Medicare: CMS & WPS

Billing New Patients P.2.

CERT Errors on 99211 P.2.

Enrollment Status via Email P.2.

Training & Teleconferences P.2.

When Primary Insurer Pays in Full, Should You Bill Medicare? P.3.

Fact Sheet on CMS-1500 P.3.

Guidelines for Ordering—Referring Providers P.3.

C-SNAP Medicare Portal Requires Annual Recertification P.5.

Nursing Home Claim Rejections Pp.1 and 11.

Electronic Claims

5010 Readiness Assessment P.4.

5010 Testing Day June 15 P.4.

5010 Implementation Calendar P.5.

PC-ACE Software Update. P.10.

EHR

Meaningful Use At Risk for Infrequent Prescribers. P.1.

New Attestation Resources P.6.

First EHR Payments Made P.6.

EHR Frequently Asked Questions P.7.

AOA: Five Optometry EHR Products Now Available. P.7.

eRx and PQRS

Start E-Rxing Now to Avoid Penal-ties. P.8.

2009 PQRS and eRx Experience Report Available P.8.

DME Suppliers

DME Suppliers Must Enroll Every Three Years. P.9.

$500+ Fee to Enroll or Re-enroll as a DME Supplier P.9.

Coding

VEP and Tear Osmolarity Not Cov-ered by Medicare P.11

Nursing Home Codes Requests and Rejections. P.11.

Medicare Nursing Home Code Rejections

Many optometrists in Nebraska, Iowa, Kansas, and Missouri are receiving requests for documentation of nursing home visits. Apparently WPS is cutting a wide swath while checking to make sure nursing home claims are medically necessary and are correctly documented. 99309 seems of particular interest to WPS. See more information on page 11.

June 2011

Nebraska Optometric Association Volume 11, Issue 6

NOA 3rd Par ty Newsletter

EHR: “How Should A Provider Who Orders Medications Infrequently Calculate The Measure For The Medication EHR Objective .....”

For the Medicare Electronic Health Record (EHR) Incentive Programs, how should an eligible professional (EP) who orders medica-tions infrequently calculate the measure for the "computerized provider order entry (CPOE)" objective if the EP sees patients whose medications are maintained in the medication list by the EP but were not or-dered or prescribed by the EP?

The CPOE measure is structured to minimize reporting burden. However, if all of the fol-lowing conditions are met it can also cre-ate a unique situation that could prevent an EP from successfully demonstrating meaningful use.

An EP who: prescribes more than 100 medications

during the EHR reporting period;

maintains medication lists that include medications that they did not order; and

orders medications for less than 30 per-cent of patients with a medication in their medication list during the EHR re-porting period.

In these circumstances, an EP may be both unable to meet this measure and unable to qualify for the exclusion.

In the unique situation where all three criteria listed above apply, an EPs may limit their denomi-nator to only those patients for whom the EP has previously ordered medication, if they so choose. [Quack Note: check with your software vendor on how to limit your denominator. The denominator is the patient’s exam code; e.g., 92002, 99214, etc.]

EPs who do not meet the three criteria listed above must still base their calculation on the num-ber of unique patients with at least one medication in their medication list seen by the EP during the EHR reporting period regardless of who ordered the medication or medications in the patient's medication list.

For more information about the Medicare and Medicaid EHR Incentive Program, please visit

http://www.cms.gov/EHRIncentivePrograms.

Source: http://questions.cms.hhs.gov/app/answers/detail/a_id/10639

In particular circumstances, you may be both unable to meet EHR Medication measure and unable to qualify for the exclusion.

Medicare will only allow a new patient office or other outpatient visit when the physician or members of the same group with the same specialty have not seen the patient in the previous three years. Medicare determines the same group by the Tax ID Number (TIN). Medicare determines the same specialty by the primary specialty un-der which the physician enrolled with Medicare. Medicare does not process based on any subspecialties listed.

You can find more information on our evaluation and management (E/M) web pages.

New patient visits: http://www.wpsmedicare.com/j5macpartb/resources/provider_types/2009_0727_newpatientservices.shtml

E/M services: http://www.wpsmedicare.com/j5macpartb/resources/provider_types/evalandmngmnt.shtml

In late May 2011, our Provider Enrollment unit will be adding a new process to confirm receipt of new appli-cations via e-mail. We will also provide the internal control number we have assigned to the application and a website link for you to check the status of that application at any time, as it moves through the various processing stages.

The different processing statuses you may see are: * Completed * Pending * Returned

* EFT response * Additional information requested

Confirmation of completion of the application and as-signment of new Provider Transaction Access Num-bers (PTANs) will continue to be sent via regular mail.

Please Be Certain To Provide Your Current E-Mail Address In The Contact Person Section Of All Ap-plications To Ensure That The Receipt Confirma-tion E-Mail With Tracking Control Number Can Be Properly Sent To You.

Are You Billing New Patient Visit Codes Correctly?

WPS: Enrollment Application Status Inquiry

CERT Alert - Low-Level E & M Services - CPT 99211

WPS Medicare closely monitors Comprehensive Error Rate Testing (CERT) review findings to identify problem areas contributing most significantly to our error rate. Inappropriate billing of Current Procedural Terminology (CPT) code 99211 is one area of concern.

Services billed to Medicare under CPT code 99211 must be reasonable and necessary for the diagnosis and treatment of an illness or injury. Furthermore, a face-to-face encounter with a patient consisting of elements of both evaluation and management (E/M) is required.

Read the full article for further guidance and examples of CERT findings for these services on our CERT web page: http://www.wpsmedicare.com/j5macpartb/departments/cert/low-level-99211.shtml

Page 2

NOA 3rd Par ty Newslet ter

Teleconferences And On Demand Trainings Available

Are you interested in learning more about the Medicare program? Are you too busy to travel to a seminar?

If you answered yes to either of these questions, con-sider joining WPS Medicare for a teleconference or taking an on demand training course. To view our cur-

rent offerings, please visit the following WPS Medicare website: http://www.wpsmedicare.com/j5macpartb/training/training_programs/

Medicare recommends you submit the claim for secondary benefits even though there is no outstanding balance. The rea-sons for this include application of the patient's deductible for allowed services, notification of certain once in a lifetime benefits, recording of certain time re-stricted services, and allowing Medicare to keep the claim on file. This last one becomes vitally important when the pri-mary insurance company requests the payment back. The Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual

(IOM) Publication 100-05, Chapter 3, Section 10.5 indicates that a primary in-surance take back alone does not consti-tute good cause to waive the 1 year filing limit. However, if we already have the claim on file, we may be able to perform a reopening. You can find more informa-tion on good cause for waiving the file limit and reopening on the "Appeals" and "Claims" departmental areas of our web-site: http://www.wpsmedicare.com/j5macpartb/departments/appeals/ http://www.wpsmedicare.com/j5macpartb/departments/claims/

When The Primary Insurer Paid In Full, Should I Bill Medicare ?

“Form CMS-1500 At A Glance” Fact Sheet

The revised publication titled “Form CMS-1500 At A Glance” (revised Feb-ruary 2011) is now available from the Medicare Learning Network® at http://www.CMS.gov/MLNProducts/downloads/form_cms-1500_fact_sheet.pdf. This fact sheet is designed to provide education on the CMS Form 1500, which is the standard paper claim form used by healthcare professionals to bill for Medicare Part B services, and includes background information and a de-scriptive crosswalk of fields in the paper versus the electronic form.

Page 3

Vo lume 11, Issue 6

“Medicare Enrollment Guidelines for Ordering/Referring Providers” Fact Sheet

A new publication titled “Medicare Enrollment Guidelines for Ordering/Referring Providers” is now available in downloadable format at

http://www.CMS.gov/MLNProducts/downloads/MedEnroll_OrderReferProv_FactSheet_ICN906223.pdf. This fact sheet is designed to provide education on the Medicare enrollment requirements for eligible ordering/referring providers, and includes informa-tion on the three basic requirements for ordering and referring and who may order and refer for Medicare Part A Home Health Agency, Part B, and DME-POS beneficiary services.

CMS Announces Version 5010 Testing Day June 15, 2011

National 5010

Testing Day is an

opportunity for trading partners

to come together and test compliance

efforts.

Page 4

NOA 3rd Par ty Newslet ter

Trading partners who are not ready to submit electronic 5010 transactions by January 1, 2012 will not be able to submit electronic transactions in any other format! Therefore, failure to successfully transition to 5010/D.0 formats by January 1, 2012 may jeopardize future claim processing and payment thereafter.

Trading partners are strongly encouraged to begin testing with version 5010/D.0 transactions as early as possible in 2011. Providers who are not ready to submit electronic 5010 transactions to Medicare-Fee-For-Service during calendar year 2011 will be permitted to continue submitting electronic 4010A1 transactions, however, all trading partners are required to begin submitting version 5010/D.0 transactions starting January 1, 2012. Trading part-ners that are new to Medicare as of April 2011 will not be permitted to submit 4010A1 transactions in 2011, but will be required to submit in the 5010/D.0 formats.

Please reference the 5010 National Call presentation on Provider Outreach and Education – Transition Year Ac-tivities found at http://www.cms.gov/Versions5010andD0/downloads/OE_National_Presentation_12-8-10.pdf for Medicare testing require-ments and protocols throughout the 2011 transition year.

Source: http://www.cms.gov/Versions5010andD0/Downloads/Readiness_5010.pdf

Electronic Claim 5010 Readiness Assessment – Do you know the implications of not being ready?

The Version 5010 compliance date – Sunday, January 1, 2012 – is fast approaching. All HIPAA-covered enti-ties should be taking steps now to get ready, including conducting external testing to ensure timely compli-ance. Are you prepared for the transition? Medicare Fee-for-Service (FFS) trading partners are encouraged to contact their Medicare Administrative Contractors (MACs) now and facilitate testing to gain a better un-derstanding of MAC testing protocols and the transition to Version 5010.

To assist in this effort, CMS, in conjunction with the Medicare FFS Program, announces a National 5010 Testing Day to be held Wednesday, June 15, 2011. National 5010 Testing Day is an opportunity for trading partners to come together and test compliance efforts that are already underway with the added bene-fit of real-time help desk support and direct and imme-diate access to MACs.

CMS encourages all trading partners to participate in the National 5010 Testing Day. This includes:

Providers;

Clearinghouses; and

Vendors

More details concerning transactions to be tested are forthcoming from your local MAC. Additionally, there

are several State Medicaid Agencies that will be par-ticipating in the National 5010 testing day; more details will follow from them as well.

Again, CMS National 5010 Testing Day does not pre-clude trading partners from testing transactions imme-diately with their MAC. Don’t wait. You are encour-aged to begin working with your MAC now to ensure timely compliance. Note that successful testing is re-quired before a trading partner may be placed into production.

We hope all trading partners will join us on Wednes-day, June 15, 2011 and take advantage of this great opportunity to ensure testing and transition efforts are on track! For more information on HIPAA Version 5010, please visit

http://www.CMS.gov/Versions5010andD0

You must register with WPS by June 14th to test; To register , go to

http://www.wpsic.com/edi/5010-Readiness.shtml

Trading partners who are not ready to

submit

electronic 5010

transactions by

January 1, 2012

will not be able

to submit electronic

transactions. Period.

Beginning in 2011, the National Government Services, Inc. Common Electronic Data Interchange (CEDI) will begin requiring all CEDI Trading Partners to recertify their user access on an annual basis. This initiative is to strengthen the security of our gateway and ensure that all Trading Partners accessing the CEDI gateway are valid. CEDI began implementation of this recertifi-cation process on January 18, 2011.

Recertification will be the responsibility of the owner of the Trading Partner ID used to exchange electronic transactions with CEDI. If you have not completed the recertification form and own a Trading Partner ID, please complete the CEDI Trading Partner Recertifica-tion form available on the CEDI Web site www.ngscedi.com under EDI Enrollment. Incomplete forms will be returned to the applicant, thus delaying processing.

Trading Partners will be asked to fax their completed forms to the CEDI fax number 317-595-4999. If forms cannot be faxed, the Trading Partner may e-mail the forms to ngs.cedihelpdesk@wellpoint.com.

Once the forms have been received and processed, CEDI will notify the Trading Partner via the e-mail ad-dress submitted on the Recertification Form. Comple-tion of the Recertification process will allow the Trading Partner to begin to use the CEDI Gateway Self-Service Password Portal. The password portal is a simple and secure Web-based process for changing/resetting passwords for CEDI Trading Partners. This system is available 24 hours a day, 7 days a week for the con-venience of the CEDI Trading Partners. This system is only available to CEDI Trading Partners with a CEDI Trading Partner Recertification form on file.

The recertification process is scheduled to be com-pleted by August 2011. CEDI Trading Partners who have not recertified will be made inactive sixty (60) days after the end of the migration.

For additional questions, please contact the CEDI Help Desk at 866-311-9184, or you may submit your ques-tions via e-mail ngs.cedihelpdesk@wellpoint.com.

Reminder - CEDI Recertification Process

Below is a reminder of the Centers for Medicare & Medicaid Services (CMS) events for June regarding the im-plementation process for 5010 and D.0. The Important CEDI Events page on the CEDI Web site at www.ngscedi.com has been updated to include the CMS upcoming events currently scheduled.

UPCOMING EVENTS June 2011

15th National MAC Testing Day (for Vendors, Clearinghouses, and Billing Services, etc.) Important 5010/D.0 Implementation Items

Reminder – 5010/D.0 Errata requirements and testing schedule can be found here http://www.cms.gov/Versions5010andD0/Downloads/Errata_Req_and_Testing.pdf

Reminder – Contact your MAC for their testing schedule http://www.cms.gov/Versions5010andD0/Downloads/Reminder-Contact_MAC.pdf

Readiness Assessment – Have you done the following to be ready for 5010/D.0? http://www.cms.gov/Versions5010andD0/Downloads/Readiness_1.pdf

Readiness Assessment – What do you need to have in place to test with your MAC? http://www.cms.gov/Versions5010andD0/Downloads/Readiness_2.pdf

Important 5010/D.0 Implementation Calendar

Page 5

Vo lume 11, Issue 6

PC-ACE Pro32 Version 2.26 Upgrade Available The CEDI Help Desk has seen an increase in calls due to the PC-ACE Pro32 software displaying an expira-tion message reminding users to upgrade their program. The PC-ACE Pro32 version 2.26 upgrade is avail-able for download from the CEDI Web site www.ngscedi.com under Software Downloads and Documentation. The link to this page is http://www.ngscedi.com/downloads/Downloadindex.htm The Installation Code to run the upgrade is NGSMAC1.

RE—

CMS has developed attestation worksheets to help providers successfully attest to meeting meaningful use through the CMS web-based attestation system.

These attestation worksheets allow eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) to log additional data for core and menu meas-ures that might not be obtained only through their certified electronic health record (EHR) system. In order to provide complete and accurate information for certain of these measures, EPs and hospitals may have to include information from paper-based patient records or from other areas. (Please note that clinical quality meas-ures must be reported directly from certified EHR technology).

You can fill out the attestation worksheets electronically or manually, and then keep the worksheet on hand as you attest so your data is easily accessible.

You can find the worksheets by clicking the links below. Make sure to use the work-sheet that pertains to you: Attestation Worksheet for Eligible Professionals

https://www.cms.gov/EHRIncentivePrograms/Downloads/EP_Attestation_Worksheet.pdf

New Attestation Resources Have Been Posted

Providers who have

successfully

attested to

meaningful use, and

who have met all

the other program

requirements, can

expect their $18k

2011 incentive

payments as soon

as they meet their

$24k paid claims

requirement for the

year. Those who do

not reach the

maximum of $24k

for 2011 can expect

payment in March

of next year; that

payment will be

75% of their paid

claims for 2011.

The First Medicare EHR Incentive Payments Issued

The Centers for Medicare & Medicaid

Services (CMS) is pleased to an-

nounce that incentive payments for

the Medicare EHR Incentive Program

were sent out in May! Providers who

have successfully attested to having

met meaningful use, and who have

met all the other program require-

ments, can expect to receive their

2011 incentive payments soon.

What Kind of Payment Can I Expect? Eligible Professionals (EPs) partici-pating in the Medicare EHR Incentive Program receive a payment based on 75 percent of their total Medicare al-lowed charges submitted no later than two months after the end of the 2011 calendar year. The maximum allowed charges used for a 2011 in-centive payment are $24,000. This means that the maximum incentive

payment an EP can receive for the first participation year is $18,000. Please note that incentive payments

will not be made to an EP until the EP

meets the $24,000 threshold in al-

lowed Medicare charges.

Incentive payments to eligible hospi-

tals and critical access hospitals are

based on a number of factors, begin-

ning with a $2 million base payment.

How Are Payments Made?

Participants will receive their Medi-

care EHR Incentive Program payment

the same way they receive payments

for Medicare services, via electronic

funds transfer or by paper

check. Payments to Medicare provid-

ers will be made to the taxpayer iden-

(Continued on page 7)

Page 6

NOA 3rd Par ty Newslet ter

CMS has posted the latest EHR FAQs document on the CMS website. Go to

http://www.cms.gov/EHRIncentivePrograms/Downloads/FAQsRemediatedandRevised.pdf

This interactive document provides updated frequently asked questions. Each FAQ is sorted by topic

to help you more easily review information about various aspects of the EHR Incentive Pro-

grams. CMS will continue to provide updates as new FAQs are added.

Want more information about the EHR Incentive Programs? Visit the CMS EHR Incentive Pro-

grams website at http://www.cms.gov/EHRIncentivePrograms/ for the latest news and updates on the EHR In-

centive Programs; also sign up for the EHR Incentive Programs email update listserv at http://www.cms.gov/EHRIncentivePrograms/65_CMS_EHR_Listserv.asp.

CMS EHR Frequently Asked Questions

Page 7

Vo lume 11, Issue 6

From the AOA News…. Austin, Texas-based Abeo Solutions Inc. has announced that its Crystal Practice Management soft-ware program has been certified as a complete EHR system for ambulatory health care practices. The Crystal Practice Management EHR is at least the fifth electronic health records product, developed specifically for optometric practices, to be approved for use in the federal HITECH incentive program. Complete EHR systems Crystal Practice Management EHR Compulink Business Systems’ Advantage EHR Version 10, Eyefinity/ OfficeMate’s ExamWriter Version 10, and First Insight Corporation’s MaximEyes® SQL Electronic Health Records Version 1.1.0. have also been certified as complete EHR systems. EHR module Only Health Innovation Technologies’ Revolution EHR Version 5.1.0, has been certified as an EHR

module.

AOA: Five Optometry EHR Products Now Available

tification number (TIN) selected dur-

ing registration for the Medicare EHR

Incentive Program. For electronic

transfers, CMS will deposit incentive

payments in the first bank account on

file and it will appear on the bank

statement as "EHR Incentive Pay-

ment."

IMPORTANT: Medicare Administra-

tive Contractors (MACs), carriers, and

fiscal intermediaries will not be mak-

ing these payments. CMS is working

with a Payment File Development

Contractor to make these payments.

Please do not contact your MAC re-

garding EHR incentive payments.

(Continued from page 6)

The Centers for Medicare & Medicaid Services (CMS) is pleased to announce that the 2009 Physician Quality Reporting System & Electronic Prescribing Incentive (eRx) Programs Reporting Experience

Report is now available.

The 2009 experience report summarizes the experience of eligible professionals in the 2009 Physician

Quality Reporting System and eRx Incentive Programs, as well as trends in the program over time,

including early results from 2010.

The 2009 experience report is available in the "Downloads" section of the “Overview” page on the

Physician Quality Reporting System web page, located at http://www.cms.gov/PQRS/ on the CMS web-

site. It is also posted as a download on the “Overview” page under “Related Links Inside CMS” on

the eRx web page, located at http://www.cms.gov/ERxIncentive/ on the CMS website.

2009 PQRS & eRx Experience Report

To avoid future penalties, the

AOA and Dr. Quack strongly

recommend that ODs successfully

complete an e-Rx at least 25 times

before the end of 2011.

Page 8

NOA 3rd Par ty Newslet ter

e-Rx Now to Avoid Penalties in Future

Beginning in calendar year 2012, some eligible

professionals who are not successful electronic

prescribers based on claims submitted between

January 1, 2011 – June 30, 2011, may be sub-

ject to a payment adjustment on their Medicare

Part B covered professional services. After

2011, not being a successful electronic pre-

scriber will result in increasing adjustments over

2012 , 2013, and 2014, of 99%, 98.5%, and

98%, respectively,

The AOA and Dr. Quack have strongly recom-

mended that optometrists begin e-prescribing as

soon as possible, preferably completing 10 e-

Rxs before July 1st of this year. However, it has

been disclosed that, despite ODs being classi-

fied as physicians by Medicare, CMS has appar-

ently not included ODs in the physician require-

ment of 10 e-Rxs before July 1st to avoid penal-

ties in 2012. According to AOA staff member

Rodney Peele JD, CMS was reportedly unaware

that ODs have prescriptive authority in all 50

states, and thus erroneously omitted the profes-

sion from the 2011 July 1st requirement.

At first glance, this would seem to be favorable

to the profession. But it is unknown whether

ODs will be penalized in 2013 for e-prescribing

actions that took place in both 2011 and 2012.

So, despite this omission by CMS, the AOA and

Dr. Quack strongly recommend that ODs suc-

cessfully complete an e-Rx at least 25 times

before the end of 2011, and, if possible, com-

plete 10 e-Rxs before July 1st of this year.

For additional information, please visit the

“Getting Started” web page on the CMS website

at http://www.cms.gov/erxincentive for more information;

or download the Medicare’s Practical Guide to

the Electronic Prescribing (eRx) Incentive Pro-

gram under Educational Resources.

CMS requires that all DMEPOS suppliers with Medicare billing privileges re-enroll with the Medi-

care program every three years through the Na-

tional Supplier Clearinghouse (NSC). Suppliers

will be prompted to revalidate, formerly re-enroll,

for billing privileges using the Internet-based PE-

COS system.

Don’t wait. Register now to use Internet-Based

PECOS in preparation for the receipt of the letter

instructing suppliers when revalidation is neces-

sary. Upon receipt of the revalidation letter, suppliers are required to go online and re-

spond to the request within 30 days. If the

NSC does not receive the completed revalidation packet, the supplier’s billing privileges are subject

to normal filing rules including revocation or inac-

tivation.

To learn more about Internet-based PECOS or to register, visit the CMS website at

http://www.cms.gov/MedicareProviderSupEnroll.

For more information, contact NSC Customer

Service during regular operating hours, Monday

through Friday, 9 a.m. to 5 p.m. ET at 1-866-

238-9652.

The reason and remark code sets must be used to report payment adjustments in remittance advice transactions. The reason codes are also used in some Coordination-of-Benefits (COB) transactions.

The RARC list is maintained by the Centers for Medicare & Medicaid Services (CMS), and used by all

payers. Additions, deactivations, and modifications to the list may be initiated by any health care or-

ganization. The RARC list is updated 3 times a year – in early March, July, and November, although

the Committee meets every month.

Both code lists are posted at http://www.wpc-edi.com/Codes on the Washington Publishing Company (WPC)

website. The lists at the end of this article summarize the latest changes to these code lists, as an-

nounced in CR7369.

Medicare Durable Medical Equipment Suppliers Must Re-Enroll (Revalidate) every 3 Years

Medicare Durable Medical Equipment Suppliers Must Now Pay $500+ to Enroll or to Re-Enroll

Page 9

Vo lume 11, Issue 6

The National Supplier Clearinghouse (NSC) has

published information on a final rule regarding

screening categories, an application fee of $505

in 2011 as part of the enrollment process, sus-

pension of payment based on credible allegations

of fraud, and authority to impose a temporary

moratorium on enrollment of new Medicare suppli-

ers of a particular type in a geographic area.

Additional information regarding this guidance and

CMS Change Request 7350 can be accessed at http://www.cms.gov/MLNMattersArticles/downloads/MM7350.pdf.

Suppliers are to work directly with NSC Customer

Service (1-866-238-9652) with any questions re-

garding this information.

Medicare Reason and Remark Codes (RARC)

Starting in June 2011, C-SNAP will require all users to re-certify. For instructions on the re-certification process, please visit our website: http://www.wpsmedicare.com/j5macpartb/resources/claims_elig_tools/csnap/csnap-recertify-inst.shtml

Here is what C-SNAP can do for your office:

Patient Eligibility (Real-time Data) Access national eligibility information to verify Medicare beneficiary entitle-ment 24 hours a day, 7 days a week. Patient eligibility includes Managed Care Organization (MCO) enrollment information, Medicare Secondary Payer (MSP) information, preventive services, therapy caps, and much more.

Claim Status (Real-time Data) Check the status of pending claims and receive detailed information about proc-essed claims. Please note, claims status is only available when the Part A and Part B claims processing sys-tems are available.

Duplicate Remittance Advice (On Demand) Request entire duplicate remittances in standard paper format. View remittances instantly on your computer and print them locally at your office.

Appeals Submit requests for a Medicare Part B redeterminations or claim reopenings. Check the status of previ-

ously submitted C-SNAP appeal requests.

Secure Message Contact the C-SNAP Technical Support staff or Customer Service. Send inquiries about C-SNAP, request clarifications on claim denials or policies, and view responses using this secure online messag-ing system. Personal information stays private and confidential.

he looked twice as glum, and the foreman asked

if everything was alright.

"Bejeezuz Boss, its even worse news," "That

was my brother, and his mother died today too!"

Soon after Paddy clocked in for work, the fore-man called him over and told him that he had a

phone call in the front office. When Paddy re-

turned, he had a mournful expression on his face

and his head hung low. His foreman noticed and

asked if it was bad news.

"To be sure it was, Boss" he replied, "I just

found out that my mother died earlier this morn-

ing.”

"Gosh, that's awful," replied the foreman "Do

you want the rest of the day off?"

"No," replied Paddy. "I'll finish the day out."

About an hour later, the foreman returned to

inform him that there was another phone call for

him in the office. This time when Paddy returned

C-SNAP Requires Annual Recertification

Page 10

NOA 3rd Par ty Newslet ter

Dr. Quentin Quack’s Quacked Humor

To access the new NOA 3rd Party web page directly:

1. Go to http://nebraska.aoa.org/

2. Click on DOCTORS (gray horizontal bar)

3. Click on THIRD PARTY INDEX (gray bar, left side of screen)

4. Enter your User Name (AOA member #) and Password (DOB MMDDYY) when requested.

Another Politically Incorrect Story from

Dr. Quack….

A Portal Direct to Medicare

Dear Dr. Quack: Today, in the mail, I received three rejections from WPS Medicare. They stated :

Please answer each question and return this letter within 30 days. Please return this letter with the requested information. If the requested information has not been received within 45 days, processing of this claim will be decided by the information pre-sent. Payment may be reduced or denied if this in-formation has not been received.

Please furnish medical records for the following service Procedure code 99309 Service Performed on 5/5/11 Performed by Dr. xxxx For 100.00

I guess I'm not sure why the rejection. Please let me know if you can help me out.

Dr. Quack’s Quote: You are not alone. Optometrists in IA, KS, NE, and MO are getting the same letter for nursing home visits...apparently WPS is checking to

make sure they are legit and doing a mass evaluation of nursing home codes.

Send in your documentation as requested, and if it is adequate for the code, you should eventually be reim-bursed.

As you know from CPT, 99309 requires a detailed history, detailed exam, and medical decision mak-ing of moderate complexity. That is the same re-quirement as for an in-office code of 99214.

Dr. Quack created a score sheet for E&M in-office services, including 99214. The 2010 May issue of the newsletter has a copy of the score sheet (pages 11 and 12), and an explanation on its use, especially in regard to in office code 99214. (pages 6 and 7). See http://nebraska.aoa.org/documents/ne/2010-05-3RD-PARTY-NEWLSETTER.pdf

Use these tools to see if your 99309 examination and resulting documentation meets the requirements of 99214.

Nursing Home Codes: WPS Requests and Rejections

VEP and Tear Osmolarity Not Covered by Medicare

Dear Dr. Quack, Regarding the updated Medicare LCD for optometry: we are looking at purchasing a new VEP unit due to recent indications that it can be helpful in glaucoma patients besides the usual things like am-blyopia, optic neuritis, etc. What is the status on that? Likewise, we are looking at the new unit to analyze tear osmolarity. What's up there? That would be a particular issue since many of the dry eye patients are Medicare. Thanks.

Dr. Quack’s Quote, As it now stands, both will be de-nied. Make sure you have a ABN signed if you plan to perform either on Medicare patients...and as you know, where Medicare goeth other insurers may follow...

AOA and J5 MAC CAC reps are working to rectify the situation...but we are not holding our collective breaths on the short term. It took 15 months to rectify omitted codes after the January 15, 2010 implementation of the WPS optometry LCD. It appears, at times, as if Medi-

care’s concept of optometry is about 40 years old, and there are those at WPS who seem to demur when confronted with today’s mode of practice of the opto-metric profession. (And rumor has it that there is little acceptance of other none-MD professions as well.)

Another depressing thought, when contemplating the purchasing of expensive toys: remember that CMS is really pushing pay-for-performance rather than pay-for-procedure. So Dr. Quack can see reimbursement for many procedures taking the same road as the recent decrease in OCT reimbursement. As you may have heard, the latest CMS proposal is to boost hospital reimbursement an additional percentage for good pa-tient evaluations, and pay other hospitals less for poor patient evaluations. I suspect this proposal will eventu-ally take place, and, if so, I suspect the next step will be to do the same for fee-for-service providers. So smile a lot.

Page 11 Vo lume 11, Issue 6

Dr. Quentin Quack’s Queries and Questionable Quotes ~~~~~~~~~~~~~~~~~~~~~~~~~~

Third Party Questions from NOA Doctors and Staff Dr. Quentin Quack

...apparently WPS is doing a mass evalua-tion of nursing home codes...

CMS ‘Learnresource’ Articles 1633 Normandy Ct, Ste A Lincoln, NE 68512 http://nebraska.aoa.org/

Nebraska Optometric Association

EHR: MEANINGFUL USE AT RISK FOR INFREQUENT PRESCRIBERS If certain prescription conditions exist in your practice, it could prevent you from demon-strating meaningful use. Suggestions are provided. P.1.

MEDICARE NURSING HOME CODE REJECTIONS Apparently WPS is cutting a wide swath while checking to make sure nursing home claims are medically necessary and are correctly documented. 99309 seems of particular interest to WPS. Pp. 1 & 11.

ARE YOU BILLING NEW PATIENT VISIT CODES CORRECTLY? Medicare will only allow a new patient office or other outpatient visit when the physician or members of the same group with the same specialty have not seen the patient in the previous three years. P.2.

CERT ALERT - LOW-LEVEL E & M SERVICES - CPT 99211 Inappropriate billing of 99211 is contributing most significantly to the WPS CERT error rate. P.2.

ENROLLMENT APPLICATION STATUS INQUIRY The WPS Provider Enrollment unit will be has added a new process to confirm receipt of new applications via e-mail. P.2.

TELECONFERENCES AND ON DEMAND TRAININGS AVAILABLE Consider joining WPS Medicare for a teleconference or an on demand training course. P.2.

WHEN THE PRIMARY INSURER PAID IN FULL, SHOULD I BILL MEDICARE ? Medicare recommends you submit the claim for secondary benefits even though there is no outstanding balance. P.3.

“FORM CMS-1500 AT A GLANCE” FACT SHEET This fact sheet is designed to provide education on the CMS Form 1500, which is the standard paper claim form used by healthcare. P.3. “MEDICARE GUIDELINES FOR ORDERING/REFERRING PROVIDERS” FACT SHEET This fact sheet is designed to provide education on the Medicare enrollment requirements for eligible ordering/referring providers. P.3.

ELECTRONIC CLAIM 5010 READINESS ASSESSMENT Trading partners who are not ready to submit electronic 5010 transactions by January 1, 2012 will not be able to submit electronic transactions in any other format! P.4.

CMS ANNOUNCES VERSION 5010 TESTING DAY JUNE 15, 2011 National 5010 Testing Day is an opportunity for trading partners to come together and test compliance efforts with the added benefit of real-time help desk support. P.4.

IMPORTANT 5010/D.0 IMPLEMENTATION CALENDAR The Important CEDI Events page on the CEDI Web site has been updated to include the CMS upcoming events currently scheduled. P.5.

PC-ACE PRO32 VERSION 2.26 UPGRADE AVAILABLE The PC-ACE Pro32 version 2.26 upgrade is available for download from the CEDI Web site. P.5.

NEW ATTESTATION RESOURCES HAVE BEEN POSTED CMS has developed attestation worksheets to help providers successfully attest to meet-

ing meaningful use through the CMS web-based attestation system. P.6. THE FIRST MEDICARE EHR INCENTIVE PAYMENTS ISSUED

Providers who have successfully attested to meaningful use, and who have met all the other program requirements, can expect their $18k 2011 incentive payments as soon as they meet their $24k paid claims requirement for the year. Others will paid at a later date. P.6.

CMS EHR FREQUENTLY ASKED QUESTIONS Each FAQ is sorted by topic to help you easily review information about various aspects of the EHR Incentive Programs. CMS will continue to provide updates as new FAQs are added. P.7.

AOA: FIVE OPTOMETRY EHR PRODUCTS NOW AVAILABLE Crystal Practice Management EHR is at least the fifth electronic health records product, developed specifically for optometric practices, to be approved for use in the federal HITECH incentive program. P.7.

E-RX NOW TO AVOID PENALTIES IN FUTURE The AOA and Dr. Quack have strongly recommended that optometrists begin e-prescribing as soon as possible, preferably completing 10 e-Rxs before July 1st of this year. P.8.

2009 PQRS & ERX EXPERIENCE REPORT CMS is pleased to announce that the 2009 Physician Quality Reporting System & Elec-tronic Prescribing Incentive (eRx) Programs Reporting Experience Report is now avail-able. P.8.

DME SUPPLIERS MUST RE-ENROLL EVERY 3 YEARS CMS requires that all DMEPOS suppliers with Medicare billing privileges re-enroll with the Medicare program every three years through the National Supplier Clearinghouse (NSC). P.9.

DME SUPPLIERS MUST NOW PAY $500+ TO ENROLL OR TO RE-ENROLL The National Supplier Clearinghouse (NSC) has published information on a final rule regarding an application fee of $505 in 2011 as part of the enrollment process. P.9.

MEDICARE REASON AND REMARK CODES Both code lists are posted on the Washington Publishing Company (WPC) website. P.9.

C-SNAP REQUIRES ANNUAL RECERTIFICATION Starting in June 2011, C-SNAP will require all users to re-certify. For instructions on the re-certification process, please visit the C-SNAP website. P.10.

VEP AND TEAR OSMOLARITY NOT COVERED BY MEDICARE Make sure you have a ABN signed if you plan to perform either test on Medicare patients. P.11.

NURSING HOME CODES: WPS REQUESTS AND REJECTIONS Optometrists in IA, KS, NE, and MO are getting letters requesting documentation for nursing home visits...apparently WPS is checking to make sure they are legit and doing a mass evaluation of nursing home codes. P.11.

Better Vision for Nebraskans...

NOA Third Party Newsletter—ABSTRACTS OF THIS MONTH’S ISSUE

The NOA Third Party Newsletter is published monthly by the Nebraska Optometric Association with the assistance of Ed Schneider, O.D., Third Party Consultant.

To reach Ed (aka Dr. Quack):

> BEST to contact via Email at: SchneiderEd@msn.com

> Ed’s mobile phone is 402-310-2367. Voicemail available.

> Fax number is 402-464-1214. Call Ed before faxing.

* 2011 Electronic Prescribing (eRx) Incentive Program Reminder-Avoiding the Adjustment

http://www.wpsmedicare.com/j5macpartb/publications/news/current/2011-0502-erx-avoid.shtml

* How Do I Get Paid for the Electronic Health Record (EHR) Incentive Pro-grams?

http://www.wpsmedicare.com/j5macpartb/publications/news/current/2011-0502-ehr-programs.shtml

* Updates from the Medicare Learning Network http://www.wpsmedicare.com/j5macpartb/publications/news/archived/2011-0428-mln-updates.shtml

* HIPAA 5010 & D.0 Implementation Calendar and Important Reminders for May 2011

http://www.wpsmedicare.com/j5macpartb/publications/news/current/2011-0509-avg-price.shtml

* New FAQs on CMS EHR Incentive Programs http://www.wpsmedicare.com/j5macpartb/publications/news/archived/2011-0505-faqs-ehr.shtml