Medicare Compliance & Reimbursement

The transition for medical practices to convert their diagnosis coding systems from ICD-9 to ICD-10 is now less than two years away, and CMS aims to offer a helping hand in the process with the issuance of several new educational documents.

On Nov. 9, CMS announced that it had developed four Implementation Handbooks that offer step-by-step instructions for small and medium-sized provider practices, large practices, small hospitals, and payers to seamlessly transition to the new coding system.

In addition to the guidance, CMS offers several templates that can aid your practice during the transition period. For instance, small and medium practices can use the "Vendor Checklist Case Template" when discussing ICD-10 with their vendors to determine whether the billing systems will be ready for the new diagnosis codes.

To access the guidebook for small and medium practices, visit www.cms.gov/ICD10/Downloads/ICD10SmallandMediumPractices508.pdf. For more on CMS's ICD-10 transition documents, visit www.cms.gov/ICD10/.

If you typically wait until you receive Medicare's third warning that you need to refund an overpayment to your MAC, you'll soon be out of luck.

In the past, if you received an overpayment from Medicare, your MAC would usually send you an initial demand letter, a follow-up latter, and an "intent to refer" letter. However, CMS noticed that most providers either pay on the initial demand or wait until the final notice -- so the agency announced on Nov. 9 that it is no longer sending a follow-up letter.

Effective Nov. 1, MACs were instructed to send an initial letter to practices that owed money back to the Medicare program. Recoupment begins 41 days after that letter. If an overpayment is not paid within 90 days of the initial letter, providers will get a final letter explaining CMS's intention to refer the debt for collection, and provider appeal rights will remain unchanged, CMS announced.

When it comes to Part B payment, you can't always count on an "effective date" being the same thing as a "coverage date."

Such is the case with 90654 (Influenza virus vaccine, split virus, preservative-free, for intradermal use), which debuted on Jan. 1, 2011, but was too late to make the 2011 CPT® book so it makes its first appearance in the 2012 manual. Even though the code was added "effective January 1, 2011," it didn't become payable by Medicare until May 9, 2011, a new MLN Matters article explains.

In fact, MACs didn't reimburse for 90654 until May 9, 2011, notes article MM7580, which came out on Oct. 28. To read the entire article, visit www.cms.gov/MLNMattersArticles/downloads/MM7580.pdf.

If you're wondering how to tackle the rise of Medicare managed care penetration, you can draw some useful conclusions from a new report from the Kaiser Family Foundation and Mathematica Policy Research. The report examines Medicare Advantage enrollment nationwide. "Medicare Advantage penetration varies substantially by state," says the report.

Ten states have less than 10 percent of the population in MA plans, while Minnesota has 44 percent of residents in such plans. Another 13 states have 30 percent or more of their Medicare benes in plans. "A small number of firms account for a large share of Medicare Advantage enrollment at the state level," the report continues. In 33 states and D.C., three MA companies account for 75 percent or more of enrollees.

What that means: Focus your MA marketing and contracting efforts on the top three plans, suggests consultant Tom Boyd with Rohnert Park, Calif.-based Boyd & Nicholas. The 13-page report is available at www.kff.org/medicare/8228.cfm.