medicaid Services (CMS) issued a new rule that will further help ensure that Medicare pays health care providers and suppliers accurately and appropriately and will help to protect Medicare from fraud and abuse. The final regulation makes Medicare enrollment requirements more uniform so a health care provider or supplier can bill Medicare most efficiently. The rule standardizes existing Medicare enrollment requirements that have been used by the various Medicare contractors that process and pay Medicare claims. "The new rule will also help bring us even closer to the development of an electronic medical record," said Timothy B. Hill, Chief Financial Officer and Director, Office of Financial Management at CMS.

The regulation requires that providers and suppliers:

While one of the primary requirements of this rule is that all providers and suppliers (both new and those already in the program) complete the CMS-855 Medicare enrollment application, existing providers and suppliers are not required to take any action at this time. CMS will notify the provider or supplier when it is time to re-certify their Medicare enrollment information.

In addition to publishing this regulation, CMS anticipates issuing revisions to the existing CMS-855 Medicare enrollment applications in the near future. The revised enrollment applications simplify the enrollment process and make it easier for providers and suppliers to complete and submit an enrollment application to Medicare.

For additional information regarding the Medicare enrollment process, visit Medicare's provider enrollment web site at www.cms.hhs.gov/MedicareProviderSupEnroll.

2006 Conference Featured Hot Topics and Networking in San Antonio

This year, San Antonio was the host city for the 2006 National Conference for Certified Professionals, held May 18 and 19 in San Antonio. The conference welcomed about 200 certified coders, billers, and office managers from across the country. The sessions went well, despite some hotel headaches, and included a Karaoke performance by 5 PMI speakers during lunch on the second day.

Mr. Winstanley Luke, OIG Deputy Chief, opened the second day with a presentation on the importance of cooperation during a federal audit. Midway during his presentation, four FBI agents burst through the door, identified, cuffed, and removed a suspect from the audience. The audience was told to remain seated and quiet. The room was quiet as people tried to determine if this was part of the show or a true bust. The agents and Mr. Luke let the effect sink in for a moment before his FBI friends smiled and released the cuffed volunteer and resuming the presentation. Murmurs filtered through the ballroom as relieved audience members were heard throughout the room as people realized it was a mock arrest. It was a memorable presentation that many participants won't soon forget.

Other sessions included a packed house for a Modifiers discussion given by Jimmie Hebert. Michael Brown, a contributing editor for Medical Economics, gave a talk about the next wave of healthcare - Consumer-driven healthcare and pay-for-performance. Other popular topics included Staff Motivation and Conflict Resolution, Upgrading Administrative Policies and Procedures, and an Interactive E&M Coding Workshop.

Some comments from the participants included:

Getting to see an assortment of programs and presenters in a two-day span made for a motivating and information-filled event. PMI has plans to make this an annual event. So stay tuned! Location and date for next year will be announced in an upcoming issue of The Link.

Managed Care Audit Tips and Checklist
By Linda Dykes, CPC

Casting fear into the bravest of managers…"AUDIT NOTICE"!. With proper preparation, any audit can be faced with confidence. The secret is knowing what the auditors will be looking for in the office and your charts. The managed care audit does not focus only on the chart audit; they look into all aspects of the office operation. The auditor will review the physician's updated medical licenses, DEA, DPS and Malpractice Insurance coverage. A site check will include the following areas:

Staffing

Exam/Treatment Patient Care Areas

Appearance and Access

Appointment accessibility

Safety and Emergency Protocols

Medical Record Keeping

Each managed care auditor will have specific forms to follow in these areas. The forms will vary from company to company, but will generally follow OSHA and CMS guidelines. These audits will also vary in specialty; i.e., what is required for an OB will be more detailed than what would be required of an Ophthalmology office. This can be the proverbial "tow birds with one stone". OSHA and CMS office compliance will also cover most managed care audit areas. While the penalties are not in the CMS or OSHA range a general overview and quarterly review should be in your office management protocols.

Denied Claims? Research is Key
By Tyessa V. Howard, CMC

I work part-time for a pre-collections agency. As the coder, I am in charge of reviewing denied claims from the Ohio Bureau of Worker's Compensation. With the Bureau's diagnosis and the doctor's notations at hand, I look over the claim to see not only if the Bureau's code applies, but if indeed it does, then why was something other than that used as a diagnosis? In doing this, I have discovered what I believe the original coder of the claim may have overlooked- research is the key.

Why was the wrong code used in the first place? I have found many times it is simply because the original coder did not search for code that better fits the diagnosis. Take for example the infamous code V67.00 which means "follow- up examination, following surgery unspecified." Does this code have to be used every time someone goes to the doctor after surgery? Is this code Worker's Comp allowable? No, that would be too easy.

What I have found when researching in my ICD-9 book and medical dictionary is that there are other codes out there that can be used, but rarely are. Take for example V58.43. The description for this code is "aftercare following surgery for injury and trauma. (Conditions classifiable to 800-999), but excluding aftercare for healing traumatic fracture (V54.10-V54.19)." Say someone came in to have aftercare after surgery of an open wound of the shoulder and upper arm (category 880). Which code would be the wiser more specific choice, even if you were not dealing with the Bureau of Worker's Compensation? The V67.00 or the V58.43? Sometimes it takes a little extra research to find the code that best fits the scenario rather than going with what's most common.

Bottom line: don't get too comfortable with common codes. Dig further and research the best code. As a biller and coder myself, I understand the time restraints of the billing process. However, I also understand that taking just a little extra time to get it right the first time would of course lead to less denials and more money.

Keep in mind that what is common to us, is probably common, generic, and very non-specific to insurance companies. . It is hard enough getting claims paid. We have to remember to come as close as possible to the description given to us by the doctor's notations, leaving nothing to guess or chance.

Learn what codes are acceptable and unacceptable to the insurance companies you are dealing with. Also look words up. For example, the words "groin" and "pelvis", are they interchangeable? When it comes to dealing with a male patient, perhaps. These small words could be the difference between a payable and non-payable code. And of course, always read the doctor's notes thoroughly. Be clear on what he or she is trying to say, so you are clear on how it needs to be coded.